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CAMHS won't see you now

More pointless than a dead parrot

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I had just had a lengthy conversation with an experienced staff nurse working in a busy nursing home. It was the middle of the night. The patient had fallen, was now back in bed, and the staff wanted to give her some paracetamol.

Which organisation is responsible for making nurses believe they are unable to recognise a dead patient? 

'Before you do that,' I asked the nurse, 'are you sure the patient is alive? I mean, can you verify that?'

'Well of course I can,' shot back the nurse, 'she’s obviously alive as she’s talking to me'.

I was immediately relieved, but at the same time slightly confused. This was the same nurse, who only a week previously, had been unable to verify that a patient (who was expected to die) was dead. When I left medical school all patients were either alive, or dead. Excepting some debate over brain stem death which we can probably overlook in a primary care setting, there was no half way house, but this may have changed of course with medical advances being what they are. Do you find it strange that some nurses are unable to verify an expected death, which by extension means that they could be treating patients who could actually be deceased, or not necessarily alive?

Each time I get asked to verify a death by a nurse, usually in the out-of-hours setting, a small part of me fades away. Which organisation is actually responsible for making nurses really believe that they are unable to recognise a dead patient? It truly is a bit Monty Pythonesque - except it relates to humans and not parrots.

'I haven’t got a certificate,' is the usual response from nursing colleagues when I ask what prevents them from verifying a death. Well apart from my cycling proficiency badge neither have I that I can lay my hands on, but it is great that the BMA actually have some guidance on this issue.

This states that there is no legal obligation for a GP to attend a deceased patient (unless the death is unexpected). Also, the patient can be declared dead by a relative, member of staff in a nursing home, ambulance personnel or the police according to the guidance. It stops short of recommending the cleaner, postman, or refuse collector but I suspect if they were available they could be called on if necessary. In one of our nursing homes a patient actually has a pet parrot who talks, so it would be great to get its opinion and open up all sorts of possibilities for a Monty Python rerun.

I’ve no doubt that in the over-regulated world that surrounds medical practice now, we will soon all be attending death verification courses, or being asked to prove that we have verified at least five deaths this year (maybe six, or even seven depending which number is plucked by the master of 'it seems a good idea but there is no evidence'-based protocols at NHS England).

So, as you reflect on each of your morning consultations before diligently adding it to your appraisal folder, remember to ask the all important question: that last patient was alive wasn’t he?

Richard Cook is a GP partner in Hurstpierpoint, West Sussex. You can follow him on Twitter @drmoderate

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Readers' comments (17)

  • What's the fuss. Get the GP to "just pop out", sorted!
    We forgot for a second we are the landfill for the uk. Dump all your s*&^ on us, be sure to only pay for a little bit of our work though.

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  • Goodness Sake ! GPs, Stop being so paranoid !
    It is surely very obvious that the nurse has been INSTRUCTED by the Nursing Home owners, probably at the risk of losing her job, that she MUST call a doctor to confirm death, whatever the hour !
    Sort it out with the Home owners ! OR politely decline as your colleagues suggest, till surgery opens in the morning !
    What exactly does one get paid for 'on call', being 'on call' or only the call outs ?

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  • Absolutely brilliant Richard! We are working on it! Love your column. Keep it up!

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  • @Mark Howson | GP Partner17 Sep 2016 9:42am

    Pharmacies in England don't have a contract as such to supply short term medicine to those who run out, but are permitted to make an emergency supply. The snag is that this is non-NHS and patients have to pay for their meds which often they won't or can't afford to do so. Hence the OOH doc gets asked for a script.

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  • Dear Anonymous pharmacist, 10.01am.
    NHS patients do not HAVE to pay for an emergency supply ! It is entirely up to the pharmacist. If the patient is elderly, or not well & has overlooked asking for a repeat prescription of a drug which would be inadvisable to stop suddenly, then ANY sensible & compassionate pharmacist would supply a small free amount to a known patient whilst awaiting the prescription.
    HOWEVER, if the pharmacist is greedy or bloodyminded, of course they could refuse or charge !

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  • June Greaves | Other healthcare professional22 Sep 2016 12:01pm

    As you say it's entirely up to the pharmacist whether he charges or not, but the fact remains that this is a non-NHS activity and the pharmacist is entitled to charge for his services. Having been bitten a few times by patients who promise to return with a prescription and are then never seen again, my policy was to charge or advise the patient to obtain a script from the OOH doctor. The only exceptions being regular patients who were genuinely stuck and not trying it on.

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  • There is BMA guidance, but it is internally contradictory. It states:

    "f an “on-call” doctor is on duty, whether in or out of hours, it is unlikely that any useful purpose will be served by that doctor attending the nursing or residential home. In such cases we recommend that the GP advises the home to contact the undertaker if they wish the body to be removed and ensures that the GP with whom the patient was registered is notified as soon as practicable."

    But then, re expected deaths in care homes:

    "If the doctor who has been treating the patient is not immediately available, a colleague should attend and then ensure that the doctor of the deceased patient is informed of the death as soon as possible and arrangements are put in place for the issuing of the MCCD and relatives informed of these."

    What is the point of the "colleague" attending if they cannot write the MCCD?

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