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Train driver on tricyclic refuses to inform employer. What should I do?

Three experts advise

You warn a train driver on amitriptyline that he must ask his employer whether he should be put on alternative duties. But at follow-up, it’s clear that he has not done this. How do you proceed?

 

Dr Justine Hall

Dr Justine Hall

Dr Justine Hall: Seek advice before disclosing confidential information

This is a difficult situation. There are no hard and fast rules about driving a train or any vehicle on amitriptyline, but it is known to cause sedating side-effects and the patient information leaflet carries this warning.

If you know that the patient is experiencing sedating side-effects from a medication and that his occupation involves driving or operating machinery that could put himself or others at risk, this would be a case for seeking advice from your defence organisation. First, though, you should reiterate to the patient his responsibility to inform his employer and tell him that if does not, you will be obliged to consider doing this on his behalf.

Recent tragic events in Croydon, where a number of people lost their lives in a tram accident, highlight the danger when things go wrong on the public transport system, although the precise details are not known.

And following the Germanwings incident (a plane crash caused by the co-pilot), there have been more calls on doctors to disclose information about patients to employers if people might be put at risk.

It is always best to seek advice from your defence organisation before disclosing any confidential information, and disclosure should not be undertaken without solid grounds or justification.

Dr Justine Hall is a GP in Guildford, Surrey, and planned care clinical lead at NHS Guildford and Waverley CCG

 

Local Hero Dr Mohammed Saqib Anwar

Local Hero Dr Mohammed Saqib Anwar

Dr Mohammed Saqib Anwar: You should talk to the patient directly

As a doctor, your primary concern will always be the duty of care that you have towards the patient. Confidentiality, public interest and autonomy are all competing considerations in this scenario.

For me, it is imperative that you tackle this issue head on. You first need to ask the patient why he has not discussed the situation, as previously agreed, with their employer. Don’t make any assumptions. Then you can decide on a shared and workable plan.

That said, whatever the reasons, you should reiterate clearly the rationale behind your advice and document it meticulously in the notes. Remind the patient that it’s illegal to drive with drugs in the body that may impair driving.

You will also need to undertake a risk assessment of the potential public safety risks, given the patient’s occupation. This includes looking at the dose, frequency and side-effects of the medication and also exploring the possibility of an alternative, more appropriate prescription.

If after all of this a major public safety concern remains, I would seek the advice of your defence organisation to discuss breaking confidentiality and undertaking disclosure to the patient’s employer on the grounds of protecting others from risk of serious harm (GMC confidentially guidance).

Dr Mohammed Saqib Anwar is medical secretary of Leicester, Leicestershire and Rutland LMC and a GP in Oadby

 

dr edward farnan square

dr edward farnan square

The medicolegal view: Assess whether the driver poses a risk

How you proceed depends on whether the train driver remains symptomatic. If the amitriptyline has had the desired effect, the need to inform his employer may be less pressing. You will need to make a further assessment of his condition and the risk associated with it. This could include whether he has any drug-related side-effects such as blurred vision or drowsiness that could affect his ability to perform his job safely.

You have a duty of confidentiality to your patient, but the GMC recognises there may be situations where there is a public interest in breaching a confidentiality without the patient’s consent, for example if it would protect individuals or society from the risk of serious harm (2017 confidentiality guidance, paragraph 661).

If you feel that the patient poses a risk to his passengers, either because of his health or because of the medication, you should encourage him again to inform his employer. Explain in detail the reasons why you feel this is necessary. A pragmatic approach might be to suggest a self-referral to his occupational health department.

If the patient declines to do either, you may be able to justify breaching his confidence by telling his employers the minimum amount of information necessary. You should inform him in advance that you intend to do so, seeking his consent if possible, and should also inform him after you have done so, clearly recording the steps you have taken, and your reasons. This is similar to the steps taken when informing the DVLA about conditions that may affect a patient’s fitness to drive.

Dr Edward Farnan is a medicolegal adviser at the Medical Defence Union

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Readers' comments (5)

  • Cobblers

    I have read some rubbish in my time but most of this article firmly comes under that category.

    It is an offence under section 27 of the Transport and Works Act 1992
    (2) for employees to carry out, and for employers to allow employees to carry out, safety critical work while under the influence of drugs or alcohol.

    The driver will know this. He will have been told many times. It worries me that this chap is not going to tell his employers. It is true that Occupational Health may well give him alternate duties whilst he is on the drug and require him reassessed before he resumes his train driving. Small price to pay.

    So he needs to be told to talk to his employers immediately. You need to document everything. Then talk to your MDO after this. After an agreed timeframe approach the employers and inform them there may be a safety critical problem with the employee. They will do the rest.

    Before you demur against the above let’s take this from another angle.

    The 1035am express to Euston runs up the back of the 1025am freight. 52 people are killed. The driver survives. At the inquiry it is found that the driver of the 1035am had fallen asleep.

    Just how much ordure would land on your head?

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  • This is what happened in real life with a tram rather than a train. 7 people were killed on a route where drivers were allegedly 'falling asleep'. Medical regulation in the UK has got its priorities mixed up. http://www.bbc.co.uk/news/uk-england-london-39457148

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  • err, stop prescribing the amitriptyline. Job done. Otherwise, report yourself to the GMC for working so hard that you've lost the plot.

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  • Cobblers

    copernicus if he comes off his amitrip and his depression or chronic pain worsens then he is not safe under the same safety critical work rules.

    Just sayin' :-)

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  • What to do? Retire, locum or emigrate. And cancel the BMA membership until the leadership starts representing the interest's of doctors and not the NHS.

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