The scene

A patient was seen by a GP registrar and issued with a prescription for an increased dose of medication. When the patient was running low on the medication, he requested a repeat prescription from the practice. At the pharmacy, he queried whether the dose was correct as he expected an increased dose. He was advised to return to the GP.

The patient returned to the practice where GP reception staff followed their usual procedure for repeat medication and explained there would be a 48 hour wait to collect the amended script. The patient demanded an amended prescription immediately, becoming angry and aggressive and threatening staff and the GP registrar. The patient later explained in court that, "If you treat me badly, you are going to get a reaction."

The police were called and spoke to the patient outside. After calming down, he returned to the surgery to collect an amended prescription.

Given the aggressive encounter, the practice took immediate steps, under their zero tolerance policy. The patient was removed from the list and assigned elsewhere under the special allocation scheme. The patient made a complaint about this to the practice and to NHS England. These were responded to, but the patient remained dissatisfied and brought a legal claim for discrimination.

The claim

The practice contacted the MDU after the patient brought a claim under the Equality Act 2010. It alleged the surgery treated him unfavourably because of his condition. The patient, who was now a claimant, alleged the practice discriminated against him indirectly by failing to make reasonable adjustments for his disability. He also alleged they put him at a disadvantage when compared to someone who did not share his characteristics. The claimant sought damages in the region of £40,000 and represented himself.

The MDU defended the case on the basis the practice did not discriminate, treating the claimant exactly as they would treat any other person acting as he had done and given their need to protect staff. The defence case was that removing the claimant from the practice list was proportionate and reasonable, given the intimidating behaviour exhibited.

The GP, practice manager and reception manager gave evidence. They described how they had felt intimidated and threatened. Both the GP and reception manager described physically shaking as a result of the incident and the reception manager considered leaving the job. The practice manager explained in court that seeing the distress caused to staff by the degree of aggression exhibited by the patient, the decision was taken to remove the patient from the list. This was only the second time the practice manager had taken this action during a 28-year career.

The outcome

Dismissing the claim, the judge found that the patient had behaved in an "aggressive and intimidating" way and that "others felt threatened by him."

The judge explained that he was unable to say whether the outburst was due to the claimant's disability, as they did not produce copies of medical records or provide an expert report.

Turning to the question of whether it was legitimate for the practice to remove the claimant from the list, the judge commented: "It seems to me that it is legitimate and necessary to protect frontline staff from abuse, especially where it reaches the level of putting them in fear."

The judge found that it was proportionate to remove the patient from the list and apply the practice's zero tolerance policy given the effect on the staff at the practice and other patients of the claimant's behaviour.

The judge commented: "I have been satisfied that this was confrontation at a different level from day-to-day rudeness to staff." The MDU was awarded legal costs, which is far from usual in such cases, and illustrates the strength of the defence case.

Prolonged action

However, this was not the end of the matter. The patient further pursued the case via the Court of Appeal and Supreme Court, even though the time to make these appeals had lapsed. This prolonged the case for many more months, causing the practice team further worry and distress. Eventually, the judges dismissed the applications to reopen the case.

Learning points

Removing a patient from the practice list is something that will rarely be necessary, but in extreme cases as intended by the zero tolerance policy, it can be done to protect practice staff. In this case, the patient was warned on joining the practice and during the incident in question of the practice's zero tolerance approach to unacceptable behaviour.

It's worth reviewing your procedures for dealing with challenging patients and ensuring staff training on this topic is regularly updated.

While GPs in England are covered by the clinical negligence scheme for general practice (CNSGP) for clinical negligence liabilities, which is overseen by NHS Resolution, Equality Act claims are excluded. This demonstrates the value of MDU membership, which can extend to assist members with such cases.

If you're an MDU member, we can offer you advice on dealing with abusive patients or help with complying with the Equality Act.

For more information on these issues, see our guides to removing patients from the list and dealing with challenging patients on our main website.