The senior trainee had a reputation for being unapproachable and unavailable and often delegated tasks to junior doctors as well as expecting them to do all the menial tasks and administration work, such as discharge summaries and take home medication prescriptions, including those that were his responsibility.
It was not unusual for the senior trainee to disappear following the morning consultant ward round and not be seen again until lunch time when the consultant had finished operating. The juniors were aware that the senior trainee had his own theatre and outpatient clinic commitments but there were days when he was assigned to the ward and was expected to be present to supervise and teach the juniors, including students.
One patient who had recently undergone surgery developed acute chest pain and the F1 was very concerned about him. He arranged for an ECG and blood tests, including a cardiac screen as he was concerned that the patient might be having a myocardial infarction. The F1 was very capable but was understandably anxious about the patient and asked the student to contact the senior trainee who was the senior doctor to be contacted in case of emergencies that day.
The student bleeped the senior trainee who answered after about five minutes. He was very off hand and made the student feel very uncomfortable. Despite this the student clearly explained that the patient had deteriorated, explained his signs and symptoms, and said clearly that the F1 needed urgent assistance. The senior trainee was very dismissive and told the student to tell the F1 to give the patient 10mg of intravenous morphine to treat his pain and then get the medical on call doctor to review the patient.
The student returned to the F1 and relayed this advice. The F1 was concerned that the patient had very low blood pressure, some respiratory difficulty and that 10mg of morphine may be too much for the patient. However, as the patient continued to be in so much pain, he gave him 5mg and asked a nurse to sit with the patient to monitor him while he rang the medical on call team.
Whilst the F1 was on the phone to the medical registrar, the patient suffered a cardiac arrest. The arrest call went out and the resuscitation team arrived but unfortunately attempts to revive him failed. The F1 and the student were understandably very upset. The surgical senior trainee had arrived on the ward after the resuscitation attempts had been made and documented in the records that he had spoken with the junior doctor on the phone and had advised him to treat the patient's pain with morphine, starting at 2mg and titrating up to 10mg if the patient coped with this and also give aspirin and sublingual GTN before calling the medical registrar.
The patient had been a poor anaesthetic risk due to severe ischaemic heart disease, hypertension and having had a previous myocardial infarction. As this was a post-operative death, it was referred to the Coroner, who was satisfied that the cause of death was a myocardial infarction and allowed the death certificate to be provided without the need for an inquest.
The nurse, who had been with the patient when he arrested, made a complaint about the surgical registrar to the ward manager. The ward manager was already aware that the registrar was difficult to work with and not supportive of the junior doctors or nurses. Probity concerns had now also been raised in view of the inaccurate documentation he had made in the patient's notes. A formal complaint was made to the medical director and a disciplinary investigation into the registrar's actions began. Both the F1 and the student were asked for their comments. For their own learning, they were advised to review the GMC's general guidance on good medical practice and also the GMC's guidance on raising concerns about patient safety.
This is a fictional case compiled from actual cases from the MDU's files.
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