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Leaving patients in locums' hands

The MDU's Dr James Armstrong advises practices on induction, patient handover and clinical concerns.

Locum GPs make a vital contribution to primary care, covering annual leave, study leave, sick leave and maternity leave and filling temporary vacancies. Locum cover generally works well but problems can occur occasionally if a practice does not have a proper induction or handover process. Or concerns may arise about the locum's conduct or performance.

These three fictional scenarios, based on calls to the MDU advisory helpline, give examples of problems that may crop up. Each is followed by advice on avoiding medico-legal pitfalls.

What went wrong

A locum was booked for a session at a surgery where she had not worked before. She arrived promptly at 9am. The practice manager showed her into a consulting room. He said she had 22 patients to see and that the first appointment was at 9.10am.

But the locum was unfamiliar with the practice's IT system and the referral processes used locally. She had to ask a lot of questions during the morning and her surgery overran by nearly two hours. Four patients complained about how long they had waited.

Preventing the problem
To minimise clinical risk practices are responsible for ensuring all locum GPs they employ for the first time receive an induction appropriate to the work they are expected to do and to the length of the booking.

This is likely to include running through key policies, procedures and local referrals systems. Practices should make sure locums have the opportunity to familiarise themselves with the computer software they will need to use, and are set up as named users so they can readily and accurately identify entries in patients' records.

What went wrong

One Friday evening before going on leave, a GP principal saw a 55-year-old man with symptoms consistent with dyspepsia. She prescribed symptomatic relief and asked the patient to return on Monday morning.

He had several cardiac risk factors so would need to be referred for an urgent ECG if there was no improvement.

The patient failed to attend on Monday when a locum GP was covering the session. The locum was unaware of any urgency as there had not been a handover of cases and the GP's written note did not clearly state her concerns.

The locum did not contact the patient, who was admitted to hospital on Wednesday night following an MI.

Preventing the problem
Part of a doctor's responsibility is to ensure a system is in place for the appropriate handover of any patient who may require ongoing review.

Paragraph 48 of the GMC publication Good Medical Practice (2006) states that doctors who are off duty must be satisfied that suitable arrangements for patients' medical care have been made and clearly communicated to their colleagues.

What went wrong

A locum GP provided cover at a practice while a GP partner was away. All appeared to go smoothly and there were no complaints during the week the locum was there.

Several patients seen by the locum returned for follow-up appointments with the GP partner, who became alarmed by some of the locum's clinical decision making.

This included prescribing an NSAID to a patient with impaired renal function.

The partner asked the practice manager not to employ the locum again but took no other action.

Some weeks later, a patient from another practice was harmed when the same locum doctor prescribed a drug to which she was allergic. The GP was criticised in a subsequent PCT investigation for not having raised his concerns earlier.

Preventing the problem
When you hire a locum you must ensure appropriate pre-employment checks are made. Check the doctor is on a primary care performers' list and can provide evidence of GMC registration and professional indemnity.

Up-to-date references from recent employers are necessary, even if this potentially delays the locum's start date.

If concerns arise about the locum's conduct or performance, you must take steps to protect patients from risk of harm. You should follow local procedures - for example, by informing the locum agency or your primary care organisation's medical director.

If the concerns are not resolved by local systems, you should inform the GMC (see Good Medical Practice, paragraphs 43 and 44).

GPs with specific medico-legal queries about employing locums or doing locum work should contact their professional indemnity provider.

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