Violence in the surgery - Dealing with aggressive patients

Safety comes first when seeing violent patients, writes Dr Emma Cuzner of the MDU.

The NHS has pledged itself to zero tolerance of violence and abuse towards staff, and GPs should feel confident to report a violent incident in the knowledge that it will be dealt with appropriately.

It is important that your primary care organisation (PCO) has local policies on the treatment of violent or abusive patients, for example by providing a secure environment where they can be seen. Your surgery should have a protocol for seeing patients with a history of violence - perhaps in extreme cases with another member of staff present or even in the presence of a police officer.

Personal safety
There are a number of simple things you can consider to improve your personal safety. It is not always practical, but you might want to think about making your home telephone number ex-directory.

Inform practice staff when you are going on a home visit, giving details of where you are going, your expected return time and your mobile number.

Beware of scarves, ties or other loose items of clothing that could be used if you are in close proximity to a violent patient.

De-escalate the initial signs of impending violence during a consultation by using active listening skills and asking open-ended questions. Reassure and acknowledge grievances as you maintain eye contact. Ensure you are a safe distance away from your patient, but do not position yourself so you can be trapped in a corner.

It can sometimes be helpful to adopt a neutral stance with your hands by your side, and offer reassurance and acknowledgment of a problem. However, there comes a stage when it is simply safer to leave the room.

Escape route
It might be possible to set up consulting rooms with two means of access.

The general layout of a room could also be altered so that the patient is not positioned between the GP and the door, allowing the GP a clear line of exit if the patient becomes threatening.

Do not leave items such as patella hammers or syringes in sight because they could be used as weapons.

Panic buttons and alarms may also be considered. Locums within the surgery should be informed of the position of any existing panic buttons.

After an incident
When reporting an incident of serious violence, it is important that you document the events in the patient's records and alert your colleagues.

The practice might want to press charges or remove the patient from the list.

When reporting an incident to the police, a GP should only provide the bare minimum details such as name and address and not divulge clinical details.

However, there are certain circumstances where clinical details might be disclosed, for example, if withholding such information might place the patient or others at risk of serious harm or death. The GMC guidance on confidentiality and disclosures in the public interest should be followed in such situations.

If it is deemed necessary to immediately remove a violent patient from the practice list, it is important to remember to contact the police first to obtain an incident number before notifying the PCO, otherwise the patient will be entitled to services during a period of notice.

- Dr Cuzner is a medico-legal adviser at the MDU

CASE STUDY - A bogus house visit request
A GP working out of hours took a call from a distressed mother whose baby was suffering from a cough.

The GP gave verbal advice and asked the mother to take the child to her own GP the following day if there was no improvement.

Shortly afterwards the GP received a call from the baby's father demanding an immediate home visit. When the GP explained that this was not necessary the father became very abusive.

The GP tried unsuccessfully to calm the father and ended the conversation.

Some time later, the GP received another request for a home visit nearby.

The man who called said he thought he was having a heart attack.

The GP made the visit but as she got out of her car, the baby's father came out of the house wielding a baseball bat. Fortunately, the GP was able to rush back to her car and drive off before the man caught up with the car.

The GP rang the police, who arrested the man, and it was confirmed that the house call about the patient with chest pain was fabricated. The father was successfully prosecuted and the practice out-of-hours service reviewed its security arrangements.

LEARNING POINTS
Protect yourself from violent patients

1. It is important that your PCO has local policies on the treatment of violent or abusive patients.

2. It is also useful to develop skills and awareness that can diffuse a potentially violent situation.

3. Make your home telephone number ex-directory. Inform practice staff whenever you are going on a home visit.

4. Keep situations calm. Use active listening skills and ask open-ended questions.

5. It may be possible to set up consulting rooms with two means of access.

6. If you feel you are in danger it is time to leave the room.

7. Where you have serious concerns about a patient, you might wish to consider consulting the PCO or the police about them.

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