Dr Sarah Jarvis
Good safety netting practice is a key part of good communication skills between you and your patients, as Dr Sarah Jarvis explains.
Safety netting advice can protect both the patient and the doctor. It can help to ensure that a patient with unresolved or worsening symptoms knows when and how to access further advice, and is an important way of reducing clinical risk and the risk of receiving a complaint.
Communicating well with patients and providing them with appropriate advice is a key part of being a safe doctor. We may provide information many times a day to patients, whether it's verbally in consultations or by giving them written information, such as regarding post-operative care.
Why is safety netting important?
In general practice, doctors see a huge number of patients with symptoms which may or may not be a presentation of a serious underlying condition. Patients present at different stages of their illness and will have different thresholds for seeking medical advice. In particular, safety netting is important where a patient may have risk factors for a specific disease, or where specific complications are recognised as part of the illness or the treatment.
Safety netting involves ensuring that systems are in place to provide safe monitoring and follow-up, as well as the specific advice given to individual patients by the clinician.
However, poor documentation of the advice given can cause problems for medical professionals. For example, if a complaint is received several months after the clinical encounter, or a claim is received regarding the care given to a child many years previously, the doctor's actions may be scrutinised.
It is not unusual in these cases for the contemporaneous records to be the only version of events to which the doctor can refer, as they may have no memory of exactly what was discussed.
What does the GMC say?
In 'Good medical practice' (2013), paragraph 32 advises that, 'You must give patients the information they want or need to know in a way they can understand.' This means that you may need to make arrangements so that the patients' communication needs are met.
The advice also covers what should go in your clinical records. This includes relevant clinical findings, decisions made and actions agreed, who makes the decisions and agrees the actions, what information is given to patients, what drugs or treatment is prescribed, and who is making the record and when.
By checking the patient understands all the information you've given them, and by making sure your communications and records are as thorough and complete as possible, both parties are given the best possible chance of identifying and minimising any risks that might arise.
Consider these two contrasting approaches to safety netting.
Mr A had COPD and had smoked for many years. His GP saw him for 'worsening cough'. Mr A then presented six months later with weight loss and was subsequently diagnosed with untreatable lung cancer. The GP records were short and simply read, 'cough, no signs, likely exacerbation of COPD, for antibiotics and steroids, see as needed.'
His family complained to the GMC about the care provided by the GP. The GMC commissioned an expert report, which was critical that the GP had made very scant medical records and had not documented any safety netting advice in a patient with risk factors for lung cancer. The MDU assisted the GP and encouraged reflection and learning including record-keeping courses.
The member agreed that she should have documented a thorough history and documented the examination she had carried out. She agreed that she should have specifically advised the patient to return for a re-assessment if the symptoms were not settling.
The case was closed with a warning from the GMC, which will remain on the GP's GMC record for five years.
Mrs B had colonic adenomas and was on a surveillance colonoscopy programme. She defaulted the programme and the hospital informed the GP, who wrote to the patient but received no response.
The GP sent a further letter by recorded delivery (to prove it had been received at the registered address), explaining about the programme and why it was important, and asking the patient to come in. However, Mrs B still didn't attend. When the patient attended for other matters the GP proactively raised the issue of screening, and clearly documented the discussion and that the patient had the capacity to make a decision.
Sadly the patient died of a bowel cancer just two years later. The family made a complaint to NHSE but the clinical adviser advised in their report that the surgery and the GP had taken every practicable step to encourage attendance for screening, as well as advising of the symptoms of bowel cancer and when to re-attend. The complaint was not upheld.
These are fictional cases compiled from the MDU's files.
Top tips for safety-netting
- Be specific in the advice given - 'If x happens, please ring the surgery or out of hours provider immediately.'
- Provide a likely timescale for when you believe symptoms should have resolved - 'Your cough should clear up soon if it's due to the chest infection. If it's still there in two weeks, please book an emergency appointment to see me.'
- It can be helpful to book an appointment for follow up yourself. Telling a patient you'd like to book them in to review their progress in a couple of weeks is safer than just saying, 'book an appointment if it's not better.'
- Consider giving written information and patient leaflets to reinforce verbal advice.
- Document the specific advice, given rather than simply saying 'advice given'.
- Check that patients are aware of how to access advice if you're not available, such as by giving the number of the Out Of Hours provider.
- Bear in mind the need to re-assess if symptoms are not settling, or if there is no response to the treatment you have given. Be prepared to reconsider an earlier diagnosis.
Dr Sarah Jarvis
BSc MBBS MRCGP
Sarah Jarvis studied at St George's Hospital medical school, intercalating a BSc as part of her studies. After completing her GP training she became a GP principal, a position she held for 12 years alongside roles as a GP trainer, prescribing lead and child protection lead within her practice. Sarah also sat on (and later chaired) the GMC and MPTS fitness to practise panels for 10 years.
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