Full report

Case No. E.515/97-98

Treatment by deputising doctors and monitoring of a GP deputising service

Complaint as put by Mrs X

1. The account of the complaint provided by Mrs X was that on 22 June 1996 her husband was taken ill and was visited by a doctor (the first doctor), who was appointed by a deputising service used by Mr X's general practitioner (the GP) for out-of-hours calls. The first doctor did not complete a thorough examination, but diagnosed a kidney infection. Mrs X told him that her husband was allergic to penicillin. The first doctor gave Mr X a painkilling injection and a prescription for antibiotic tablets. Mr X took the first tablet the next morning but became ill. A leaflet supplied with the tablets said that they should not be taken by patients with kidney problems. Mrs X telephoned the deputising service about that, to be told by a different doctor (the second doctor) that Mr X's reaction was probably caused by the interaction of the injection and the tablets, that he should 'sleep it off', and then take another tablet. Within an hour of taking the second tablet Mr X began to vomit and collapsed. A third doctor from the deputising service visited, identified the tablets as penicillin, and expressed concern about the diagnosis made by the first doctor. Subsequent tests confirmed that Mr X did not have a kidney infection.

2. Mrs X complained to the GP on 11 July 1996 about the actions of the first doctor and the advice of the second doctor. The GP replied on 6 September, enclosing statements which he had received from the two doctors, but Mrs X remained dissatisfied. On 29 October she asked South Essex Health Authority's convener for an independent review (IR) of her complaint, but he declined, suggesting instead that Mrs X should attend a meeting at the surgery. On 16 May 1997 Mrs X wrote again to the convener informing him that she had met the GP, but that the deputising service had considered a meeting unnecessary as the first doctor no longer worked for them. She expressed her continued concern about the standard of doctors employed by the deputising service. The convener replied on 16 June, refusing an IR, and Mrs X remained dissatisfied.

3. The complaints investigated were:

• Against the deputising service and the GP
1. (a) that the treatment provided to Mr X by the deputising service on the GP's behalf was inadequate. In particular:
1. (i) the first doctor failed to assess Mr X's condition adequately and failed to provide appropriate treatment; and
2. (ii) the second doctor failed to assess Mr X's condition adequately; and
2. Against the GP and the Authority
3. (b) that they failed to take adequate steps to make sure that the deputising services were adequate and to take adequate appropriate action in response to Mrs X's concerns.

Investigation

4. The statement of complaint for the investigation was issued on 26 March 1998. It noted that I would need to examine the circumstances to decide whether part of the complaint concerned actions in respect of personnel matters, which are outside my jurisdiction. I obtained the comments of the Authority, the GP and the deputising service. Relevant papers were examined, and a tape-recording of some of the telephone conversations between Mrs X and medical staff at the deputising service was obtained. My staff took evidence from Mr and Mrs X, the GP, the first and second doctors, staff from the deputising service and the Authority, and the Authority's convener. I appointed two independent professional assessors to provide clinical advice; and their report is reproduced as an appendix.

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Complaints (a)(i) & (ii)
Inadequate treatment by first and second doctors

Evidence of Mr and Mrs X

5. Mr X said that he had suffered chronic back pain for some years. During the evening of 22 June 1996 the pain was worse than usual. Two years previously he had been treated for kidney stones. Mrs X telephoned the deputising service to ask a doctor to visit. When the first doctor arrived Mr X told him that the pain emanated from the lower right hand side of his back. Mr X recollected that the doctor took his temperature, and pressed the site of the pain with his hand while Mr X was in a sitting position. Mr X said that the doctor made no other examination or test. Both Mr and Mrs X recollected (when interviewed separately) that Mrs X told the first doctor that her husband was allergic to penicillin. The doctor gave an injection and wrote a prescription for Augmentin tablets. He left the syringe behind at the house. Mrs X collected the prescription the following morning and gave Mr X the first tablet. Shortly afterwards Mr X began to feel sick and giddy and he returned to bed. (Mrs X subsequently discovered that Augmentin is a penicillin-based drug.)

6. Mr X became more ill. Mrs X telephoned the deputising service again and spoke to the second doctor. (My staff played the tape recording of that conversation to Mrs X, who then agreed that her recollection of that conversation, as described in her complaint to me, had been mistaken. The tape showed that she had told the second doctor that Mr X was not allergic to penicillin. Consequently she withdrew her complaint against the second doctor.)

Statutory Terms of Service

7. The National Health Service (General Medical Services) Regulations,1992, Schedule 2, Terms of Service for doctors, states:

Documentary evidence

8. The notes completed by the first doctor upon examining Mr X comprised:

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Evidence of the first doctor

9. The first doctor said that the deputising service usually passed him details of several patients at a time, and he then prioritised them. From the details given he decided that Mr X's condition was neither serious nor urgent. He examined Mr X; his description of that examination matched that given by Mr and Mrs X. He did not check Mr X's pulse or blood pressure, or examine his abdomen. The history he took from Mr X included that he had had a kidney problem the previous year; the first doctor concluded that either the kidney problem had recurred or Mr X had sustained a back injury. The first doctor said that he decided to deal with both potential problems by giving an injection for the pain and prescribing an antibiotic for a potential kidney infection. He accepted that he had left the syringe at the house. He usually checked whether patients were allergic to penicillin, but he could not recall whether he had asked Mr X. The notes which he made at the time were not very full. He would usually have made more complete notes of an examination: he could only suggest that he must have been either busy or tired on this occasion; he was working a 12 hour overnight shift and had also been doing day-time locum work. The first doctor admitted that he sometimes concluded in advance that a call could be trivial and he had probably reached such a conclusion with Mr X. However he did not think that his treatment of Mr X was clinically inadequate, or that Mr X's subsequent symptoms were typical of an allergic reaction to penicillin.

The GP's evidence

10. The GP said that when he received Mrs X's letter of complaint he wrote to the deputising service asking for the comments of the doctors involved. He was satisfied with the second doctor's explanation. However he was concerned about the first doctor's actions, as he did not believe that he had conducted a sufficiently thorough examination.

Evidence of deputising service

11. The local medical director said that he had concluded that the first doctor's record of the consultation was insufficient to have diagnosed a kidney infection. He was surprised to learn that the first doctor had not checked Mr X's pulse and blood pressure, examined his abdomen, or carried out a'leg raise test'. He considered that the first doctor should have done all of those things.

Commissioner's assessors' comments

12. The assessors' report (reproduced in full in the appendix) includes:

Findings (a)(i)

13. From Mr and Mrs X's evidence, from the very limited amount the first doctor recorded about the visit, from what he has himself said, and from the advice of my assessors, I conclude that the first doctor's assessment of Mr X's condition was inadequate and his treatment inappropriate. Although he took some note of Mr X's past medical history, his examination was perfunctory and did not provide him with the information to make a confident diagnosis. On that basis, he could not have been confident of prescribing the appropriate treatment. He prescribed antibiotics without good evidence for their use. Furthermore, Mr X was allergic to the type of antibiotic prescribed, and Mrs X says that she had warned the first doctor of the allergy. The first doctor does not recall that. While I have not been able to resolve the conflict of evidence on that particular point, the first doctor's actions merit my criticism in several other regards, as described above.

14. The regulations governing the use of deputising services are clear. The responsibility for the actions of a deputy lies with a patient's GP, even though in reality he or she has no control over a judgement (or misjudgement) made by a deputy in treating a particular patient on a particular day. The wider role of the GP in monitoring the quality of deputising services is covered in the second part of this investigation. However, the deputising service which approves, appoints, and allocates deputies cannot completely wash its hands of responsibility for their actions: indeed in reality the deputising service has far more scope to influence them than has the patient's own GP. I therefore uphold the complaint against both the GP and thedeputising service.

Findings (a)(ii)

15. This part of the complaint was withdrawn.

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Complaint (b)

16. The arrangements for monitoring the standards of deputising services changed on 1 April 1997, after the events in this case. Before April 1997, under Department of Health circular HC(FP)(84)2, that responsibility rested with health authorities. It included:

17. From April 1997 GPs have been required to take all reasonable steps to satisfy themselves that deputising services they use provide services which are adequate and appropriate. That requirement was imposed by the National Health Service (General Medical Services) Amendment Regulations 1997. The primary role for monitoring standards of services then passed to GPs. Health authorities then took only a secondary role, with power to intervene through the GP if services were inadequate or inappropriate.

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Documentary evidence

18. On 18 September 1996 Mrs X's complaint about the first doctor was considered at a meeting of the deputising service's own Medical Advisory Committee. The minute of the meeting included:

19. Following a telephone conversation with one of the deputising service's managers, on 2 April 1997, an officer of the local Community Health Council noted:

• '.... [the deputising service] do not think there is anything to be gained by having a meeting. [The first doctor] has now left ....'

Evidence from the Authority

20. In his comments to me the Authority's chief executive wrote:

21. The chief executive said that before 1 April 1996 Essex Family Health Services Authority (a predecessor of his Authority) had been responsible for monitoring deputising services in the area. Its medical adviser had been a member of the panel which appointed deputising doctors, had taken an active role in monitoring aspects of deputising services' performance, and had also liaised with this deputising service in monitoring complaints. When the new Authority was formed on 1 April 1996 it had no specific post of medical adviser, though it had public health staff with a background in general practice. From April 1996 to April 1997 (when the primary responsibility passed to GPs—paragraph 17) his Authority had not monitored deputising services. They had not had a Deputising Services Sub-Committee, or a liaison officer. The issue of deputising services had not been a high priority compared to the other tasks facing the Authority. Furthermore, the Authority had been reasonably confident about the standards of this particular service: it employed a significant number of local GP principals and had a history of providing a good service. In addition, the service's local medical director was a respected local GP who was exacting about standards. The chief executive said that although the events which led to the complaint occurred at a time when the Authority was not monitoring the service, he did not believe that that had contributed to the events which were the subject of this complaint.

Evidence of the GP

22. The GP said that when he saw the responses from the deputising doctors to Mrs X's complaint, he wrote back to the deputising service to explain his dissatisfaction and to ask what would be done. At the same time (in September 1996) he sent copies of the correspondence to Mrs X informing her that if she was dissatisfied it was open to her to ask the Authority for an IR. He had felt satisfied when he heard that the first doctor had been dismissed. A meeting had been held within the practice to consider whether they should continue to use the deputising service. The GPs agreed that they were satisfied with the overall standard of the deputising service and that there was no reason to cease using them.

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Evidence of deputising service staff

23. The regional manager said that the service's local medical advisory committee (MAC) was responsible for approving applications from doctors who wished to work for the deputising service and for dealing with complaints. MAC membership included a representative of the Local Medical Committee (a representative body of all GPs in the area), and the deputising service's local medical director; and until April 1997 (while health authorities were responsible for monitoring deputising services) the MAC would have included a place for an Authority representative. Deputies were not strictly'employed' by the service; they were self-employed, but applications to act as deputies were approved (or not) by the service. The local medical director was responsible for considering complaints made about the clinical actions of deputies. If appropriate, he would refer complaints to the MAC. The first doctor had been approved by the service in March 1994, and left suddenly of his own choice in December 1996. A total of 16 complaints had been received about the first doctor, out of approximately 7,400 consultations that he had completed.

24. The local medical director said that he, together with the medical adviser of a predecessor body to the Authority, had interviewed the first doctor before he was approved. He had monitored the first doctor's performance for three months by examining consultation notes. He had been concerned about the brevity of his notes and his attitude, but not his clinical competence. He had raised his concerns with the first doctor and eventually decided that he was working too many hours and reduced the number of sessions offered to him.

25. When he referred Mrs X's complaint to the MAC they had decided to warn the first doctor about his attitude and also about leaving behind a hypodermic needle at Mr and Mrs X's home. He did not consider that the number of complaints against the first doctor was excessive, given the total number of consultations he had carried out. After leaving the deputising service the first doctor had applied to rejoin but the local medical director had refused to take him back. The first doctor then applied successfully to another branch of the deputising service in a different part of the country.

(ii) Consideration by convener

26. In her letter of 16 May 1997, requesting an IR, Mrs X wrote:

Statutes and guidance

27. Where a health authority's convener considers that a complaint concerns, wholly or partly, the exercise of clinical judgment by a GP he must consult a person whose name is on a list kept by the Secretary of State and nominated by the relevant local medical committee. This requirement is imposed by Article 22 (1) of the Secretary of State's Directions to health authorities on dealing with complaints about Family Health Services (FHS) practitioners.

28. Guidance by the NHS Executive on the implementation of the NHS complaints procedure, ('Listening ... Acting ... Improving') states that complaints and disciplinary procedures should be separated. Paragraph 4.27 includes:

Evidence

29. On 16 June 1997 the Authority's convener informed Mrs X that hehad decided not to convene an IR as:

30. The Authority's convener said that after taking advice from an independent lay chairman, he had concluded that there would be no value in convening a panel. He understood that the first doctor had been dismissed by the deputising service, though that had not in fact influenced his decision. He had thought that all practical action had been taken and nothing further would be achieved by a panel. He had not taken clinical advice as he did not consider that the complaint concerned clinical issues, but a breakdown in communication. In any event, if a complaint about diagnosis, treatment or care was serious enough to represent a potential breach of a doctor's Terms of Service—by failing to provide a reasonable standard of care—it would have been a disciplinary matter and thus outside the scope of the NHS complaints procedure, and his remit as convener.

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Findings (b)

31. Although I, and others, have criticised the actions of the first doctor that does not necessarily mean that the deputising service as a whole was inadequate. Its adequacy should have been monitored. From April 1996 to March 1997 that was the responsibility of the Authority. However, they made no effort to exercise that responsibility. While I recognise that it was a busy time for the Authority, I cannot condone such disregard of responsibility, and I criticise them for that. Although there is no evidence that it had a direct bearing on the failures in the first doctor's treatment of Mr X, that possibility cannot be ruled out. I note that one factor which the doctor felt might have affected his performance, and which the service later recognised as relevant, was the hours he was working. That was a point which should have been considered by the Authority (paragraph 16), and an apparent lack of interest by them was unlikely to lead to an improvement of standards. I uphold the complaint against the Authority that they failed to monitor the adequacy of the service.

32. I accept that the GP pursued the complaint appropriately, though he may have been misled (as were many of those involved) by the mistaken impression that the first doctor had been dismissed. After the event, he and his partners actively considered the adequacy of the service: even after the complaint they concluded that the service as a whole was adequate and that they should continue using it. In any event, only in April 1997 did the primary responsibility for monitoring the service pass to the GPs. I therefore do not uphold the complaint against the GP about monitoring the adequacy of the service or the response to the complaint.

33. The adequacy of the deputising service was not under investigation nor was their response to the complaint. However, I must say that I find it surprising that more action was not taken, given the pattern of complaints and concerns about the first doctor.

34. Mrs X sought an IR of her complaint, but her request was turned down by the convener. He has said that that was because he considered that nothing further could be achieved through convening a panel. Though he wrote at the time that the removal of the first doctor from deputising service list meant that practical action had been taken, making an IR unnecessary, he later told my staff that the merits of the request itself had been the deciding factor. He took no clinical advice in reaching his decision. Mrs X knew that the first doctor had left, but was still keen to have her concerns about the service aired. She was turned down and remained frustrated. I believe that the circumstances of that refusal were unreasonable: the complaint remained unresolved; and it is clear from the Directions on the NHS complaints procedure (paragraph 27) that clinical advice should have been taken. Furthermore, as this investigation has shown, contrary to what the convener said, it was possible—by obtaining the tape of the telephone call—to resolve the conflict between what Mrs X and the second doctor said about their telephone conversation. I uphold the complaint against the Authority with regard to the convener's handling of the request for an IR.

Conclusion

35. I have set out my findings in paragraphs 13-15 and 31-34. The deputising service, the GP and the Authority have asked me to convey through my report—as I do—their apologies to Mrs X for the shortcomings I have identified.

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Appendix to E.515/97-98

Report by external professional assessors

Matters considered

1. We have considered whether the actions of the first doctor were a reasonable exercise of clinical judgement or whether, by a different course of action Mr X would not have been given Augmentin (antibiotic) and might not have fallen ill thereby and whether some other outcome would have resulted.

Actions of the first doctor

2. The medical record from the deputising service for the disputed consultation is very limited. It states "Kidney problem .... [illegible] .... pain" and prescribes Zydol—a strong pain-killer and Augmentin—a penicillin-based antibiotic. There is no mention of any other history, physical sign or other feature. There is no record of blood pressure, temperature or pulse even though we are told by Mr and Mrs X that he took Mr X's temperature.

3. A letter from the first doctor to the deputising service's local medical director says that his examination was sufficient to diagnose a kidney infection but there is no record of what he did. His letter does not enlarge on this either.

4. His interview with the Commissioner's staff (paragraph 9) reveals that he did not perform an examination any more thorough than Mr and Mrs X claimed, and that he felt that that examination was adequate. He further said that he sometimes went to visits with preconceived ideas as to what he would find, especially if he considered that the calls were trivial.

5. The interviews with Mr and Mrs X (paragraph 5) indicate that no history was taken and that the only examination was of Mr X's back whilst he was sitting up. No other part of the body was examined.

6. We conclude that his examination was inadequate and perfunctory. The examination should have included Mr X's spine and abdomen as a minimum and many would have included appropriate neurological testing as well. He prescribed antibiotics without good evidence that he should have done so and gave an analgesic that would have been appropriate for someone with severe back pain, but not routinely used for someone with a kidney infection. He did not offer, as we believe he should have done, to visit again on request, particularly as he had just given a narcotic injection. He should have arranged for possible follow-up if that would have been indicated when Mr X awoke. He therefore did not demonstrate the knowledge or skill that an ordinary GP would have done in dealing with a visit to Mr X at that time.

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The deputising service's local medical director

7. At interview he told us that there had been 15 previous complaints about the first doctor and that he and others had tried to advise him that his attitude was brusque and rude and that his record keeping was poor. However, he said that no lessons seemed to have been learnt.

8. At interview, the local medical director agreed that the consultation—as agreed by Mr and Mrs X and the first doctor—had been inadequate, brusque and poorly recorded. In particular, there had been no recording of temperature, pulse or blood pressure and no full examination of the spine, limbs or abdomen. All of these would have been indicated from the diagnoses that the first doctor considered.

Assessors' comments:

9. We believe that the first doctor's performance fell outside that which the average GP would have regarded as acceptable. His performance was poor. Although his communication skills were also poor and his manner unprofessional, we do not think that the clinical issues can be ignored in this case.

Conclusions:

10. The first doctor showed a pattern of poor performance which must make it difficult for him to put himself in a position to make a diagnosis.

11. On this occasion we think his consultation was poor and fitted with the pattern of other complaints made to the deputising service about him.

Recommendations:

12. We recommend that the Commissioner should consider whether the first doctor's performance is poor enough to be considered by the GMC.

13. We recommend that the deputising service be asked to reconsider their policies on practitioners who receive significant numbers of complaints.