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Selected Investigations Completed April - September 1999 > Part II, Case no. E.1125/98-99
Complaint against:
A GP in the Herefordshire Health Authority area
Complaint as put by Dr X
1. The account of the complaint provided by Dr X was that his wife, Mrs X, had a long-standing medical history of serious cardio-respiratory disease and panic attacks which were precipitated by stress. In October 1997 she was bed-bound with 'cold and flu-like' symptoms. On 5 November Mrs X telephoned her GP to request the administration of influenza vaccine at her home. The GP refused that request on the grounds that it was not practice policy to administer the vaccine in a home environment to patients with a history of severe allergy or to those who had been recently ill. Mrs X became distressed and put down the telephone. The next day, Dr X visited the GP at his surgery, and the GP informed him that both he and his wife were removed from the GP's list of NHS patients. As a result of that, and because there were no other GP practices in the area, Mrs X then had visits from unfamiliar GPs on a three-monthly rota system, which increased her distress.
2. On 15 January 1998 Dr X complained to Herefordshire Health Authority (the Health Authority) about his concerns. The GP responded to Dr X on 12 February. Further correspondence between Dr X and the GP failed to resolve the complaint to Dr X's satisfaction. On 11 May, Dr X wrote to the Health Authority's chief executive to request an independent review. On 24 August the Health Authority's convener refused that request. Dr X remained dissatisfied.
3. The matters investigated were that the GP:
(a) failed to provide an adequate explanation to Mrs X during the telephone conversation of 5 November 1997, about his refusal to administer influenza vaccine in the home; and
(b) unreasonably removed Mrs X from his list of NHS patients.
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Investigation
4. The statement of complaint for the investigation was issued on 28 October 1998. Comments were received from the GP, and relevant papers, including Mrs X's medical records, were examined. Two independent professional assessors, both GPs, were appointed to advise on the clinical aspects of the complaint; their report is reproduced in full as an annex to this report. One of the Ombudsman's investigators took evidence from Dr and Mrs X, the GP, the GP's receptionist and a manager at the Health Authority. The investigator was accompanied by one of the assessors at the interview with the GP.
Complaint (a): the GP failed to provide an adequate explanation to Mrs X during the telephone conversation of 5 November 1997
Medical records
5. On first seeing Mrs X on 29 October 1996, the GP noted in her medical records the following information about her past medical history:
'.... Asthma
1987 - Anaphylaxis [an abnormal response of the body to a foreign substance which may lead to profound shock and collapse]
6 x respiratory arrests due to multiple food allergies,
1 x cardiac arrest,
- Acute depressive illness with panic attacks ....'
Mrs X's medical record for 5 November states:
'[telephone call] 11.15 am requesting flu vaccination at home—has been in bed for a few days. Explained - not our policy to give 'flu' vaccination at home especially with her problems (and also unwell at present). Mrs X angry and told me to "go to hell"—then put the phone down.—Letter—requesting [patient] to change practice'
In Mrs X's medical records for 6 November the GP wrote:
'.... wants to change practice .... I explained that I would not be willing to give flu [vaccine] at home, especially if she was not well. I offered to see her at home if she was unwell but it was made clear that I would not be welcome.'
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Professional guidance
6. Guidance from the General Medical Council entitled Good Medical Practice, dated October 1995, includes:
'.... Successful relationships between doctors and patients depend on trust. To establish and maintain that trust you must:
.... give patients the information they ask for or need about their condition, its treatment and prognosis;
.... give information to patients in a way they can understand ....
'.... you have a special responsibility to make the relationship with your patients work. ....'
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Documentary evidence
7. The manufacturers information sheet for Inactivated Influenza Vaccine (Split Virion) BP, the vaccine that the GP would have administered to Mrs X, states:
'.... Do not administer to patients with acute respiratory or other active infections or illnesses ....'
Dr and Mrs X's evidence
8. Dr and Mrs X told the investigator that they registered with the GP's practice in 1996 following their retirement to the UK from the United States (US). Dr X had practised abroad as a physician for approximately 30 years and Mrs X was a retired nurse. They described the care which Mrs X had received in the US as 'outstanding' throughout her long history of chronic illness. Mrs X said that she normally led a relatively active life, but, unusually, she had been housebound for much of September and October 1997, suffering from 'breathlessness and gasping' which she attributed to her exposure to new allergens following their move to a rural area. Mrs X had not involved the GP in her care during that period because she and Dr X were well used to managing her symptoms with prescribed medication. However, she was anxious to have her annual influenza vaccine (the vaccine) because of her particular vulnerability to, and fear of, respiratory infections.
9. Mrs X said that on 5 November she telephoned the GP and asked him if she could have the vaccine at her home because her breathing had been poor for some weeks, and she did not feel well enough to attend his surgery. The GP told her that it was not the practice's policy to administer the vaccine in patients' homes. Mrs X repeatedly asked why, but the GP gave her no explanation. At one point she told him that her house was cleaner than the surgery because she thought that might have been the reason for the refusal. After about the fifth time of asking Mrs X became so angry and frustrated that she told the GP to 'go to hell' and abruptly replaced the receiver. She said that at no time during the telephone conversation, which had lasted three to five minutes, had the GP reassured her, referred to her temperature or allergies, or offered to visit her at home.
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10. Mrs X said that she did not understand the GP's refusal because her husband had administered the vaccine to her when they lived in the US, and it had been administered even when she was a hospital in-patient in the US. The previous year she had been required to go to the surgery, but the GP had administered the vaccine without any special precautions, and she had left his surgery within five minutes of receiving it. At the time of the telephone call she was feeling depressed, and her medication, prednisolone, (a drug which suppresses inflammation and allergy) caused her to be irritable. She said the GP was well aware of her medical history, and should have known about the adverse effect which prednisolone had on her. Mrs X said that in her experience as a qualified nurse and as a patient, explanations were very important. She felt that the GP had 'put her in her place'.
11. Dr X said that he arrived home during the telephone call and Mrs X was extremely distressed. He thought that there was a clash of medical cultures with the GP, and on this occasion the GP had taken the opportunity to 'exercise his power' over Mrs X's treatment. Dr X felt that in not offering adequate explanations, the GP had not been sensitive to Mrs X's particular needs and had breached the GMC guidelines for good medical practice. In a letter of 15 January 1998 to the Health Authority, Dr X said that the GP's insensitive treatment 'precipitated an acute anxiety attack within a few hours'.
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The GP's response to the statement of complaint
12. In his formal response of 10 November 1998 to the statement of complaint the GP wrote:
'.... I was telephoned by Mrs X who was requesting a "flu" vaccination at home because she was suffering from a viral upper respiratory infection and could not leave the home. I tried to explain that it was not our policy to give "flu" vaccinations to someone who was suffering from a viral infection nor was it our policy to give such a vaccination at home to somebody who has a history of severe anaphylactic reactions with respiratory arrests. Mrs X became very abusive, told me to "go to hell" and put the phone down. I saw Dr X the following day and reiterated my reasons for not visiting Mrs X at home to give her a "flu" vaccination, as detailed in my medical notes at the time.
'I am very sorry for any distress caused to Mrs X .... but I fully stand by my decision regarding the "flu" vaccination.
'Any explanation by me on 5 November 1997 was cut short by Mrs X herself.'
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The GP's evidence
13. The GP told the investigator that Dr and Mrs X had been on his list of NHS patients for approximately a year when the complaint was made. He was aware of Mrs X's medical history, but her health needs had not created any real demands on his services. Dr X had cared for his wife for many years, and he and Mrs X had not found it necessary to consult him during the weeks that Mrs X had been unwell prior to her telephone call on 5 November. He had never been asked to visit Mrs X at home, and he had not been consulted about, or made aware of, any panic attacks throughout the time he had known her.
14. On 5 November 1997 the GP received a telephone call from Mrs X. She said that she was unwell, that she could not attend the surgery and asked whether she could be given her annual influenza injection at home. The GP could not remember her exact words, but had no doubt that she described viral symptoms. The GP then told Mrs X that it was not his practice's policy to give the vaccine in a home environment. When she asked why, he explained that in view of her history of allergic reactions, it was better that the vaccine was given in the surgery and in any case she should not have the vaccine if she was feeling unwell. He did not say repeatedly that it was 'not policy', and she gave him no opportunity for further explanations because she put down the telephone abruptly. He could not recall how long the conversation lasted, but thought it was probably about a minute. He did not recall Mrs X asking whether the cleanliness of her house was the reason for his not giving the injection at home. She did not seem anxious, but he believed that she became angry because of his refusal. He also did not believe that he should have related Mrs X's behaviour to the effects of prednisolone; it was difficult to differentiate between anxiety and the general attitude of a patient. He had never had an easy relationship with Mrs X, and he related that to what he believed was a general antagonism towards the NHS.
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15. The GP said that he was unaware that Mrs X had not understood the reasons he gave for refusing to administer the vaccine. Given the opportunity, he would have provided any further explanations that Mrs X had required, but after being told to 'go to hell' he did not consider a return telephone call was appropriate. Also he did not consider that a home visit was necessary, because she had not telephoned primarily about being unwell. He judged that her request was not urgent, and that it was better to wait for an opportunity to provide the vaccine when her health had sufficiently improved. He could not recall the previous year when he had administered the vaccine to Mrs X at his surgery, but it was his usual practice to ask patients to wait for ten minutes following a vaccination. However, if the consultation period had been of sufficient length, he probably would not have asked her to wait.
The receptionist's evidence
16. The receptionist told the investigator that the practice was very friendly and it was unusual to receive complaints. She did not see Mrs X very often as Dr X tended to 'be in charge of' her care. However, on 5 November Mrs X telephoned just as the GP had finished his surgery. She transferred the call to the GP's office. As his door was open, she was aware that the call lasted about two minutes and that the GP's tone was polite, as usual. She had noticed that the GP always made a special effort to be polite to Dr and Mrs X, who were 'not easy people to deal with'. Following the call, she heard the GP remark to a locum GP (who was attached to the practice at the time) that Mrs X had 'slammed the phone down on him.' He then went to speak to his partner.
Findings (a)
17. The assessors are in no doubt that the GP's clinical decision not to administer the flu vaccine to Mrs X on 5 November was correct. The assessors note that the GP's decision was supported by the manufacturers information sheet (paragraph 7) and are also clear that patients with a history of multiple allergies should not be given immunisations at home. I agree with those views, even though I recognise that Dr and Mrs X's experience of health care in the US might be very different.
18. The Ombudsman's investigation has centred on whether the GP provided Mrs X with an adequate explanation of his decision not to immunise her. He says that during the telephone conversation he tried to explain the position to her about his practice's policy and also about why he thought she should not have the vaccine while she was unwell, let alone in her own home in view of her history of allergic reactions. Mrs X says that he offered her no explanations at all. The GP says the conversation lasted only a minute or so; Mrs X remembered it as lasting between three and five minutes. Whatever the length of the phone call, and whatever was said by both parties, it is clear that it was an unsatisfactory conversation, with Mrs X, by her own admission, becoming angry with what the GP was telling her, and abruptly putting the phone down. The question that remains is whether the GP should have then made efforts to re-establish contact with Mrs X to make sure she understood what he had told her. The assessors' conclusion is that he had done enough, it not being normal clinical practice to detail all the side effects, complications, or background to a course of action or inaction. I find no reason to disagree with that, or with their view that Dr X could have sought further explanations if he thought they were required, rather than, as recorded in the clinical records, telling the GP the following day that a home visit by him would not be welcome. I would add that I think it was reasonable for the GP not to consider a return call when the conversation had been curtailed rudely and so abruptly by Mrs X.
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19. The assessors have also addressed the issue of Mrs X's mood swings and her irritability on the day of the telephone call which could have been caused by the drug prednisolone which she was taking at the time. Although Mrs X thought the GP should have been aware of the adverse effect that prednisolone had on her, the assessors felt that it was unreasonable for the GP to have been expected to understand fully the reasons for her irritability during such a brief conversation, particularly as it centred on Mrs X's request for immunisation, rather than on her mental or physical condition. They also felt that Dr X, as a fellow professional, could have smoothed the situation by subsequently telephoning the GP to explain about his wife's irritability. Although I do not doubt that Mrs X felt let down by the GP, I agree with the assessors' conclusions. I do not uphold the complaint.
Complaint (b): the GP unreasonably removed Mrs X from his list of NHS patients
Professional guidance
20. The National Health Service (General Medical Services) Regulations 1992, Schedule 2, Terms of Service for doctors states:
'.... 9.-(1) A doctor may have any person removed from his list and shall notify the FHSA [Family Health Services Authority] in writing that he wishes to have a person removed from his list ....'
The Royal College of General Practitioners issued guidance in June 1997 on the removal of patients from GPs' lists. A section listing those situations in which GPs should not consider removal of a patient from a list includes:
'.... where there is an exacting or highly dependent patient ....'
Advice from the General Medical Services Committee (GMSC) (the elected representative body of general practitioners and a sub-committee of the British Medical Association) on the removal of patients from GPs' lists, issued in September 1996, includes:
'.... The removal of patients from GPs lists should .... be an exceptional and rare event .... In the vast majority of cases the sole criterion should be irretrievable breakdown of the doctor-patient relationship .... the decision .... should be considered carefully .... not made in the heat of the moment. It is worth considering alternatives such as transferring the patient's care to a partner .... or persuading the patient that it will be better for all concerned to go to another doctor outside the practice.'
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21. Dr and Mrs X told the investigator that in 1996 their first impression of the GP's practice was that his surgery was 'unkempt.' That made them feel uneasy about his general standards, but as long as the GP was prescribing Mrs X's medication, they were reasonably satisfied. After about two months, Dr and Mrs X began to feel that the relationship with the GP had deteriorated. Mrs X said that at one consultation the GP had expressed bias against US medicine, and she thought that was very unprofessional. Mrs X recalled an occasion when the GP had been 'stiff and angry' following the discovery of labelling errors on her medication, made by the surgery's dispensary. Following their discussion about the matter, she formed the impression that the GP did not like her to ask questions and that he resented her being knowledgeable about her treatment. She said his attitude did not inspire her confidence or trust.
22. On 6 November 1997, Dr X went to see the GP to discuss the telephone call of the previous day, and to obtain an explanation. The meeting lasted no more than five minutes and the GP, who Dr X described as hostile, told Dr X that he had already dictated a letter about the removal of Dr and Mrs X from his list. The reason he gave was that the doctor-patient relationship had broken down. Dr X asked whether the matter could be resolved amicably and the GP said it could not; Dr X felt he had no option but to accept that. The GP said he had discussed the matter with his partner. Dr X was given no opportunity to discuss the GP's decision to remove him and his wife, and there was no discussion about a transfer to his partner, the impact of the removal on Mrs X, or registration with another practice. Dr X thought he and Mrs X were immediately without GP cover.
23. Dr X said that in the absence of any other GP practice in the area, Mrs X was assigned subsequently by the Health Authority to GPs on a three-monthly rota system. However, the resentment of those GPs, who were compelled to care for Mrs X, further exacerbated her anxiety. Despite moving to Scotland in November 1998, and being assigned to a permanent GP, the whole experience had left Mrs X with a complete loss of confidence in UK medical practice.
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24. In a letter to this Office dated 14 September 1998 Dr X wrote:
'.... the final straw was the delisting .... In an area where no other practices exist .... acceptance by a GP is impossible .... If he says he could not have foreseen the effects of delisting .... he is incompetent.'
The GP's response to the statement of complaint
25. In his formal response of 10 November 1998 to the statement of complaint, the GP wrote:
'I agreed that under the circumstances I had come to the same conclusion, that the doctor/patient relationship had irretrievably broken down .... I afterwards wrote to Dr and Mrs X detailing my decision, which I had fully discussed with my partners. I sent a copy of this letter to the Health Authority but did not formally ask them to remove these patients from my list. .... I understood my duty to continue providing such medical cover but also accepted that Mrs X would not want to consult me.
'.... I acted properly in the long-term interests of the patient.
'The removal .... was a mutual decision as detailed in my records at the time.' (paragraph 5).
The GP's evidence
26. The GP said that his professional relationship with Dr and Mrs X had not been straightforward. However, as they were a 'medical family', he had 'bent over backwards' to maintain a good relationship. He had always tried to involve Mrs X in decisions about her care and treatment and to provide careful explanations. He had never given her cause to think she had no right to know about her treatment. He was aware, however, that Dr and Mrs X were experiencing a period of adjustment following their move to the UK and the change to an unfamiliar NHS system. For example, Mrs X had to accept that some drugs which were available in the US were not available in the UK. Also, they had to adjust to the GP's role in the referral system and had expressed dissatisfaction about referrals to other clinicians which the GP had made. The GP said that he had no bias against US practice, and certainly would not have given that impression to a fellow professional. He had not been angry with Mrs X about labelling errors which had been made on Mrs X's medication; on the contrary he was sorry that they had occurred. The GP had considered that Dr and Mrs X's concerns were about the NHS rather than any mistrust or lack of confidence in him personally.
27. The GP had not previously considered removing Dr and Mrs X from his list, but following the telephone call on 5 November he realised that 'something was seriously wrong' and that the future of their doctor-patient relationship had been jeopardised. After discussing the matter with his partner, he decided later that afternoon to draft a letter to ask them to change practices. He then decided not to send the letter, pending discussion with Dr X. On 6 November, Dr X visited the GP. The GP said that, although he felt 'defensive', he did not feel hostile towards Dr X, but he defended his decision not to administer the vaccine to Mrs X. When Dr X then suggested that he would 'sign a waiver' to accept full responsibility for administering the vaccine to Mrs X in the event of any adverse effect, the GP had serious concerns about the nature of the conversation. He again felt that the relationship was 'not right' and that he could no longer carry on caring for Dr and Mrs X. Dr X said that Mrs X wished to change doctors, and the GP agreed that that was the best thing to do. Dr X did not say 'anything conciliatory', or that he wished to resolve the situation or reach a compromise. The GP was mindful of his duty to his patient and offered to visit Mrs X, but Dr X said that he would not be welcome. There was no discussion of transfer to the GP's partner and the GP did not try to persuade Dr and Mrs X to stay with the practice, because he believed they wanted to be allocated elsewhere. The GP said that at no time was Mrs X without medical cover, but he had not thought to tell Dr X that he would continue to be responsible for their care until they found another GP.
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28. The GP said that he spoke to his partner again on 7 November. They agreed that it was not appropriate to transfer Mrs X's care to the partner because either GP might be called upon to care for her, depending on who was conducting a surgery or covering for emergencies. The GP felt that their transfer to another practice might provide them with an opportunity to develop a better doctor-patient relationship; that had been his experience when he had taken patients who had 'fallen out' with their previous GPs. In 25 years, he had previously removed only three other patients from his list. On this occasion he did not ask the Health Authority to remove Dr and Mrs X from his list; he informed them that he had asked Dr and Mrs X to find another GP. He was unaware that Dr and Mrs X would be assigned to a three-monthly GP rota, as he had never come across that system in referrals to his own practice.
29. On 7 November the GP wrote to Dr and Mrs X. The letter, copied to the Health Authority, included:
'There sadly appears to be a lack of agreement between us over your primary care and in view of this and your rudeness over the telephone I must ask you to change practices.'
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The Health Authority's evidence
30. One of the Health Authority's managers (the manager) told the investigator that following the GP's request that Dr and Mrs X should find another practice, Dr X approached another GP to whom they had both been temporarily assigned on their arrival in the UK. That GP declined to take them back on his list as they did not live within the practice's catchment area, and therefore Dr X informed the Health Authority that he was having difficulty in finding a GP. The manager then implemented the first stage in the Health Authority's 'official allocation' scheme (the 'voluntary route') and asked three GPs in the Ross-on-Wye area, if they would consider voluntarily accepting Dr X and Mrs X on to their lists. Each declined on the grounds that Dr and Mrs X lived outside their practice catchment areas. The Health Authority then implemented the second stage in the scheme (the 'formal route') in which they compelled the two nearest practices to care for Dr and Mrs X on a three-monthly rota basis. She said it was very unusual in Herefordshire to implement the scheme and, at the time she spoke to the investigator, there were only two patients in the whole of Herefordshire so assigned.
Findings (b)
31. Statutory regulations (paragraph 20) entitle a GP to remove a patient from his or her list of NHS patients. However, GMSC guidance says that this should be in exceptional circumstances only, normally after an irretrievable breakdown of the doctor-patient relationship. The decision should not be made in the heat of the moment and other options for the patient's care should be considered.
32. In their report, the assessors have concluded that the GP did not unreasonably remove Dr and Mrs X from his list. They cite the telephone conversation on 5 November and the meeting with Dr X the following day as evidence that the doctor-patient relationship had finally and irretrievably broken down, coupled with the fact that they believe the decision to move practices was not made by the GP alone but by Dr and Mrs X also. They also refer to the fact that Mrs X was not heavily dependent on her GP due to the role her husband had traditionally played in the management of her care. Although there are some differences in the accounts of the conversations that took place, I believe there is sufficient evidence to support the GP's view that the relationship, which had clearly been under strain for some time, had finally broken down. I agree with the assessors' conclusions.
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33. I have also considered whether the GP acted appropriately once he decided that transfer to another practice was the best way forward. The assessors have pointed to the fact that the GP spoke twice with his partner about Dr and Mrs Xs' future care and that two days elapsed after the telephone conversation before he wrote to the Health Authority. They believe his decision was not taken in the heat of the moment, and that in any event it was what Dr and Mrs X wanted. The GP decided that an internal transfer was not a practical proposition, and the assessors agree with that. I am satisfied that the GP did meet his obligation to consider as best he could arrangements for Dr and Mrs X's future care. It is true that he was not aware of the Health Authority's rota system, which the assessors have said was unfortunate, but having come to the view he did, I do not see what more he could have done. Indeed, he agreed to maintain caring for Mrs X until the family found another GP. However, he has admitted he did not tell Dr X that specifically, an omission which left Mrs X feeling unnecessarily anxious, believing as she did that she had no immediate GP cover. With that one proviso, I do not believe that the GP acted unreasonably during what was clearly, for both parties, an anxious and stressful time. I do not uphold the complaint.
Conclusion
34. I have set out my findings in paragraphs 17-19 and 31-33. The GP has asked me to convey through my report—as I do—his apologies for the shortcoming I have identified.
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Annex A to E.1125/98-99
Professional Assessors' Report
Professional Assessors:
The first assessor
Experience: 37 years in rural practice
Special interests: Care of the Elderly
The second assessor
Experience: 11 years in rural practice
Special interests: Adult medicine and Women's Health
Matters considered
That the GP:
(a) failed to provide an adequate explanation to Mrs X during the telephone conversation of 5 November 1997, about his refusal to administer influenza vaccine in the home; and
(b) that he unreasonably removed Mrs X from his list of NHS patients.
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Basis of Report
The following documents were made available to us by the Ombudsman's Office:-
Head of Complaint (a)
i) Copies of correspondence between Dr X and the Health Authority with letter from the Health Authority to the GP;
ii) Copies of correspondence between the GP and Dr X on behalf of Mrs X;
iii) Copies of medical records relating to Mrs X whilst a patient of the GP;
iv) Copies of medical records relating to Mrs X referring to medical condition treated whilst a resident in the United States of America;
v) Copies of hospital reports relating to out-patient consultations at a hospital attended by Mrs X;
vi) Interview notes—Dr and Mrs X—Friday 11 December 1998; and
vii) Interview notes—the GP—Tuesday 26 January 1999.
Head of Complaint (b)
i) Copy of letter from the GP to Dr and Mrs X informing them of removal from his NHS list;
ii) Copies of communication from Herefordshire Health Authority and another Health Authority to local practitioners relating to allocation of Dr and Mrs X as patients on a three-monthly term basis; and
iii) Copies of correspondence from practitioners to health authorities and consultant hospital staff relating to Mrs X.
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CONSIDERATION AND CONCLUSIONS
Head of Complaint (a)
1) The telephone contact on 5 November 1997 was initiated by Mrs X to ask for a flu vaccine at home on the grounds that she was unable to attend the surgery because of her medical condition. Mrs X claimed that the conversation was of three to five minutes duration and that having been denied her request she had been offered no explanation as to this decision other than it was not the policy of the practice to administer vaccine at a patient's home. She admitted to frustration and anger and that she had terminated the conversation abruptly.
2) The GP's evidence is that the telephone conversation lasted approximately one minute and that he had calmly informed Mrs X of the practice policy not to administer the vaccine in a home environment, particularly having regard to her previous history of allergy, and that at that time it was contra-indicated in view of her admitted clinical state. He denied that he had repeated his statement and said he was given no other opportunity of further explanation as the conversation was abruptly terminated by Mrs X.
3) In view of the fact that the GP was aware of Mrs X's emotionally labile background, would it have been reasonable for him to initiate further contact by telephone in order to establish definitively her precise state of health from her medically qualified husband? the GP could then have taken such an opportunity to expand his policy with regard to the administration of vaccine in a home environment. In our view his decision not to follow this course of action was reasonable in that the telephone conversation was curtailed so abruptly by Mrs X. Furthermore, he knew that her husband was medically qualified; her husband had expressed several times in the past that he had been responsible for treating his wife over the years, and had a further opinion been necessary on this particular occasion, her husband could have made a request in the normal way.
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4) We are persuaded that the explanation offered, as recorded in Mrs X's notes, was adequate. During a consultation it would not be normal practice in the UK to detail all the side effects, complications, or medical background of a course of action (or inaction). It would be, in some cases, sensible to offer a subsequent longer consultation to go through such details both verbally and/or in writing. Examples of such cases might be antenatal screening, drug treatment with common serious side-effects, and pertussis immunisation. A second category might be when talking with health care professionals. On this occasion we believe that the GP was not given an opportunity to do so as Mrs X terminated the conversation and the next day her husband made it clear (in the GP's notes) that a home visit to Mrs X from him would not be welcome.
5) Dr X's claim that prednisolone was responsible for irritability on the part of his wife is not wholly justified. Had these iatrogenically induced (induced by medical treatment) symptoms featured frequently over the years, the continuation of the drug would have been questioned.
6) It is true that some patients have mood swings when taking prednisolone, but it is also possible that Mrs X had mood swings as a reaction to her various medical problems. Regardless of their cause, it is unclear how the GP was expected to find out the reason for her irritability during the brief telephone conversation that occurred which centred on a discussion about the immunisation, not on Mrs X's mental state or her feeling unwell. Dr X, as a fellow professional, could have phoned back immediately after comforting his wife, to explain her irritability. The GP might then have taken an early opportunity to start conciliation.
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7) We agree that a patient with a history of multiple severe allergies which could lead to respiratory arrest should not be given any immunisations at home, whether ill or not. The GP knew this from his previous knowledge of the patient and would not have needed a long conversation to refuse home immunisation on these grounds. Mrs X did not request a home visit for her clinical condition.
8) We agree that the immunisation was contra-indicated for Mrs X on that day; the GP's decision is supported by the manufacturers information sheet. It is not reasonable for a GP to contact a national centre to seek clarification when a readily available data sheet indicates a clear course of action: in this case not to immunise Mrs X at home.
Head of Complaint (b)
9) The GP justified his decision to remove Dr and Mrs X from his NHS list because of a breakdown of the doctor-patient relationship. That decision was obviously fuelled by the telephone conversation with Mrs X and, no doubt, also by the statement made by Dr X that he and his wife would be willing to sign a waiver stating that they would take the risk of her reacting to the vaccination. The GP became convinced that, as a result of these recent events, he could no longer carry on caring for Dr and Mrs X. We feel that the GP's conclusion about this matter was not unreasonable. Furthermore, although the GP drafted a letter to the Health Authority on 5 November he did not send it until 7 November, after he had spoken twice to his partner and also to Dr X. The decision seems to have been taken in the cold light of day.
10) The GP also contends that the discontinuation of the doctor-patient relationship was mutual, while Dr X claims that the GP had initiated the subject of removal. We will never know exactly what was said on 6 November, but we note that Dr X accepted, albeit reluctantly, the GP's decision that the doctor-patient relationship had broken down. Although there are differences in the evidence, we believe that both Dr and Mrs X had reached the stage where they did not want the GP to attend Mrs X.
11) However, should the GP have discussed his decision with Mrs X herself? We have concluded that it was reasonable for him not to do so for three reasons. First, it was Mrs X who terminated the telephone conversation on 5 November, secondly the GP discussed the matter the day after the phone-call with Dr X, who being a doctor himself had managed much of his wife's previous care, and thirdly the medical records indicate that Dr and Mrs X wanted a change of practice.
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12) The GP has said that he did not discuss with Dr X the possibility of Dr and Mrs X transferring within the practice to his partner because he was of the view that they wanted to transfer to a different practice. He also thought it would be impractical. Dr X agrees that they did not discuss the matter. However, was a transfer within the practice a viable option? We have concluded that it was not. It is sometimes possible within large practices to effect a change of GP without the original GP being involved in future care. However, in small practices, as in this case, such flexibility is not possible.
13) The GP stated that he was unaware of the three months rotation policy operated by the Health Authority. That was unfortunate, but he clearly didn't think that being allocated to another practice would cause additional hardship to Dr and Mrs X. As mentioned above, Mrs X's own care had mainly been managed by her husband so she had not been heavily dependent on her GP; the necessity for visiting the practice surgery had been infrequent.
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