Advice line dilemma - Concerns about monitoring

A GP had recently joined a practice. One of her first appointments was seeing a 14-year old boy who presented with oedema. He had recently suffered nephrotic syndrome and, following discharge, had been well for several weeks until the oedema returned. The GP found that, although his blood pressure was satisfactory, a urine dipstick test showed the presence of protein. There were letters from the consultant paediatrician in the notes indicating that the boy had been followed up for some time in the paediatric clinic and then discharged with a recommendation that he should have his blood pressure and urine tested every fortnight at the GP practice. That had not happened.

The GP made an urgent referral back to the consultant paediatrician. The GP was concerned that the recommended testing had not happened at the practice and she mentioned her concerns to a senior colleague. After some weeks nothing had happened, so she contacted us for advice.

Our advice

The GP has a duty to act if she believes patients are at risk because of inadequate policies or systems. Rather than simply telling her colleague what has happened, she should use the established practice procedures for reporting adverse incidents and near misses, in line with the GMC's guidance in Raising and acting on concerns about patient safety (2012) and the obligation set out in Good Medical Practice (2013) to "contribute to adverse event recognition" (paragraph 23b). She should also keep a record of her concerns, relevant conversations, correspondence and the action she has taken for future reference.

In the circumstances, the practice will probably hold a significant event audit to investigate why the patient had not been regularly tested in accordance with the recommendations by the consultant paediatrician.

Outcome

The GP spoke to the practice manager who asked her to complete a significant event incident form. The case was discussed at the next practice significant event audit meeting where it was decided that the system for reviewing hospital letters needed to be improved.  Following the practice's established significant event procedures, the incident was logged with the National Reporting and Learning Service.

Learning points

• If you have a concern about patient safety, it's your responsibility to raise this immediately using your practice's policy.
• Put your concerns in writing and record the steps you have taken to resolve them.
• Establish that appropriate action has been taken to investigate and act on your concerns. If you believe patients are still at risk, consider taking the matter further.
• Contact the freephone medico-legal advice line about escalating your concerns, on 0800 716 646. Our medico-legal team is available between 9am - 5pm Monday to Friday and is available for medico-legal emergencies or urgent queries 24 hours a day, 365 days a year.
• Other sources of help include the NHS whistleblowing helpline (08000 724 725), the GMC's confidential patient safety helpline (0161 923 6399), or the charity Public Concern at Work (020 7404 6609).