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Complaint about your care of another GP's patient

Dr Steve Brown stresses the need to make a clear record when visiting another practice's patient out of hours

Dr Steve Brown stresses the need to make a clear record when visiting another practice's patient out of hours

Case history

You are asked by the triage nurse from your newly formed out-of-hours centre to visit John Poulter, 72, who has developed hip pain after bending to pick up his keys. She tells you he had a total hip replacement some years before and it regularly dislocates.

Mr Poulter does not want to go to hospital and has insisted on a visit.

What are my immediate thoughts?

I would feel slightly set up by having to see somebody who may well need to be sent to hospital for an X-ray. I would also be aware there are potential problems seeing patients from other practices who you don't know, and whose out-of-hours request has been dealt with initially by another professional. I would like to know more about the exact way the pain developed and whether it was similar to previous episodes. I would be concerned about the possibility of a stressed, anxious or potentially complaining patient.

I decided to minimise confrontation by visiting. How did I go about it?

I introduced myself to the patient and his carer. I had not expected somebody else to be present and I felt slightly vulnerable, so I had to tell myself to keep calm and think clearly even though the shift was a busy one.

I took a history, in particular finding out about previous episodes, the current symptoms and his past medical history. The carer told me in coded language that Mr Poulter had some memory problems. I found out the pain this time was not as severe as the last episode six months before.

On examination there was no leg-length discrepancy and no rotational deformity, but slight tenderness over the greater trochanter. I felt the prosthesis was not dislocated and Mr Poulter was able to walk a few steps, in minor discomfort with his frame.

I explained that in my opinion the hip was not dislocated and prescribed some analgesics. I explained to Mr Poulter and the carer that if the pain worsened or there was difficulty walking he would need to go to hospital for an X-ray. I recorded my findings and advice on the call sheet.

Two months later you receive a letter from Mr Poulter's brother who states that four hours after you visited he needed admission to reduce a dislocated hip and he feels he should have been admitted when you saw him.

Initially on reading the letter I felt anxious, but I was able to write a reply after reading my records, talking to my defence organisation and to the PCT manager. In the letter I stated that in my opinion the hip was not dislocated at the time I saw Mr Poulter and that I had left careful instructions with both Mr Poulter and his carer in the event of a deterioration of his condition. I obviously stated that I was sorry for any suffering that Mr Poulter experienced.

What factors are particularly relevant in this case?

  • Triage by another professional of a patient you do not know
  • Insistence on a visit, but not wanting admission
  • Possible dementia, making history-taking more difficult
  • How to make the patient and carer understand your instructions for what to do in the case of deterioration
  • Complaints made after the event, by somebody who was not present at the time
  • The need to make clear records
  • Should I have rung back?
  • Did I feel pressured by the patient?

How common is a dislocation of a hip prosthesis?

About 3 per cent of all hip replacements will dislocate, mostly in the first three months. This figure rises to 16 per cent for revision replacements. Factors include poor surgical positioning of femoral or acetabular components, weak hip abductor muscles, pre-existing neurological disease or avulsion/non union of the greater trochanter.

Late dislocations (10 years or more after initial surgery) are usually caused by wear of the prosthesis. A dislocation may occur if the hip is flexed to more than 90° (as in Mr Poulter's case) or if the legs are crossed. The management involves analgesia, X-rays to confirm the diagnosis (74 per cent are posterior dislocations), reduction under sedation or general anaesthetic, traction and bedrest in abduction for up to 12 weeks.

The outcome

The brother did not take further action after the PCT manager wrote a supportive letter.

Steve Brown is a GP trainer in Beaconsfield, Buckinghamshire

Key points

  • Don't be afraid to repeat the history taking if you need more information
  • Don't be afraid to admit a patient even if you know they are not keen
  • Use relatives/carers positively to help patient to understand management
  • Make instructions clear about when further action is needed
  • It should not be too difficult to reply to a letter of complaint when your management was correct and good records were kept ­ think of it as a challenge!

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