The scene

A 72-year old female patient attended the practice with weight loss, malaise and temporal headache. During the consultation, the GP discovered she had experienced some pain in the neck and shoulders over recent months. The GP then performed a physical examination, which revealed some tenderness over the temples and a reduced range of movement of the neck and shoulders. Blood tests including FBC, renal and liver profile and ESR were requested.

The patient had the bloods done just before the Easter bank holiday weekend and the results were received by the practice the day before the Good Friday bank holiday. The bloods were normal apart from a raised ESR of 60 mm/hour.

The results were viewed by a locum GP the following week and a text message was sent to the patient two days later asking her to book an appointment to discuss her results.

The same day as the text message was sent to the patient, she attended A&E with loss of vision in her right eye. A diagnosis of temporal arteritis (giant cell arteritis) was made and the patient was started on high dose prednisone.

MDU advice

The GP who had initially seen the patient called the MDU advice line to discuss the case and determine what action the practice should take. The MDU adviser explained that in addition to the ethical duty on all doctors to be open and honest with patients when things go wrong, the practice should also consider whether the statutory duty of candour applied.

The statutory duty was introduced in 2014 for NHS bodies (such as trusts and foundation trusts) in England, and was extended in April 2015 to cover all other care providers registered with the CQC, including GP practices. The duty applies to organisations rather than individuals, but staff should cooperate to make sure the organisational obligation is met.

Patients should be told of a 'notifiable safety incident' as soon as is practical. A notifiable safety incident has two statutory definitions, depending on whether the healthcare organisation is an NHS body or not.

For non-NHS bodies - such as the GP practice - a notifiable patient safety incident is defined as something unintended or unexpected occurring in the care of a patient that, in the reasonable opinion of a healthcare professional, appears to have resulted in:

their death (not relating to natural progression of the illness or condition)
impairment of sensory, motor or intellectual function, lasting or likely to last for 28 days
changes to the structure of the body (e.g. amputation)
prolonged pain or psychological harm (defined as experienced or likely to be experienced for at least 28 days)
shortening of life expectancy
the need for treatment to prevent death or the above adverse outcomes.

The outcome

The practice decided that the statutory duty applied and they apologised to the patient for the delay in reviewing and acting upon the raised ESR result. A notification was made by the practice to the CQC. The patient accepted the practice’s apology and appreciated that changes had been made to how blood test results were managed as a result of her experience.

Notifiable or not? Reporting safety incidents

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