Causes for concern quiz

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GPs have a duty to raise concerns but there may be times when you may need to balance your duty to protect confidentiality against your duty to protect patients and the public at large. Test your knowledge of this difficult ethical area with this quiz.

You are a GPST. During a check-up, a woman confides her fears about her daughter's new boyfriend. She tells you he has a short temper and her young grandson is afraid of him. She asks whether you had noticed any problems when her daughter attended the previous month and begs for advice. How do you respond?

A - Explain that you can't discuss the welfare of another patient and tell her that there is probably nothing to worry about. Her grandson probably resents having a rival for his mother's affection.

B - You know that children living with their natural mother and a boyfriend are at greater risk and you decide to report the matter to social services straight away. There is no time to lose so you do not seek advice or talk to the child's mother first.

C - After explaining to the grandmother that your duty of confidentiality prevents you from discussing another patient, you seek advice from your trainer because you are worried about what you have been told. With their agreement, you invite the daughter to visit the surgery. When she attends, you ask her about her situation and explain your concerns about her child. She eventually gives her reluctant consent for you to speak to the local designated person for child protection.

Correct answer: C

You have a duty to act on any concerns you have that a child may be at risk. The child's interests should take precedence over those of parents or carers. If a child is at risk or is suffering abuse or neglect, it will usually be in their best interests to disclose information.

The GMC's guidance Protecting children and young people: The responsibilities of all doctors, says that you would be justified in taking action, as long as your concerns are honestly held and reasonable and you take action through appropriate channels. You are not expected to investigate the concerns yourself; indeed this could be counterproductive.

Your duty of confidentiality means that you should usually ask for consent to share information unless there is a compelling reason not to do so, for example if it would put the child at further risk.

While providing locum cover, you are asked to attend a nearby NHS care home for adults with learning disabilities where several patients are suffering from gastroenteritis. During your visit you notice an unpleasant smell and discover that one of the patients is lying in her own excrement while patients in the communal areas appear listless and unkempt. When you speak to the manager, he does not seem shocked. Instead he tells you that his staff are very busy but they will get to the patient as soon as they can. What do you do?

A - Conclude that the staff are probably overstretched because of the outbreak of sickness and decide to ask one of the other practice GPs to visit later that week to check things are back on track.

B - You are upset by what you have seen and not satisfied by the manager's response. After discussing the matter with a colleague at the practice you decide to report your concerns about the lack of care directly to the Care Quality Commission (CQC) or the local equivalent. The CQC makes an unannounced inspection several days later and takes enforcement action.

C - You are so appalled by the neglect that you decide to research the home during your lunch break. When you discover a local campaign group has been calling for the home to be shut down, you contact the group's organisers and pass on your concerns.

Correct answer: B

If you believe that patients are not receiving the basic care to meet their needs, the GMC expects you to 'immediately tell someone who is in a position to act straight away'2. As you are not satisfied with the manager's response and there is an immediate risk to patients, you would be justified in contacting a body with the authority to investigate (which may be the CQC for practices in England, or the local equivalent).

Only consider making your concerns public if you have done all you can to raise the matter through the appropriate channels and have good reason to believe patients remain at risk. Before taking this step, the GMC says you should get advice from your medical defence organisation or one of the other organisations listed in Raising and acting on concerns about patient safety. You can also seek advice from the NHS and Social Care Whistleblowing Hotline on 08000 724 725 (open 8am until 6pm, Monday to Friday).

A long-standing patient has recently been diagnosed with Alzheimer's disease. When she attends for review you discover that she drove herself to the surgery. You are concerned about the risk she poses to other road users but you also know she lives alone and wants to remain independent as long as possible. What should you do?

A - Talk to the patient about your concerns and explain that she has a legal duty to inform the DVLA that she has a condition that might impair her ability to drive. When she refuses to accept this, you offer to arrange a second opinion but tell her that she should not drive in the interim and make a note of your advice. Warn her that if she does not inform the DVLA and continues to drive against your advice you will have to do so yourself.

B - You warn the patient that she might have to give up driving but because she is in the early stages of the disease, you decide she doesn't actually pose a risk. You have a quiet word with the patient's daughter who is also a patient and ask her to keep an eye on her mother.

C - You believe that the patient is a danger to others if she continues to drive and you inform the DVLA because you cannot trust her to do so.

Correct answer: A

It is for the DVLA, not a GP, to determine whether a person is medically unfit to drive but you do have a responsibility to warn the patient if their condition may affect their ability to drive. The GMC says that in these situations you should make every reasonable effort to persuade patients to stop driving, including discussing your concerns with family members, with the patient's agreement. If the patient continues to drive despite your advice you would be justified in informing the DVLA but you should try to tell them of your intentions and notify them in writing afterwards. You can disclose relevant medical details to the DVLA's medical advisers in confidence.

You may also find it helpful to review the following guidance: 

The MDU medico-legal advice line is available to answer any questions you may have about raising concerns.

Call 0800 716 646 between 9am-5pm Monday to Friday. For medico-legal emergencies, or urgent calls, the helpline is available 24 hours a day, 365 days a year.

Dr Emma Sedgwick is a director of Healthcare Performance Ltd, who run a number of workshops for the MDU, including effective patient and colleague communication and medical ethics and law. Find out more by visiting the learn and develop section of our site.

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This page was correct at publication on . 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.

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