When patients miss appointments, it can be disruptive for both healthcare providers and other patients in need of care. But there are also medico-legal consequences to consider. Who assumes responsibility when a patient fails to attend an appointment - the doctor or the patient?

This is a particular concern for GPs, who are responsible for the overall care of patients, but can also be an issue for hospital doctors.

A competent adult patient is clearly responsible for ensuring their own attendance at an appointment, but doctors may also have responsibility in cases of non-attendance. For instance:

patients may not fully understand the need to attend an appointment.
patients may not understand how the appointment system works.
there may be other health and social problems which, although not immediately apparent, might contribute to a patient's failure to attend.

If any harm came to a patient who misses an appointment, and a claim is made, the doctor would need to demonstrate that:

their actions had not fallen short of those of a reasonable clinician
their approach was supported by a responsible, authoritative body of medical opinion practising in the same specialty.

A missed emergency appointment

If a patient who may be acutely unwell fails to attend an emergency appointment:

the practice or hospital should be able to demonstrate that all reasonable and timely steps were taken to investigate the circumstances and need for care.
these steps should be documented carefully in each individual case.

Failing to attend a screening appointment

Some patients fail to attend GP screening appointments, such as for cervical cancer screening, despite receiving reminders.

Practices need to be aware of local arrangements for contacting and following up with patients - for example, under the NHS Cervical Screening Programme.
There need to be clear procedures in place to follow up with patients who fail to attend such appointments.
Doctors should ensure that patients have been given adequate information to enable them to make an informed decision.
Document all steps taken to inform the patient of the importance of attending a screening.

Missing a chronic disease review

A patient with a chronic disease who fails to attend for review can present a dilemma for doctors responsible for their care, particularly when they require repeat prescriptions.

Respect a patient's decision to refuse an investigation or treatment, even if you consider the patient's decision to be wrong or irrational.
Explain any concerns clearly to the patient, as well as the possible consequences of their decision, and document your discussion in the patient's clinical records.

The GMC's guidance on good practice in prescribing medicines states that:

a doctor who prescribes for a patient takes responsibility for that prescription.
doctors should ensure that prescriptions are appropriate, responsible and in the patient's best interests.
arrangements for repeated prescriptions should include suitable provision for monitoring a patient's condition.

It's clear that a patient who fails to attend for follow-up makes it difficult to comply with the GMC's guidance. Doctors may find themselves balancing the need for monitoring and the risks associated with a failure to monitor, against the needs of the patient to receive medication.

You are therefore advised to consider patients on a case-by-case basis and review the steps taken to attempt to engage the patient in monitoring their condition.

It may be worth undertaking a review of the information that has been given to the patient, checking their contact details are correct, and ensuring that each patient has been given the information they need in a way they can understand.

Failing to attend a hospital appointment

Previous knowledge of a patient's circumstances, including the severity of their condition necessitating referral or follow-up, will need to be considered. For example, a patient failing to attend a hospital appointment arranged via a two-week wait for suspected cancer referral may require different action to a patient failing to attend a routine hospital appointment.
A patient's GP practice may be asked to follow up with the patient who misses an appointment.
GPs should have a system in place, such as a protocol, for dealing with failed hospital attendances. There may need to be different systems for children compared to adult patients, as a child's non-attendance at hospital appointments may indicate a child's welfare is at risk.
If a patient makes an informed decision not to attend a hospital appointment, with access to information presented in a way they can understand, it's unlikely that a GP would be criticised.

In summary

Ensure your practice or clinic has a clear, consistent protocol for making appointments and dealing with missed appointments. Make sure all clinical, reception and administrative staff are familiar with it.
Ensure your practice or clinic has a system for identifying patients who fail to attend for follow-up.
Inform all patients about the appointment system, how it operates and the potential consequences of missing appointments. You may want to include this in the practice/clinic information leaflet.
Where a patient continually misses appointments, it may be worth exploring whether there is an underlying problem - such as anxiety.
Provide patients with sufficient information about the need for a referral, including other options for treatment and investigation, to enable them to make a decision about whether to attend.
Keep patients' contact details up to date.
Maintain an adverse incident reporting system so that any mistakes or near misses can be analysed and lessons can be learned from them.
Keep clear records of steps taken to investigate missed appointments, and attempts made to inform the patient of the importance of attending.

Missed appointments

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