Warning letters are issued to patients when GP practice partners or the trust believe a patient's behaviour has been inappropriate and unacceptable. This can occur, for example, when a patient has used aggressive, obscene or threatening language, or when the patient has acted unacceptably.

Clinicians and staff members who come into contact with patients whose behaviour or language is abusive, intimidating or threatening should be protected from it happening again; a warning letter puts the patient on notice that such conduct will not be tolerated.

Inappropriate behaviour

In March 2017, NHS Protect updated its guidance on warning letters, but was disbanded shortly afterwards. Nevertheless, the guidance it initially provided in 'Unacceptable behaviour: Guidance on warning letters and other written communications' remains appropriate. 

Patients don't have to be physically threatening for a warning letter to be appropriate. Addressing a clinician or staff member in an abusive, threatening or offensive manner may be deemed a non-physical assault, which is defined by the NHS as 'the use of inappropriate words or behaviour causing distress and/or constituting harassment.' This can include (but is not limited to) the following, as defined by NHS Protect: 

• offensive language, verbal abuse, swearing
• unwanted or abusive remarks of a sexual nature
• racist, sexist, homophobic or other discriminatory remarks
• offensive gestures
• threats whether verbal or physical
• bullying or intimidating behaviour
• attempted assaults where contact is not made including spitting
• brandishing weapons or objects which could be used to inflict harm
• throwing a weapon or object and missing
• stalking or other forms of harassment.

This type of conduct is unacceptable and may be appropriately addressed by a warning letter. Physical assaults, however, are usually a matter that should be reported to police. These are defined in the NHS as 'The intentional application of force to the person of another without lawful justification, resulting in physical injury or personal discomfort.'

The definition would include not only physical contact made by the patient such as punching or kicking, but also contact with an object thrown by the patient or spitting where contact is made with a person or their clothing. Such encounters don't require someone to inflict a physical injury to constitute an assault. In general, the victims of these acts should report them to the police to consider appropriate action.

How to write a warning letter

Warning letters written to patients when their behaviour has been unacceptable should be detailed, complete, and clear, and include the following:

• the name and role of person sending letter (normally someone not involved in the events)
• a description of the incident
• any measures taken previously to address unacceptable behaviour
• an explanation of why the behaviour is inappropriate, including a description of the impact of the behaviour on staff, other patients and services
• an explanation of the consequences of repetition of the behaviour (which might include, for example, restricting the patient's entry or providing care at a different location, notification to the police or civil legal action if appropriate)
• a description of anyone else who will be informed of the behaviour or copied in to the warning letter
• ·notification as to whether the patient's clinical record will be marked and the events documented in the clinical record or those of other patients as appropriate (eg, partner or relatives)
• a date when the warning will be reviewed and/or any marking removed
• information as to how the decision can be challenged or a complaint made.

Records of unacceptable behaviour should be detailed and accurate, in case the decision to issue a warning letter or take further appropriate action is challenged. Incidents involving such behaviour should be documented in statements compiled as contemporaneously as possible by any staff members who were witnesses to the events.

For instance, phone calls in which the patient uses offensive or abusive language should be documented by staff members involved in the call, documenting if possible the exact words used by the patient. For letters or packages, envelopes should be retained and handled as little as possible in case a further forensic review is required. Abusive or threatening e-mails should be printed and inappropriate text messages transcribed and stored in the practice adverse events and/or complaints folder. 

Issuing a letter

In some instances, where the information about the patient's behaviour is not completely clear cut, it might help to seek the input of the person accused of inappropriate behaviour. The organisation can consider the seriousness and potential risk of the alleged behaviour, and determine whether interim measures would be appropriate until further information and a response from the patient are received. Any letter to this effect should emphasise that these measures are temporary and explain that they may be upheld or removed when the extra information comes through. 

When deciding whether to issue a warning letter, take into account the possibility that the behaviour may have resulted from or been exacerbated by a medical or mental health condition or a medication or treatment. Think about if the action being considered may adversely affect the patient's mental health.

If there is someone in the local trust or CCG responsible for ensuring security within the relevant organisation, they should be consulted on possible measures in response to inappropriate behaviour. For GP practices, NHS England may be able to provide further guidance in circumstances where warning letters are being considered.

If a patient has behaved in an inappropriate manner, the GP partners as data controllers should consider whether the incident should be documented in the patient's clinical record (and/or, if appropriate, those of family members or the patient's partner).

The GPs will also need to consider whether other staff members or an external body should be informed of the incident so they can conduct a risk assessment – again, if appropriate. If the practice decides that other organisations or individuals should be notified of a patient's behaviour, it should only share the minimum relevant information, and this must be done securely.

The decisions made by the GP partners about whether to issue a warning letter, mark the clinical record or inform others of the behaviour are subject to the complaints process. Moreover, the warning or any actions taken should be reviewed within a specified time period, normally between six and twelve months.

Consider the seriousness of the events and the possible risk posed by the patient when determining whether a warning remains in place while any complaint is being considered or any actions taken are reviewed. The patient should be informed in writing of the review's outcome and any further risk assessment that has been carried out, as should any other parties who have been notified of the patient's behaviour. Staff members who have been affected by or informed of the events must be kept updated about the decisions made and actions taken.

Dr Sissy Frank BA JD MD MRCGP

MDU medico-legal adviser

Dr Sissy Frank BA JD MD MRCGP

MDU medico-legal adviser

Sissy trained in law in the US graduating from Stanford University in 1990. She then changed careers and trained in medicine, obtaining an MD from Harvard Medical School in 1998 and completing her residency in paediatrics in 2001. She came to England in 2001 and completed further training in general practice, receiving her MRCGP in 2006. Before becoming a medico-legal adviser she worked as a GP partner in Kent.

See more by Dr Sissy Frank BA JD MD MRCGP