Raising concerns about poor prescribing

MPS Medicolegal Consultant Dr Rachel Birch shares a case scenario involving a locum GP who was working in a practice with poor prescribing issues

Dr L was working three days a week as a maternity locum at a busy medical practice. Every day she was asked to manage the acute prescription requests, even though she knew only a few of the patients and there were two full-time GP partners.

She was asked to prescribe Diazepam for a patient she had never met and noted that the patient had not been reviewed in the last year. She felt it might be unsafe to issue Diazepam in these circumstances and she asked the senior partner, Dr M, to review the request as he knew the patient best. The next day the same prescription request appeared on her screen. She sent a message to the receptionists to let them know she had asked Dr M to deal with this request.

On the third day she was called in to see Mr F, the practice manager. The patient had run out of Diazepam and became angry with the receptionists at the front desk when they told him the prescription wasn’t ready. Mr F ordered Dr L to issue the prescription. Dr L declined to do so and Mr F started shouting, stating he would discuss the incident with the partners.

The following week Dr L received a formal warning from the practice, alleging a lack of co-operation in undertaking the prescription tasks.

Over the next month Dr L found that she was being asked to do more and more of the prescribing work. She noted two patients were asking for Methotrexate when they hadn’t had their bloods checked for several months. She identified several patients, who hadn’t had their blood pressure checked in over two years, taking the combined oral contraceptive pill, and a patient on Ramipril whose U+Es hadn’t been checked since it was commenced six months previously.
Dr L became concerned about the systems for safe prescribing in the practice and asked to see a copy of the prescribing policy. She was told that there wasn’t a policy and was asked to stop interfering and “just do the work”.

Dr L felt she had to raise the matter formally and wrote an email to Dr M. She gave a summary of the cases where she felt the patients should have had more monitoring, and offered to carry out an audit of patients on the combined oral contraceptive pill to ensure they had had their blood pressure checked in the last year. She also suggested that she could develop a practice prescribing policy as she felt it would improve patient safety.

Dr M did not reply to her email. Instead she was called into a meeting with the two partners and the practice manager and told that they did not wish her to do the prescriptions any more. They also gave her two weeks’ notice to leave her post and stated that they had personal issues and felt they could no longer work with her.

This situation concerned Dr L and, after she left the practice’s employment, she felt that she should inform the medical director of the local commissioning group. He instigated a formal investigation of the practice’s prescribing; the outcome was that it was criticised. Numerous recommendations were made to improve patient safety.

Unfortunately, the practice manager made a complaint about Dr L to the GMC. She was assisted by her medical defence organisation in her response to the GMC and they concluded that no further investigation was necessary.

Good practice points to prevent poor prescribing

  • Dr L didn’t prescribe the Diazepam as she didn’t know the patient and felt a medication review was needed. She didn’t compromise her position even when asked to prescribe by the practice manager.
  • Dr L raised her concerns about prescribing with the practice as soon as she realised there could be patient safety issues.
  • As well as raising concerns, Dr L offered solutions to try to improve the situation.
  • When the practice failed to act on her concerns, Dr L reported the issue to the appropriate person outside the practice.
  • Dr L documented her concerns well. This proved invaluable when the practice made a complaint to the GMC, as she was able to demonstrate that she had raised concerns appropriately and promptly, whilst maintaining safe prescribing herself.

What the General Medical Council says:

  • Doctors should only prescribe drugs when they have adequate knowledge of the patient’s health and are satisfied the drugs serve the patient’s needs.
  • Although prescribing errors may occur, harm is usually avoided by professional colleagues intervening before the errors can affect patients.
  • Doctors must protect patients from risks of harm posed by a colleague’s prescribing. They should question any actions they consider might be unsafe and respond constructively to concerns raised by colleagues, patients and carers about their own practice.
  • All doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organisations in which they work. They must also encourage and support a culture in which staff can raise concerns openly and safely.
  • Doctors may be reluctant to report concerns for numerous reasons, including the possibility of a negative effect on working relationships, their career or a counter-complaint. However, they have a duty to put patients’ interests first and act to protect them.
  • If doctors believe that patients are, or may be, at risk of death or serious harm for any reason, they should report their concerns to the appropriate person or organisation immediately.

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