pitfalls of minor surgery victoria wilson solicitor legal department

Pitfalls of Minor Surgery

Victoria WilsonSolicitor

Legal Department

@MDU Services Ltd 2009

Introduction

• Benefits for patients include:• GPs have been doing minor surgery for

years • Avoid long waiting lists • A familiar setting• Save private clinic fees• GPs can get a Direct Enhanced Service

(DES) fee under the new contract


Before you even start….

• You MUST:• Be properly trained-supervised clinical

experience in primary or secondary care• Be trained in resuscitation• Responsibility for ensuring skills are

regularly updated• Demonstrate a continued sustained level of

activity


Before you even start….

• Conduct regular audits

• Be appraised on what you do

• Take part in necessary supportive educational activities

• Have satisfactory facilities

• Nursing Support


Relevant Guidelines

• National Guidelines for the accreditation of GPwSIs from March 2009

• Guidance and Competencies for the provision of services using GPs with special interests (Department of Health April 2007)

• NICE Improving Outcomes Guidance for skin cancer


GMC Guidance

• Good Medical Practice

• Effective as from 13 November 2006

• Para 2 ” Good clinical care MUST include

• -referring a patient to another practitioner when this is in the patient’s best interests

• And…………..


GMC Guidance

• Para 3- In providing care you MUST

• “recognise and work within the limits of your competence”

• Para 12 GMP re keeping up to date

• Para 13 GMP re adherence to code of practice


Consent

• Particularly relevant to minor surgery as akin to major surgery for consent purposes

• New GMC guidance booklet- “Consent:patients and doctors making decisions together” (my underlining for emphasis) (2008 General Medical Council)

• Getting consent is a MUST• Why?


Consent

• If no consent, Tort of Battery or assault- could result in an award of damages in the civil court +public finding of negligence+/-GMC complaint

• What makes consent valid? • Free from coercion• It must be informed • Before the procedure-? On the day or not?


Consent

• GMC says you must:• 1. Listen to patients and respect their

views,e.g I do not want it• 2. Discuss with the patient what their

diagnosis, prognosis, treatment and care involve

• 3. Share with patients any information they want or need to know to decide


Consent

• 4. Maximise patient’s opportunities and their ability to make decisions for themselves

• 5. Respect patients’ decisions• Emphasis on language that patient can

understand-avoid jargon • General trend is doctor & patient should

make decision together


Consent

• See para 9 subparas (a) to (l) GMC consent booklet

• It is a long list

• Encourage patient to ask questions and answer them honestly

• Check patient understands

• Who should take consent?


Discussing side effects, risks and complications

• GMC guidance

• Please see paragraphs 28 to 36 of the Consent booklet for the detail

• Side effects

• Complications

• Failure of an intervention to achieve desired outcome (especially relevant to vasectomy)


Practicalities

• If you are the doctor doing the procedure, YOU are responsible for getting consent

• BUT you can delegate to for e.g. a nurse

• Who must be suitably trained and qualified

• Has enough knowledge to consent the patient and who…….

• Will act in accordance with GMC guidance


Consent

• You must ensure your record of any treatment provided includes the consent of the patient (NHS (GMS) Regulations 2004, schedule 2, paragraph 8)

• Written consent form

• Only a valid signed consent form if patient has been properly consented


Vasectomy

• Consent in these cases means……..

• Follow most recent Guideline Summary from Royal College of Obstetricians and Gynaecologists (January 2004)

• In following these, what should you tell the patient?


DPP v Morgan 1976

• Definition of offence of Rape

• s1 Sexual Offences Act 1956

• Hailsham : For rape to be established, there should be an intention

“… of having intercourse, willy-nilly, not caring whether the victim consents or not.”


Vasectomy

• Other long term methods of contraception

• Advantages and disadvantages of each

• Comparative failure rates

• Associated failure rate

• Use effective contraception until two clear results

• Small possibility of chronic testicular pain

• Reasons it might fail• twofold


Vasectomy

• Your training must conform to the Faculty of Family Planning and Reproductive Health Care

• Examples of claims arising from vasectomy procedures

• Failed vasectomy• Testicular pain• Example of a Breach of Confidence


Minimising risk

• Excisions - avoid face, areas prone to keloid formation, hypertrophied scar excision

• Protocol for aftercare, timing of suture removal (document this)

• Keep minor surgery book

• Consider hand-outs for follow-up arrangements


Mishaps

• If something goes wrong, tell the patient the facts, avoiding speculation or comment on the actions of others

• Apologise – not an admission of liability • What does the patient need clinically at this

time? • Consider discussing at Significant Event

Audit meeting


Avenues for the patient

• NHS and social care complaints procedure (ref to be added)

• GMC

• Civil claim

• In case of all/any of the above, best to contact MDO


MDU Services Limited (MDUSL) is authorised and regulated by the Financial Services Authority in respect of insurance mediation activities only. MDUSL is an agent for The Medical Defence Union Limited (the MDU).The MDU is not an insurance company. The benefits of membership of the MDU are all discretionary and are subject to the Memorandum and Articles of Association. MDU Services Limited is registered in England 3957086. Registered Office: 230 Blackfriars Road London SE1 8PJ . Copyright MDU Services Limited 2008.

pitfalls of minor surgery victoria wilson solicitor legal department

Documents

consent valid

gmc consent bookletit

patient understandswho

written consent formonly

patients opportunities

long listencourage patient

gmc complaintwhat

gmc guidancepara