UKBA seeks information about a patient
A practice manager received a letter on Home Office headed paper from the UK Border agency (UKBA) which asked the practice to provide a patient's address, his mobile phone number, the date he first registered at the practice and when he was last seen. The attached form made clear that the request was made under Section 29 of the Data Protection Act 1998 and that failure to disclose this information might prejudice their investigation. The investigation was into offences under the Immigration and Asylum Act.
The practice manager was uncertain what to do and called the MDU advice line.
The medico-legal adviser explained that section 29 permits authorities to seek information for the purposes of detecting or prosecuting a crime, but it does not compel disclosure. If the practice were to disclose this information they would not be in breach of the Data Protection Act, but section 29 does not absolve the doctor of his ethical duty of confidentiality.
The GMC provides guidance on disclosure without patient consent. Such disclosure is appropriate if it is required by law, for example, in response to an applicable court order or if the case involves certain communicable diseases. Doctors may also disclose confidential patient information without consent if they judge this to be in the public interest. In order to decide whether disclosure might be in the public interest, you must weigh the harms (to individuals and society) of disclosure without consent, against the harms of not disclosing. Even when disclosing information in the public interest, you should usually inform the patient that you intend to make a disclosure.
The adviser confirmed that ultimately this was a decision for the practice and that a doctor should be involved in the decision as they would take overall responsibility. She recommended that the practice should explain to the UKBA that they had an additional duty of confidentiality to the patient and set out the circumstances in which they might be able to disclose without consent. GMC guidance states that disclosure in the public interest might be appropriate 'to assist in prevention, detection or prosecution of a serious crime, especially crimes against a person'. This information would allow the UKBA to provide more information about the alleged offences or to confirm that they would not object to the practice seeking the patient's consent for the disclosure.
A lesson in breaking bad news
A patient with known disseminated cancer was reviewed by her oncologist, who recognised a marked deterioration in her condition since her last appointment. The patient and her husband had known of the diagnosis for some months. From her knowledge of the extent of the disease and the recent deterioration, the doctor assessed that it would not be in the patient's best interests to arrange further invasive tests or treatment.
With little preamble, she explained this to the couple and told them that she was going to refer the patient to the palliative care team. The patient was obviously taken aback by the news and became tearful, but did not ask the consultant any questions about her decision.
Several weeks later the Trust received a complaint from the patient's husband.
Until she read the complaint, the consultant had been unaware of any problem. She was distressed to read that the patient had become severely withdrawn from the moment she had mentioned palliative care in the clinic. The couple had not used the contact they had for a cancer nurse specialist and the patient showed significant psychological deterioration by the time she was seen by the palliative care team.
The consultant sought multi-source feedback on her communication skills from colleagues in various professions and she was reassured by the generally positive responses. Even so, she accepted that on this occasion she had misjudged the situation and had failed to note the distress in her patient.
The consultant sought specific advice from a colleague in palliative care on how she might have improved her management of the case. She learnt that the palliative care service proactively arranges for a cancer nurse specialist to contact all patients on the day after they are given bad news and determined that in future she would do the same. The consultant offered a sincere apology to the family. She also gave an account of the learning points she had identified and the steps she had taken to improve her practice in the response to the family.
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Texting at the bedside?
A doctor called the MDU seeking advice on responding to a complaint to the Trust by the family of an elderly patient who later died. The complaint was wide-ranging, but one sentence referred to a young doctor in intensive care whom the son reported had been 'texting on his phone by the bedside, showing complete disrespect for my mother and the family'. The Trust asked the doctor to respond to this.
When the doctor reviewed the notes, he clearly remembered the case and realised what might have led to the family's complaint. When the patient was admitted to ITU from the Emergency Department, the doctor had been responsible for writing up her drug chart and intravenous fluids. She had been started on an inotrope infusion in the ED and he had checked the doses using an app on his phone. He had been aware of several distressed family members at the bedside. He did not introduce himself or discuss what he was doing but instead had tried to keep out of their way and be as unobtrusive as possible.
The adviser gave initial advice over the phone and the doctor emailed his draft response for review by a medico-legal adviser. The draft included a well-worded explanation of the doctor's part in the patient's care and explained what he had been doing with the phone. He apologised for failing to explain this and for giving an unfortunate unprofessional impression to the family. He went on to say that he had since made a point of introducing himself and, if he had to use his phone in front of them, explaining why to patients and family members to avoid any misunderstanding.
The doctor submitted his response to the trust and the complaint was readily resolved.