GMC 'One-Off Mistake' Pilot Reduces Full Investigations

Nicky Broyd

April 18, 2019

Fewer doctors involved in single clinical incidents will face full General Medical Council (GMC) investigations following a 2-year pilot scheme.

During the pilot the GMC was able to close 202 out of 309 cases of one-off mistakes involving a single patient without a full investigation.

During the pilot study evidence from the doctors in question, medical records, independent experts, and doctors' responsible officers was taken quickly and a swift assessment made on whether there was an ongoing risk to patients.

The new approach will be rolled out, the GMC said, in the interests of patients and to reduce stress and delay for doctors.

The decision was welcomed by the British Medical Association (BMA).

Case Study 1

The GMC supplied two anonymised case studies to demonstrate the new approach.

The first involved a plastic surgeon mistakenly gluing a child's eye shut while trying to treat a forehead laceration from a cycling accident.

The surgeon had not tilted the patient’s head back far enough, or laid them down, or covered their eyes.

The glue could not be removed by the plastic surgeon and a procedure under general anaesthetic was required at a specialist eye hospital. This involved cutting of the eyelashes, and a risk of corneal damage. The patient was left traumatised.

Independent reports, relatives' feedback, and input from the plastic surgeon’s responsible officer were considered.

There were no other concerns about fitness to practise, careful consideration was given to the error, and he expressed remorse.

The plastic surgeon was found to be unfamiliar with the tissue glue used in the casualty department, the optimum position for the procedure, or the use of a swab to prevent leakage. It was also found that his magnifying loupes reduced his field of vision. This was a rare procedure for a plastic surgeon to be asked to carry out, according to an independent expert who said it was more often done by A&E nurses.

An assessment was made that the issues raised were mistakes and not clinical concerns.

The GMC's decision was that there was no risk raised for future patients and it was processed as a Single Clinical Incident provisional enquiry.

The case was closed without a full investigation or any further action.

Case Study 2

The GMC was told of a police investigation into the death of an elderly man with the allegation that a doctor had prescribed an overdose of medication that contributed to the patient’s death.

Provisional enquiries by the GMC found the patient had complex medical problems, including type 2 diabetes treated with insulin at breakfast and tea time.

There was a misunderstanding leading to a dosage error when the medication was administered. The patient died overnight from hypoglycaemia.

The GMC considered independent reports, engagement with the patient’s relatives, and feedback on the doctor during provisional enquiries.

The doctor's health trust considered that a similar incident was unlikely because the doctor had thought carefully and at length about what went wrong.

All other dealings with patients and his prescribing were found to be exemplary and there were no concerns about overall performance.

The doctor was very distressed by the tragic event and was aware of his role in the prescribing error.

The body responsible for medical training and education considered the incident to have been caused by human error.

There was no evidence of persistent or reckless failure to follow guidelines.

The GMC said that due to the insight shown by the doctor after admitting the error, the case did not raise ongoing risks to patient safety.

The case was processed as a Single Clinical Incident provisional enquiry and was closed without a full investigation or any further action. The police also took no further action.

Reducing Stress and Delay

GMC Chief Executive Charlie Massey said in a statement: "Protecting patients is our priority. But opening full investigations unless absolutely necessary is not in the interests of patients or doctors, and causes additional stress and delay. We’ve found that getting more information quickly in certain cases clarifies if there is any ongoing risk to patients, and so whether we need to take action.

"The pilot was to see if using that approach in cases involving allegations of one-off clinical mistakes would allow us to properly assess the risk without the need for a full investigation. It does, and as the pilot was a success it will now be implemented as our standard practice.

"Not all complaints are suitable for this process but during the pilot we were able to avoid the need for full investigations in many cases that involved single clinical incidents. Even where doctors had made a mistake we were able to check if they understood what had gone wrong and had taken steps to make sure it wouldn’t happen again, avoiding the need for action."

BMA chair of council Dr Chaand Nagpaul commented: "Being subject to a fitness-to-practise complaint can be an extremely serious and distressing experience for doctors, not least as investigations are all too often delayed and drawn out, even when they result in no further action being taken. To serve the public effectively, the GMC must ensure that the investigations which it rightly conducts are fair and efficient and do not cause unnecessary stress for doctors.

"The GMC's recent pilot clearly shows that complaints against doctors can be dealt with promptly and effectively without requiring burdensome processes. The decision to implement this approach as common practice is a significant step forward towards a fairer, more proportionate system of regulation, so we welcome today’s announcement."


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