An elderly female resident of a care home with mild dementia was brought into A&E after an unwitnessed fall. The patient was seen by an FY2 doctor, who carried out a comprehensive assessment and examination and noted a wrist injury but nothing to suggest anything more serious.
X-rays confirmed the patient had a Colles fracture, which was stabilized before she was discharged. However, 36 hours later she was rushed back to A&E by ambulance after becoming short of breath and was admitted with a haemothorax.
The FY2 doctor found out about the admission when his consultant approached him to write an incident report. Anxious about the implications, he called the MDU advice line.
The adviser explained that since 2010, all NHS trusts had a statutory duty to identify, investigate and report all serious incidents to facilitate organisational and NHS-wide learning. The adviser reassured the doctor that such processes are not designed to be punitive, but empathised with his anxiety that an investigation could identify system or individual errors.
They recommended that the doctor write his report as soon as possible while the details were fresh in his mind and using his contemporaneous notes for reference. Although the shift itself had been particularly busy and his recollection was somewhat limited, the doctor had written detailed notes which corroborated his holistic assessment of the patient.
During the call, the adviser explained how the doctor could approach writing the incident report to ensure it was comprehensive, open and provided a rationale for his actions at the time. The report, which should be capable of standing on its own, should include a factual chronology of the consultation, stating who he was and the capacity in which he was seeing the patient. Most importantly, the report should set out what the doctor found and what he looked for and did not find during his assessment.
The adviser forwarded written guidance to help the doctor draft his report and suggested he could send it to the MDU to review, to ensure it gave a sufficiently detailed and accurate account of his interaction with the patient.
The FY2 doctor submitted his report, drafted with assistance from the MDU. The trust concluded its investigation without finding any errors or omissions in his individual practice.
The patient’s haemothorax was successfully drained and she was discharged back to her care home.
This page was correct at publication on 02/07/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.