What, If Anything, Happened Subsequently?

What, If Anything, Happened Subsequently?

Date:

26/11/2014

Subject title:

Absconding

What happened?:

I was asked to review a patient after they had attempted to abscond from the ward. When I arrived at the patient's room with the consultant he was not in it.

What, if anything, happened subsequently?:

I asked the nurses where he had gone and they were unsure. Normally after a patient has attempted to leave, the nurses would ensure someone closely monitors the patient by sitting with them on a 1:1 basis. However on this occasion this had not happened. The patient was contacted on his mobile and he had walked 5-10 minutes away and was on a busy main road. We were concerned that he had done this in a moment in his recovery when he was emotionally fragile and could be likely to impulsively hurt himself. We contacted his family who agreed to go and pick the patient up to return him to the hospital without the need to call the police. When he returned we placed him on 1:1 nursing observations.
I debriefed this episode with our nursing staff. The nurse in question did not seem to think that the standard of care she delivered was inappropriate. She became quite defensive and stated that if we wanted the patient on 1:1 observation we should have said so. This discussion was in danger of turning into an argument so I avoided confrontation and ended the conversation prematurely.

What did you learn?:

That some members of staff can react quite badly to negative feedback. I reflected on the episode to see whether there may have been a failing in the way I had broached this topic with a doctor at a similar level to me and my consultant. Both agreed that there did not appear to be a problem in the way I had delivered the feedback and both raised concerns about the nurse in question and difficulties they had in the past with offering her feedback. This made me feel a little better.

What will you do differently in future?:

I ultimately felt the situation was left unresolved. I did not take the complaint any higher as this was a one off isolated event, but decided that if the nurse continued to make similar errors or judgements which I and my colleagues deemed inappropriate in future that I would raise it with the ward manager.

What further learning needs did you identify?:

How and when will you address these?:

Shared?:

Yes

Date shared:

26/11/2014 11:58

Record Created:

26/11/2014 11:58

Date locked:

06/01/2015 22:15

Comments

Educational Supervisor 06/01/2015 22:13
This was an unsatisfactory situation for all concerned and I am not sure, what if any role the consultant played. Did you consider, or did anyone suggest, that this be treated as a significant event because it certainly seemed to have been a near miss?
Giving feedback is not easy, particularly negative feedback, and it may be helpful to review some of the recommended strategies for doing this.
2.02 Patient Safety and Quality of Care
3.10 Care of People with Mental Health Problems
Working with colleagues and in teams /
Fitness to practise

Date:

26/11/2014

Subject title:

Anxiety

What happened?:

A patient suffering from Anxiety and depression was admitted for the third time in 2 months. She was an elderly patient of 71 years of age. She proceeded to make ward staff and other patients very anxious. It was impossible to walk past her in the corridor without her attempting to engage you in a 15 minute discussion about her anxiety.

What, if anything, happened subsequently?:

Due to how anxious the patient was and how resistant she was to pharmacological treatment the patient became a source of great annoyance to ward staff and patients. This in turn meant that she tended to be avoided where possible by staff to stop a prolonged discussion which was very cyclical in its nature and seemed to have no definite end or conclusion.

What did you learn?:

I learnt how patients can transfer a great deal of their feelings onto people around them. Her presence made everyone feel anxious and made members of staff attempt to avoid her. This obviously would negatively impact her standard of care. It also reminded me of patients I have previously seen in general practice who colleagues report similar feelings about. I felt that her frequent attempts to engage us in conversation about her symptoms likely gave her some gain in terms of making her feel less anxious. However objectively there was no change in her mental state following such a discussion which left ward staff frustrated that nothing that they did by way of discussion seemed to make her feel better. This idea of 'the doctor as the drug' for this patient seemed to only make everyone including the patient feel worse.

What will you do differently in future?:

It is most important to remain open minded about such patients when everyone around you is losing patience. At the same time it is also important that for our own health and feelings we do not allow patients to repeatedly transfer their emotions onto us. This require a strong will on the part of the clinician and must involve a degree of boundaries for the patient so that they learn what things are appropriate and what are inappropriate. I tried not to avoid the patient at all cost, and merely informed her on these chance meetings in the corridor that discussing her mood in a non confidential setting was not appropriate and asked her if we could discuss it later at a pre-agreed time and place. This was an approach which worked well for me and I will try to adopt in future.

What further learning needs did you identify?:

How and when will you address these?:

Shared?:

Yes

Date shared:

26/11/2014 12:16

Record Created:

26/11/2014 12:16

Date locked:

06/01/2015 22:23

Comments

Educational Supervisor [06/01/2015 22:19]
You have reflected well on this case and developed a clear management strategy.
You touch on a very important subject and a useful lesson for life which is the importance of remaining objective when others are not
2.01 The GP Consultation in Practice
3.05 Care of Older Adults
3.10 Care of People with Mental Health Problems
Communication and consultation skills /
Maintaining an ethical approach /
Fitness to practise /

Date:

26/11/2014

Subject title:

OCD

What happened?:

I went to review a patient with OCD to perform a set of blood tests.

What, if anything, happened subsequently?:

When I arrived at her room she asked me to wait whilst she walked to the other end of the corridor and back. On returning she was quite specific about the way in which I had to take the blood test. She asked me to do the test in her right arm. She felt weak so I recommended she lay down. I asked her to lie on the right side of her bed so I could take the blood from her right arm. She stated she could not lie on that side of the bed. So I had to take the blood in a less than optimal position. I initially managed to get 1 bottle for a full blood count but was unable to obtain any further and the patient requested I stopped.
This left me feeling a little frustrated that I was not able to dictate the situation more to ensure I took the blood easily on the first attempt. It also made me feel a little inept to have failed at such a simple task because, in part due to stipulations placed on the technique by the patient and also because of apprehension from the patient preventing me from attempting a second time.

What did you learn?:

I learnt that these situations can be difficult to manage and it can be difficult to maintain a position of authority if you allow the patient to dictate the entire procedure.

What will you do differently in future?:

If I could do the procedure again I would have explained to the patient beforehand that doing the blood test in that way was less likely to be successful and may result in me having to have more than one attempt. This would have challenged her behaviour to see how rigidly fixed she was on the stipulations she had placed on our interactions. This would also have given me greater insight into the severity of her OCD before starting the procedure.

What further learning needs did you identify?:

2.01 The GP Consultation in Practice
3.10 Care of People with Mental Health Problems
Communication and consultation skills /
Clinical Examination and Procedural Skills /

Again, you suggest a practical solution to the problem.

Date:

30/01/2015

Subject title:

End of life care and communication

What happened?:

An 89 year old lady who had been admitted for community acquired pneumonia failed to respond to multiple courses of treatments. A decision had been made between the team and family that antibiotics weren't effective and the patient had been gradually deteriorating since her admission. Because of this the decision was made that further antibiotics weren't to be given and that the lady was for palliative treatment.
As all family members were not in attendance when the decision was made, there were occasions I had to communicate our reasoning and decision to family members. We also had to liaise with the palliative care team about management and possible discharge plan.

What, if anything, happened subsequently?:

Conversation with family members were sometimes difficult - often they did not understand why treatment was not working and why further antibiotics were not being given. They also did not understand why blood tests were not being done. All of these issues were discussed with the family and after conversation they did understand the reasoning behind them

What did you learn?:

1. Care in end of life - although the LCP is no longer in existence, various guidance on care of patients who are terminal and approaching the end of their life is still available. It was important to liaise with the palliative care team in the hospital and I also became aware of the role of the palliative care team in the community.
2. Communication and consultation skills - it was important to relay our decisions to family members and explain the reasoning behind them. This avoided any potential conflicts and problems. It was sometimes difficult to discuss these decisions with family members, who often saw them as the team giving up on their mother.

What will you do differently in future?:

Sometimes speaking to as many family members as possible at the same time may avoid the same conversations having to be had - but often this is not possible. During busy days, it was sometimes time consuming but something that had to be done. It was also not fair to put this burden on more junior members of the team as some of these encounters were difficult for even the senior members.

What further learning needs did you identify?:

Communication skills is an always evolving skill and something that will can always be improved with further clinical encounters.

How and when will you address these?:

Online learning resources:

Shared?:

Yes

Date shared:

01/01/2015 18:03

Record Created:

01/01/2015 18:03

Date locked:

Comments

Educational Supervisor 05/01/2015 22:32
Well done for taking responsibility for communicating with the family. How did it make you feel to have these discussions? Were there any communication techniques which were particularly helpful? You mention that you learned about the role of the palliative care team. How did you work with them? What was their input in the case of your patient?
3.09 End-of-Life Care
Communication and consultation skills /

Date:

25/12/2014

Subject title:

Anorexic patient admitted and under section 3

What happened?:

A severely anorexic patient was admitted due to malnutrition. She had previously been an inpatient at Springfield Hospital but was sent into St Georges. She was reviewed by the medical consultant on-call who initlally decided oral feeding could be commenced cautiously. However, when the dieticians and Gastroenterology team reviewed her the decision was made to NG feed the lady exclusively.
I was shocked at how underweight this lady was. She had a BMI of 8 and it was not something I had previously witnessed before. I thought that lady would have objections to be fed but after discussion with the team she agreed to have the NG tube for feeding. I think that she felt that she would not have control over what her intake was. But she was informed along every step of the way what the caloric intake of the NG feeds were and why we were giving them to her. I think keeping her well informed of what was going into her body made her much more amenable to treatment as she felt a certain element of control.

What, if anything, happened subsequently?:

NG tube was placed and cautious feeding was commenced. She currently remains an inpatient and continues to be NG fed. Daily blood tests were done to endure that there was no evidence of refeeding syndrome.

What did you learn?:

This was another opportunity to review the Mental Health Act 1983 which is something that I wanted to do earlier in the year. I also learned about refeeding syndrome.
And working with the dieticians and gastroenterologists it highlighted another case where we worked with colleagues and in teams.

What will you do differently in future?:

I think that the case was handled very well by the team. We tried to maintaining an ethical approach and not force anything on the patient that she did not want - even though she was under a section 3. It was very important to keep this patient informed of decisions that the team were making and why the were being made. I think we also worked well with our dietician and gastroenterology colleagues and in teams. I think this was vital as the acute medical team were taking their lead in the management of this patient. And most importantly, it highlighted the importance of communication and consultation skills - there were times when talking to the patient was time consuming, and especially demanding on the busy Medical Assessment Unit but this was a necessity in this case.

What further learning needs did you identify?:

Continue to learn the different sections of the Mental Health Act 1983.

How and when will you address these?:

rotation from Feb - August 2015

Shared?:

Yes

Date shared:

28/12/2014 20:17

Record Created:

28/12/2014 20:17

Date locked:

Comments

Educational Supervisor [05/01/2015 22:42]
This sounds like a very difficult case. You mention that communicating effectively with the patient, but how did you do this? Do you think your personal feelings of shock at the patient's low BMI influenced how you communicated with her? What techniques worked well?
3.10 Care of People with Mental Health Problems
Communication and consultation skills