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CAMHS won't see you now

Significant event analysis causes upset in practice

Three GPs share their approach to a practice conundrum

Case history

You organise a whole-practice significant event analysis (SEA) exercise after a patient dies from myocardial infarction.

He had mentioned chest pains when he saw the nurse for a cholesterol check, and she suggested he made a doctor's appointment. He booked for the following week when his result would be back, but rang on the day asking if he could be seen before his booked appointment time. However, there were no free slots, and he eventually collapsed and died in reception that afternoon.

The analysis raises other questions about the practice's general management of coronary heart disease; several training needs are identified, and you conclude that the whole exercise has been very useful.

However, after the discussion, the nurse and receptionist concerned come to you separately in tears, saying they feel they were blamed for the man's death.

Dr Des Spence

'The priority is to reassure staff that the patient's death was not their fault'

If this SEA has resulted in staff feeling blamed and upset then this should be an SEA in itself. The key priority here is to support and reassure both nursing and reception staff that the patient's death was not their fault.

I would simply start by apologising on behalf of the practice that the SEA has upset them, as this is not the purpose of the exercise. More generally, I would explain that the problems raised by this event are problems for the practice and not individual staff. Also that the responsibility ultimately lies with the doctors and any 'blame' largely rests with them.

More directly, they should understand that medical intervention for myocardial infarction saves relatively few patients.

A different perspective also helps and I would ask them to consider the scenario where the patient had in fact been seen the previous week and referred for an exercise ECG. If the patient had died at home while waiting for it, how would they have felt? Don't dismiss the patient's death but 'uncertainty' is a core general practice theme as in life itself.

I would also do a little honest 'sharing' of 'mistakes' past and present of my own. These can be dark professional experiences but talking them through I have always found cathartic.

Most colleagues can relate to my diagnosis of constipation in a girl who delivered a concealed pregnancy in her bathroom three hours later. Mother and child were both well but the local newspaper enjoyed my misery.

Finally, I would thank them for being able to come to me to speak about their concerns and ask them to reflect on what we had discussed. I would informally meet both members of staff the next week. The practice would review the process by which it conducts SEA as a matter of urgency.

Things that I wouldn't do: to re-run the SEA with all the practice would merely serve to open more wounds. I would not suggest occupational health or counselling for the same reasons. The key in this situation is closure.

Des Spence is a full-time GP in Glasgow and a tutor in general practice at the University of Glasgow – he completed the VTS in 1995

Dr Jason Twinn

'We must deal with this properly now or pick up the pieces later'

The staff have either not been informed properly about the SEA process or have not grasped the concept of it being a blame-free way of looking at system failures. I can empathise with them as I have squirmed myself in similar scenarios where I have been involved with significant events, however blame-free the environment supposedly was.

Unfortunately no practice systems are robust enough never to need SEA at some point and none of us are infallible enough never to foresee where the cracks in the system are, nor be involved in the failures when they occur.

If we don't deal with the staff sensitively then we will probably end up with sickness and stress problems. It is important that they see we are not apportioning blame and that we have been in the same boat at some point in the past.

I would plan to sit down with them individually or both together and in the presence of the practice manager. The first thing to do would be to explore why they feel they are to blame and see if there have been any deficiencies in the SEA which have made them feel this way, or perhaps the other staff have been whispering behind their backs. If either of these is the case then they need addressing. The second would be to re-explain that the process is not about determining culpability and that if there is responsibility to be borne it is more upon my shoulders as employer and the responsible clinician.

If we deal with this properly and convincingly now then it can be limited to a storm in a tea cup, but if we don't we could be picking up the pieces for months to come

Jason Twinn completed the VTS in 2001 and is about to launch a career as a full-time locum in Scotland

Dr Jane Bowskill

'Further training in identifying serious illness would be helpful'

While this man's death was probably unavoidable and no one person was to blame, it does sound as though neither the nurse nor the receptionist picked up on the severity of his symptoms.

The patient may well, of course, have played down his symptoms. Chest pain mentioned in passing during a blood test should have been further investigated – a brief history taken by the nurse and the patient referred on to a doctor for assessment, regardless of how busy the practice was.

Staff need proper training in what should ring alarm bells, and if uncertain, should refer to the duty doctor.

Similarly, the receptionist should have been alerted by the fact that the man requested to be seen earlier. Was he asked what the problem was before being told he couldn't be seen? Staff will soon get to know which patients tend to panic, who always demands their child is seen as an emergency, and so on. It doesn't sound as though this man was in either of those categories.

Doctors have the duty of care towards patients, and we carry the can for omissions or errors made by our staff. It is essential therefore that they are given adequate training and not made to feel that they cannot interrupt the doctor if they are uncertain. An

e-mail message is an unobtrusive way of alerting the doctor, or a message can be delivered between patients.

I would try to reassure the nurse and receptionist that it might not have been possible to prevent this man's death, but that further training for both in identifying serious illness might be helpful and reassuring to both of them, and help restore their confidence.

Jane Bowskill is a part-time GP

in Kingston upon Thames and is

also a school doctor and does occupational medicine –she completed the VTS in 1985

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