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: 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
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
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