PCTs must review their processes around safeguarding - particularly for patients in their late teens - say Stephen Cox and John Holden

More than two million teenagers aged 16 and 17 live in Britain, and when they attend their GP surgeries alone they are managed as adults. If an allegation is later made that the GP acted or examined them inappropriately this can lead to huge problems.

When teenagers aged 16 and 17 attend their GP alone they are managed as adults

Although the GP has considered the patient to be an adult, following current NHS and General Medical Council regulation, any safeguarding investigation will regard the patient as a vulnerable child since they are not yet 18.

For the past 10 years, in our role as assessors, we have been involved in managing clinical underperformance cases across the North West of England. Last year a GP in the region was retrospectively accused of sexually assaulting a teenage girl. We believe the lessons from this have a much wider application, which includes the GMC, local authorities and the police.

Case summary

A 16 year old girl was seen alone by a senior GP as an emergency complaining of abdominal pain. The consultation involved an abdominal examination, the reason for which was very briefly, if at all, explained to the patient.

Ten days later the girl’s mother phoned the practice stating she was concerned about her daughter’s consultation and made serious allegations against the GP involved. She was referred to the primary care trust complaints team.

At the primary care trust, details were logged and a director immediately spoke to the mother, clarifying the sexual nature of the allegation. The medical director was informed and organised to visit the GP in question.

After making initial contact with the GP the medical director discovered that he was already aware of the allegation. The PCT’s legal representative advised contacting the police, who in turn advised initiating the local Safeguarding Children pathway.

The process by which suspension “without prejudice” would occur, and the likely course of events, including GMC notification, was explained to the GP, who agreed to cease all work. Acknowledging his vulnerability, he agreed that following established process was the best way of ensuring a timely resolution.

The GP was advised to contact his defence organisation and was immediately offered support from both a local GP whom he knew well, and from a local medical committee member. A neighbouring practice agreed to see the complainant’s family should they need medical care.

The PCT chair, chief executive and the GMC were informed, and financial support for locums to staff the practice in the GP’s absence was arranged. A serious untoward incident was notified, as is required of all PCTs. All involved were well aware of the need for maximum discretion and confidentiality.

The PCT was advised by the safeguarding team to defer investigation of the incident so as not to affect the evidence trail for an investigation that would occur through the safeguarding board, a group comprising the local authority, the police and the PCT

Three days later the GP was formally suspended without prejudice at a performers list meeting.

Wider implications

Medical records issues Unlike the records of a consultation with a child aged under 16, a 16 or 17 year old “adult” patient must give consent for information about their care to be shared. If they refuse then their records cannot be used to assist a parent to understand the context of the consultation and, for example, why an examination was undertaken. This may hamper the resolution or investigation of concerns.

In this case the consultation concerned a routine, non-intimate, abdominal examination so the records contained no reference to an intimate examination nor the offer or presence of a chaperone. The safeguarding review team expressed concerned about this and interpreted it as poor record keeping.

Locum costs The PCT contract with the practice requires the continued delivery of usual primary care services. Current regulation and advice regarding suspension without prejudice from a performers lists identifies a standardised financial support package for a GP of £979 per week. This is not enough to provide a full time locum, which often costs £4,000 per week. In this case the PCT supported the practice at above the standard rates both to protect the GP’s income and pay for locum costs, despite the fact the organisation had no legal or contractual obligation to do so.

Reputation management The GP voluntarily left the practice before suspension. Our experience shows that this action reduces both the chance of spurious additional claims, for instance by associates of the claimant, or conflict with the public if publicity occurs. It should also protect the public against offenders.

Timeliness In our opinion once the GP had been removed from his post all apparent urgency left the safeguarding investigation, particularly the social worker and subsequent police child assessment. This led to an unnecessarily long delay in investigation, and a four month suspension.

Problems also occurred because some members of the safeguarding team were registered with the same GP practice, which led to delays while replacement assessors without this potential undue interest or prejudice were found.

Allegations A parent or patient may raise concerns or make allegations which result in the suspension of a GP “without prejudice” and which triggers a full safeguarding investigation by the local authority, police and the PCT. The PCT should not investigate any allegations during this process as the local authority leads the investigation with a social worker assessment of the child and parent, followed by a police investigation.

Statutory responsibility The prime responsibility of the PCT in this situation is the safety of the public, as well as protecting the professional reputation of clinicians. PCTs are therefore increasingly likely to suspend “without prejudice” doctors, dentists, nurses, optometrists and pharmacists from clinical practice while an investigation is being held. It is important that clinicians understand the mechanisms for managing underperformance and are able to trust the system and those running it.

General Medical Council It has been our experience that informing the GMC of a local investigation along with plans for assessing and managing that investigation, rather than just referring cases, greatly assists the process.

To support GPs the GMC offers guidance on examinations and chaperones in this situation.

In this case, the GMC opted to wait for the outcome of the safeguarding board’s investigation.

Length of the investigation Despite an experienced team, a cooperative, understanding GP and early GMC notification, the suspension lasted four months. It took several weeks for the child to be interviewed and assessed by the safeguarding team.

The investigation team eventually declared there was “no case to answer”.

The PCT was required by the GMC to commission an independent assessment of the clinical systems and adherence to chaperoning policy by the GP and practice. This had been anticipated and was achieved within two weeks and was satisfactory.

Who pays the costs? We estimate the financial cost of this investigation and four month suspension to have been at least £80,000. This was largely borne by taxpayers, but also by the GP and his practice.

The intangible costs were far higher. The GP and his wife lost several months of normal life, replaced by overwhelming anxiety. The practice was severely disrupted for four months and morale was undermined throughout this time.

A large number of patients lost the services of the GP whom they knew well and preferred to consult. Several terminally ill patients were not cared for by the doctor whom they had known over many years, and who had made specific requests for this GP to visit them.

The overall outcome of this case was probably about as good as it could be. The allegations were thoroughly investigated before being dismissed and the GP returned to his practice and is now working normally again.

This case demonstrates the need for clear action to protect the public.

PCTs must urgently review their processes and systems and address this area of high corporate risk. The Department of Health and General Medical Council should consider offering clearer guidance for the clinical management of 16 and 17 year olds; safeguarding processes; chaperoning; and the suspension processes and financial support for “without prejudice” cases.

Lessons learned

  • Public safety and protection is a PCT priority
  • “Without prejudice” suspensions are likely to increase over time while investigations occur
  • Justice and thoroughness make it essential that investigations should never need to be reopened

Development points for the PCT and practice:

Local development areas

  • Effective practice teams are essential for a good outcome
  • Good records of chaperoning need frequent reinforcement
  • A prior financial agreement and shared protocol for suspension should be in place, agreed with the local medical committee, which can also stand up to external scrutiny
  • “Major incident” practice and continuity planning should include such events
  • Safeguarding investigations should be timely and have independent medical input at the outset
  • Inter-organisational communications should be further developed so everybody involved understands the consequences of the suspension of clinicians

National development issues

  • Chaperoning guidance is needed for the routine examination of 16 and 17 year olds
  • What constitutes an intimate examination needs explanation
  • National guidance does not meet the current costs for a “without prejudice” suspension and the workload cover of a GP principal
  • Primary care trust boards and executives need training in these issues
  • The new safeguarding regulations need to be well understood by PCTs and their legal advisers
  • Clarification of safeguarding policy for 16 and 17 year olds regarding consulting clinicians is needed
  • The suspension processes for performers list management needs reconsideration

 

FIND OUT MORE

0-18 years: guidance for all doctors and Maintaining Boundaries: guidance for doctors, GMC

National Clinical Assessment Service casework - the first eight years