Case study: No reply

BACKGROUND

Ms G is a 58-year-old type 2 diabetic who takes insulin. She suffers from chronic angina and is on statin treatment for high cholesterol. She has missed her last three annual diabetic reviews at hospital and has recently been discharged from the clinic. Her general practice has written to her on numerous occasions inviting her in for review and her GP – Dr W – has attempted unsuccessfully to phone the patient to discuss the importance of regular monitoring of her health.

Ms G attends the surgery in regard to a throat infection and Dr W takes the opportunity to discuss the need for her to attend regular reviews – including screening for diabetic retinopathy and foot checks. He arranges for bloods to be taken and again refers Ms G to the diabetic outpatient clinic.

A few days later the practice nurse informs Dr W that Ms G has failed to turn up to have her bloods taken. Efforts are again made to contact her including messages left on her prescriptions via the chemist. The practice then later receives notice that Ms G has missed another appointment at the diabetic clinic. Dr W contacts MDDUS for advice in regard to wording on a further letter to the patient.

ANALYSIS/OUTCOME

A medico-legal adviser responds in writing advising Dr W that care of the patient should remain his paramount objective but also pointing out that the NHS Constitution and Patient Charter state that patients must engage with healthcare professionals and take an active part in their own wellbeing. Patients have rights but also responsibilities.

GMC guidance on Good medical practice and Good practice in prescribing and managing medicines and devices both state that doctors must ensure that suitable arrangements are in place for monitoring, follow-up and review of conditions and medication, taking into account the patient’s needs and any risks arising from their conditions or prescriptions. The GMC expects that doctors make all reasonable efforts to encourage patients to attend for reviews and such attempts must be documented within the medical records.

It is apparent that the practice has been proactive in continuing to engage with Ms G and has made significant attempts to inform her of the importance of concordance and monitoring. All adults are presumed to have capacity unless demonstrated otherwise and, as such, a competent patient is entitled to make an autonomous decision, which may involve not wishing to engage with certain aspects of their care. In the end the practice can only take proportionate steps to encourage engagement.

Dr W drafts a letter to Ms G, which the MDDUS adviser reviews. In it he explains his professional obligation to provide safe ongoing care and his responsibility to prescribe medications only when satisfied that they serve a patient’s needs and can be monitored. He further points out that the NHS Patient Charter reminds patients of their responsibilities to engage with their healthcare providers and take an active part in their own wellbeing. He reaffirms the practice’s commitment to Ms G’s ongoing care but requests her engagement to ensure that she is given appropriate and safe medical treatment.

The MDDUS adviser suggests that the letter could be hand-delivered or sent by registered post.

KEY POINTS

• Adult patients with capacity can choose not to engage with some or all aspects of their medical care.
• Ensure that reasonable attempts are made to inform non-compliant patients of the importance of monitoring the treatment of chronic conditions.
• Record all attempts to contact non-compliant patients to avoid complaints or claims of negligence.