The scene

A patient was admitted with acute pyelonephritis on a Friday afternoon and was started on a course of intravenous gentamicin. Unfortunately, the scales on the ward were incorrectly calibrated and the patient was given an excessive dose.

While a pre-dose level was checked after 24 hours and the result available soon afterwards, this was not acted upon and the patient received three excessive doses before a foundation doctor spotted the excessive gentamicin level and contacted the supervising consultant. By this point the patient had already reported headache and joint pain and further tests showed they had developed moderate renal impairment.

The foundation doctor was distraught because he had been on call on the Saturday night and had not reviewed the result nor mentioned it during the shift handover on Sunday morning. When the incident was deemed to meet the duty of candour threshold and the trust began an investigation, the doctor became extremely anxious.

In the following days, the doctor found it increasingly difficult to cope and put off writing the statement requested by the trust. He could no longer focus at work and was struggling with some tasks, while obsessively re-checking test results he had already acted upon.

He started to fall behind on his ward responsibilities, and after a consultant criticised him one day for his note taking and a patient complained about his abrupt bedside manner, the doctor decided to call the MDU helpline.

MDU advice

The foundation doctor was extremely worried about the ongoing investigation into the original patient safety incident, which he felt would be critical of him. He was convinced this and more recent concerns would result in a disciplinary investigation and he would not be allowed to continue his training.

The adviser listened to the doctor’s concerns and reassured him that everyone made errors, especially when they were still training. However, it was important to recognise that most adverse events were caused by a combination of organisational or systems errors, as well as human factors. The trust’s incident investigation would consider all the contributory factors, such as the faulty scales and the result also being overlooked by the nursing staff, so lessons could be learned for the wider team.

For his part, it was essential that the doctor produced a statement detailing his involvement while his memory was still fresh. The GMC expects doctors to contribute to patient safety inquiries, and not doing so was more likely to cause problems for the doctor than any errors he might have made. The adviser explained how the doctor should approach writing his statement and offered to review it once he had finished. He also suggested that the doctor discuss the incident with his educational supervisor and document his reflections on the incident and the learning points he had taken from it in his training log.

The adviser also asked about the foundation doctor’s wellbeing, as he was struggling to control his emotions during the call. They listened to him as he spoke about the impact the investigation was having on his mental health and encouraged him to seek professional help. His educational supervisor could provide support and he might also reach out to his GP.

The adviser explained that it was important for the doctor to act promptly, as suffering in silence was affecting his performance and was making things worse. If he felt unfit to continue working at the time, he should discuss this with his educational supervisor and GP. The adviser also emailed the doctor a link to the relevant resource page on the MDU’s website signposting the different sources of mental health support available to doctors.

The outcome

After being encouraged to express his concerns on the advice line, the foundation doctor found it easier to confide in his educational supervisor. They arranged for him to receive additional support during his shifts and arranged for him to see a local mental health support service, where he was able to obtain therapy for his panic attacks and anxiety.

With assistance from the MDU, the foundation doctor wrote his statement for the trust. The investigation report acknowledged that the overlooked high test result should have also been flagged to the clinical staff by the laboratory, and recommendations were to made update training for the doctors and ward staff on the trust’s gentamicin monitoring protocol.

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