Dr Richard Innes, Consultant in Intensive Care in Taunton and ICS Council member, discusses our duty of Candor
Consider the following hypothetical scenario. A patient is admitted with a blood clot on the brain. A neurologist saw the patient at 6 pm and decided that urgent anticoagulation with heparin was required. This was started at 7 pm with an APTT ratio needed at around 1 am to check therapeutic levels.
The junior doctor who took the blood sample found it difficult as the patient was obese and agitated. Eventually a sample was obtained and sent to the lab. The doctor was very busy and didn’t check the result until 3am, only to find that the lab had not processed it as there was insufficient blood in the bottle. Repeating the sample would be a time consuming task. An attempt to re-take the blood at 6 am failed; repeating it was left to the day time doctors who started ward work at around 9 am.
On the morning ward round the consultant noted the absence of an APTT test and arranged for it to be expedited. At midday the result was reviewed and showed that the heparin was grossly sub therapeutic. Unfortunately the patient had developed a dense stroke overnight and the neurologist felt this could be because he was inadequately anticoagulated.
The consultant had 3 options:
To take the junior doctor aside and remind them of the importance of prioritising their work and asking for help if they were busy.
To ignore it.
To complete a serious untoward incident report as a major clinical complication may have occurred following the delay in the test.
What would you do?
Under the duty of candor we must tell patients and family when things have gone wrong. This is no bad thing but it has implications.
We see more patients who have experienced problems as a result of clinical errors in ICU than most other areas. The errors generally do not occur on ICU; though they can. Often the colleague implicated is a medical trainee or other health care professional. We know from the literature that maybe 5-10% of patients die following sub optimal care, and many of these patients will end their days on ICU.
According to the lawyers, and I know this as I asked an experienced clinical negligence lawyer to review the scenario, the junior doctor here was negligent.
The hospital will naturally support its staff if they make a mistake – to err is human after all.
But as an ICU consultant I see lots of errors and, with the duty of candor, I must, in theory, incident report them and tell the families and patients. This exposes other staff, often hard working, excellent junior docs, to the risk of a clinical negligence claim, or worse if the patient or their family takes a dislike to the particular health care professional involved. Junior doctors aren’t trained to cope with this, and there aren’t the systems they deserve to support them through such events.
However we must learn from errors.
In this case by reporting, investigating and modifying practice, we might avoid the use of heparin for anticoagulation; it’s difficult to monitor safely after all. Using a low molecular weight heparin, adjusted for patient weight, doesn’t necessitate blood levels.
Now let’s change the story a bit. Imagine this patient didn’t just develop a stroke but died. The junior doctor may not only be negligent but grossly negligent! So now, if you incident report this case, you may be exposing a trainee to very serious, potentially criminal, charges.
In my opinion the current system for duty of candor does not adequately protect the health care professionals implicated and is unfit for purpose.
If we want to learn from mistakes we need a system that doesn’t lay blame at an individual trying their best in difficult circumstances, and often with previously blameless professional careers. I didn’t have this hanging over me when I was training and I think it is grossly unfair to expect my successors to be so exposed.
Dr Richard Innes