Exercises in candour

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I am presenting some cases on the Duty of Candour next week, so I thought I would explore them on the blog first. The Duty of Candour is now a legal requirement rather than a vague, moral imperative. If a patient comes to avoidable and significant harm the patient must be informed within 10 days of it being recognised, an apology must be made and an explanation given which should include what will be done to ensure that it does not happen again.

Error is a fact of life in medicine. Not all error leads to harm, and not all harm is significant. But working out when the Duty of Candour should be invoked is harder than it looks on paper. Over the last few months many of us will have been involved in discussions with colleagues, or in our own heads, as to whether something that happened that was not quite right should be explored with the patients or their family as part of this Duty. You cannot check an adverse event off against a list of significant harms. A judgement first needs to be made whether the harm was significant, but even having done that it is not easy to progress.

These cases are intended to be based on everyday life in hospital, and the responses to these cases are just my first thoughts. I don’t know the right answers!

 

1] A house officer is tabulating her patients’ blood results first thing on a Friday morning before the ward round. She finds that yesterday a man’s potassium was extremely high at 6.9. The blood was taken in morning and the result was on the system by the middle of the afternoon, but for one reason or another the result was not checked and no action was taken. The doctor knows that this put the patient at risk of cardiac arrest, and even as she sits at the computer looking in horror at the number on the screen, she knows that her patient could drop dead any second. She runs onto the main ward and sees from a short distance that a patient is absolutely fine. He glances up and sees the concern on her face. She steps forward and says… What should she say?

There has been an error, a significant omission. The patient’s life has been put at risk. But the patient is fine. No harm has been done. If she chooses not to tell the patient what she is worried about, but quietly rechecks the blood or prescribes some insulin and dextrose, he may never know the danger he was in. The problem will just receded into history. What would you do?

My feeling here is that the Duty of Candour is not invoked because harm was not done. It is a near miss, and you could argue that the event should be recorded on hospital’s register of adverse events. But I think the reasonable doctor would tell the patient that she was concerned about a blood test, and should probably come out with it and say “we checked your potassium yesterday, it was very high, but I’m afraid the result did not get through to the team,” or something like that. There is no denial, but there is no dramatic telling of what might have happened. Or perhaps she should say more, or her consultant should, along the lines of, “I’m afraid there was a mistake made yesterday. You were at risk of having a heart attack overnight and thankfully that did not happen. We are very sorry… we think we know why it happened, and we have made sure that all results are seen every evening…” That sounds better.

 

2] A registrar inserts a central line into a patient’s neck having obtained their written consent. On the list of potential complications, on the consent form, are infection, bleeding, inadvertant cannulation of the artery and pneumothorax (collapsed lung). Two hours after the central line insertion, while the patient is waiting for the check x-ray which has been somewhat delayed, the patient experiences chest pain and breathlessness. He is examined and there is clear evidence of a pneumothorax on the side where the line was inserted. A portable chest x-ray is done straight away and shows a large pneumothorax. A chest drain is inserted as an emergency, the patient symptoms are relieved, but he stays in for 10 days longer than intended.

Was this an error? It was a known complication certainly, but it was not intended that the sharp needle would pierce the pleura. Whoever pushed the needle pushed it into the wrong place. That sounds like an error. But the patient agreed to have a procedure knowing that this could happen. Is Duty of Candour invoked here?

Well, the patient did come to significant harm (an extra procedure, 10 more days in hospital). If I was the doctor I would certainly come back to the patient, when they were feeling better, and explain what happened; but I would explain also that this is not a particularly infrequent problem, hence the reason we take a focused consent. I would probably say sorry, but not as a personal admission of guilt, but more to say that I was sorry for the situation and sorry that it happened to him. I would feel able to maintain this attitude if I felt that I went into the procedure confident that I was well trained and that I had done everything by the book – be it the use of ultrasound or a good track record of successful insertions. If everything was done as well as it could, then you could argue that the complication was not avoidable.

Such a conversation would be an example of openness, transparency and certainly in the spirit of candour, but I’m not sure if it would tick the box for a formal Duty of Candour response from the Trust.

 

3] An SHO prescribes the antibiotic Tazocin for a patient who is known to be penicillin allergic. Tazocin contains penicillin, and all competent hospital doctors should know that. The drug chart states clearly that the patient is penicillin allergic. It is a grave error and should not have happened. The patient suffers an anaphylactic reaction, spends three days in intensive care and an extra seven days in hospital. Their recovery from a minor operation is seriously impeded.

The SHO is called in by his educational supervisor, and the circumstances behind the mistake and prescription are explored. It was probably just a consequence of the doctor being in a hurry. He admits to that, and says he cannot even recall looking at the front of the drug chart for the list of allergies. The consultant and the SHO agree that the harm must be explained to the patient, and that Duty of Candour requires them to apologise, explain how it happened and how they will try to stop this in the future. There is no question of not admitting that an error occurred, because it is obvious. The question is how to apologise. The SHO decides that he must do this himself, under supervision, but he feels morally obliged to initiate the conversation. He wonders, as the time scheduled for the meeting with the patient and her husband draws near, what he will say. Will he cry? He certainly came close to crying on the day itself. He was horrified with himself. He wanted to give up medicine. He had nearly killed someone who had come in for a minor operation. But he has asked around, and he knows that better people than he have made the same mistake. That is no excuse of course, and he knows he will never do it again because the scar is burned deep into his memory. He cannot talk like this in front of the patient. It will depend on the patient’s attitude. Sometimes they feel sorry for a clearly regretful or distraught doctor, and they wish to comfort them. Sometimes they, or their relatives, appear to be burning with anger and resentment; they want someone to pay a price. He decides that he will say sorry straightaway. Then he will explain how it happened, but he can’t make it sound like he’s blaming the hospital for keeping him busy. He will just have to say that for those few moments he did not pay enough attention during an important task. And then, well, the conversation will go in the direction the conversation wants to go.

 

4] The medical registrar on call, Lucy, spends several hours of the night with one particular patient, trying to make her better. She is 79 and appears to have a horrible infection. Her blood pressure and temperature are very low and however much fluid the registrar gives she cannot increase it. Intensive Care say they will come down to review, but in the meantime the registrar writes up bag after bag of fluid (which is a reasonable initial treatment of severe sepsis.) She does all the other things that she should, takes blood cultures, gives antibiotics, monitors closely, arranges a high dependency bed. The BP eventually comes up a few points, just enough to avoid the patient going to intensive care. The consultant comes in next morning to see the patient with the registrar, and immediately recognises something is wrong. As he examines the patient there is a rapid deterioration. The blood pressure falls to dangerously low levels and the oxygen saturation goes down to less than 60%, barely compatible with life. The consultant, holding the ECG, cannot hold himself back. He turns Lucy and says “Have you seen this? She’s had a posterior infarct, this isn’t sepsis, this is cardiac failure. You’ve drowned her!” And then all hell breaks loose. The patient crashes, the cardiac arrest team run onto the ward and the patient is intubated then rushed off intensive care. She is literally drowning in the fluid the registrar prescribed overnight, 6 litres of it.

Lucy, remaining on the ward, looks at the ECG. She remembers seeing it in the emergency department, but she didn’t make much of it. It was not that dissimilar to a previous one, but it’s all a blur now and she can’t remember correctly. The truth is she missed an acute myocardial infarction, and she treated this patient incorrectly, as incorrectly as it is possible to do. The patient follows a rocky course, but survives intensive care and makes it out of there onto the cardiac ward. Her brain is not what is was, and there is talk that the period of low oxygen levels in her blood led to a mild degree of brain injury.

During this time Lucy subjects herself to much criticism. How could she get it so wrong? She is aware of the ‘new Duty of Candour’ and finally, having considered it carefully, asks her consultant if they should tell the family that their relative was mismanaged for the first five hours of her admission. What would you say, as the consultant?

Treatments given are often on the basis of diagnoses which are not clear cut. This is a case in point. I remember myself mistreating a patient who had cardiogenic shock when I was a junior doctor, and I remember the look on my registrar’s face when she recognised my error the next morning. In this era of candour how do we manage misdiagnosis? Diagnosis is a skill and sometimes an art, and cannot always be correct. The point about the Duty of Candour is avoidable error. To avoid this error the registrar would have had to have been a different person. Let us assume that she is of good medical standing, has maintained her continuing education and is generally up to scratch. Nevertheless a gap in her knowledge was revealed that night. She failed to identifying an important medical condition, one that many would expect a medical registrar to have done successfully. But we all have gaps in our knowledge. She made a diagnosis based on the data before her, processed that data through the mind of someone educated to the same level as any other doctor in the hospital. Yet she made the wrong diagnosis. Was that avoidable? Probably not. Yet this lady, now permanently injured, might well have had a much better outcome if only another doctor had been on duty that night.

This scenario I find very challenging. I honestly do not know whether it should be expected of the medical team, or the doctor in person, to apologise for what happened. Yet the decent doctor, I believe, would want to meet with the family and go through things, to communicate – to tell the story of what happened and why. This might include describing how patients with cardiogenic shock can sometimes look as though they have severe sepsis, and that this is what happened. The diagnostic ‘mistake’ is revealed, but not in way that would categorise it as formal ‘medical error’. Perhaps this is splitting hairs, or over-thinking the whole issue.

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What I take home from these cases is that the formal process of applying the Duty of Candour may not be well suited to the wide spectrum of everyday medical error, and the many grey areas that exist. The message that I take away is that we must develop the habit of explanation, be quick to tell the story of what happened and why, but not to dwell too long on the emotional or moral weight that comes with the concept of apology. If we have made a mistake we must say so, but all error occurs within a context of uncertainty, and without trying to make excuses it is reasonable to explore mitigating circumstances. We must find a way of displaying candour while preserving the ability to pick ourselves up and deliver care to the next patient.

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