Malpractice or clinical risk? Iatrogenic injury in PVD

Patient care should not be reduced to a distasteful game. You're right, best I refrain from further comment.

 

patient care is based on clinical standards were the patient is central to the pace and direction care moves in and we must fully inform patients of all possible clinical risks

podiatrists work at many levels care and with many risk groups
the case scenario i thought was simple and did not need in-depth medical history or results of medical tests ect

the use of antibiotics and off-loading is academic as it was not applied in this case as it was not felt to be relevant due to no current infection and type of wound cause.

I was highlighting the case were a simple cut caused at routine care resulted in loss of limb

Yes many factors are involved but not in the case of the pod who caused the cut as the patient left his care after the follow up visit.
yes the vascular team and hospital team would have done many things to try and save the limb.
This is again academic as the blame perceived by the patient fell at the door of the pod causing the cut.

the main question is that in this case is accidental cut in routine care on high risk patients is it clinical risk or malpractice when the pod follows all available protocol (not guide lines )

the vole possible way a wrong comment and i apologise for that.
guys you can have many years experience but still be wrong!

 

Ahh looking at the empty bottle on the counter this morning, it's spelt Banrock not Bannrock, but it tastes the same.
Ros

 

Is an accidental cut in routine care on high risk patients a clinical risk or malpractice

An action for damages will be determined on the 'negligence with causation' principle.

Simplified, if there is a negative outcome to treatment, was it caused by a less than acceptable standard of care ?

Is an accident to be expected when receiving treatment from a professional ?

The health status of the patient is irrelevent, as are any leaflets you may concoct.

The very fact that 'you' had the accident, makes you liable !

It's very straightforward !

 

the vole possible way a wrong comment and i apologise for that.
guys you can have many years experience but still be wrong!

Fine. I have already suggested that you avoid being rude. If you don't want an answer from experienced colleagues, then don't waste their time by asking.

Bill Liggins

 

I'm sure there must be an 's' missing somewhere in this sentence! :drinks

 

Tony it's not really about following protocols per sae, its about a reasonable expectation of care. As you can see from the posters many folks do not consider that this has happened and as such constitutes malpractice. Overhauling your protocols needs to occur, if you feel an information leaflet for patients may help them make an informed decision as to their treatment plan then fine write one. The patient may request debridement but that does not mean that in her case it was reasonable course of action for the podiatrist to follow knowing the risk factors better than her. Might help if you have an M&M meeting and honestly discuss with staff how the patient ended up with a BKA. What can be learned, how to document, photography, follow up care, what were the comments from the court, how did they arrive at their verdict.
Yes Mark your right, never count the empties!
Regards
Ros

 

yes and no
with ischemic wounds delay in wound closure is usually seen and ischemic foot wounds are usually painful with or without infection

yes this was considered hence the swab so any antibiotics would be appropriate

Like i have tried to point out this was a clean wound dressed with sterile dressing and portal for infection route limited.

I agree that infection is always complicated in the ischemic foot and oral antibiotics may or not be effective depending on blood supply.

the swab taken was superficial as wound painful the microbiology showed no significant growth.
routine bloods showed no raise in CRP ESR but she was anemic at .9

ABPI taken at assessment was .6 in the cut limb and .8 in the other limb

dressing plan was to use Flaminal Hydro and Bordered foam honey had been considered and was used when wound started to show clinical infection along with oral antibiotics and codeine (i don't recall the exact pain control but progressed to morphine) as the wound progressed
Dressing plan was guided by pain and vascular team as some overlap in care usually is seen with this type of patient ie vascular nurse, consultant,podiatry and is usually (in my experience lead by the vascular team as podiatry input limited at this level unlike diabetic neuropathic wound stuff.

patient had a bka at level of effective blood supply which was determined by duplex scan.

not seen for some time after this by pod team next we knew requests for notes as legal action had been taken against community pod.

As you will know the details of this are not usually shared around but the claim included the words malpractice and some insinuation that as she had had no problems prior it must have been this advent that caused the amputation.

The debate I wanted to start was not about the care after the 1st review by the podiatrist it was a simple question that could the risks associated with routine care ie nail care and soft tissue care in the high risk patient be classed as malpractice if an accidental cut occurs.
or is this clinical risk and if so how are patients made aware that podiatry carries risks.
Yes i understand the follow up care is paramount to care packages and legal proceedings but it seemed academic in this case.

Sorry if i seemed rude to any members must be my dry wit!!
sometimes when you work in sadness the light comes via humor what ever that is?

thanks again for all the posts again sorry if I sounded rude belinda

 

thanks ros
banrock got it will try to find some.
Yes your points are well valid with each "clinical incident" we must look at the factors and change as needed.

I understand that malpractice seems likely and have been mulling the comments over in clinic all day and how things could have paned out better.


seems the only way the outcome could have been avoided is by no debridement as one of the posts suggested.
still feel that following the cut the pod done all he could as outcome seems to be the same.

i may be wrong but don't courts view the what difference would it have made to the outcome as a major factor.

started looking at a leaflet and its feasibility
thanks gain

 

hi john
i agree with the way you have put the case

 

I'm back in NSW Supreme Court in September, not the same scenario but pt had a BKA. If anything can be leaned from this case then I'll post it. Until then happy Banrock day.
Ros

 

No problem, Tony.

Without going over old ground again, I`ll just say that I wish you well in your endeavors to develop the information leaflet. Hopefully this will aid patient concordance with regard to their treatment plan, whilst at the same time raise awareness of risk factors for both practitioner and patient alike.

Cheers,
Bel

 

I wish you well in your endeavors to develop the information leaflet. Hopefully this will aid patient concordance with regard to their treatment plan, whilst at the same time raise awareness of risk factors for both practitioner and patient alike.


Maybe, but I`m sure it will not include 'I may have an accident and cut you' !

An accident is a mistake, with consequences that may end in litigation. That is why you pay for professional indemnity, no leaflet or consent form can absolve you from the responsibility for a mistake !

As a skilled professional a patient is entitled to expect a level of care commensurate with the average for the profession and that will not include mistakes.

Now if you chose to get a non professional to treat you, and a mistake occurred, litigation would be unlikely to succeed. That is why patients seek professional care !

 

Pity, the gems are missing !

 

Hi Craig

What are the missing gems?

Cheers

Bill

 

hi
john

you must accept that as part of routine clinical podiatry work a risk of cutting the patient exists.
this has nothing to do with skill as many factors may be at play.

If you debride callosities in fragile skin this risk is higher and i feel the patient should be informed of the risks of this if not consent by leaflet.
possibly different wording then you suggest.

benefit + risk = outcome

 

Tony,

I totally agree with you. Yes, we have to be very careful, but it simply is not malpractice if you happen to error on going a bit deeper than you like when debriding.

We are human and mistakes are going to be made. Malpractice is about markedly deviating from the standard of care and all the signed consent forms will not help.

Do not practice over your ability, always get consults when appropriate, have the best intentions, and do not practice in fear of getting sued. Accept that mistakes and poor outcomes will happen to EVERYONE. Just do everything possible to mitigate the problem once diagnosed.

Steven

 

Tony, Steven et al.

This is, as I previously stated, very simple.

I am speaking about the accidental cut as per descibed at the start of this thread, one that has subsequent serious consequences.

A passenger on a bus expects the driver to be appropriately skilled and does not expect to be injured by consequences of any lapse on the driver's part; of course there is always a statistical chance of such an accident. Does the passenger take out insurance to cover this unlikely occurence, no, he expects the driver to have such cover. In the event, the driver may claim that the occurence was due to 'other factors at play' but the passenger's recourse will be against the driver whose care they were in ! The driver may sue the 'other factors'

Likewise, a patient can expect not to be 'accidentally cut' by a chiropodist (although there is a statistical chance) but if such a cut occurs and there are serious consequences, being in the chiropodist's care they will have a case against the chiropodist. The accidental cut is down to negligence and the consequences will be the causation; negligence with causation.

All protestations such as the 'risk of cutting exists', are irrelevent.

Yes, Unfortunate outcomes need not constitute malpractice, yes you will get pinpoint bleeds with some treatments, but do not confuse them with 'accidental cuts'; the courts certainly won't.


Regards

 

hi
so is infection after pna tna in your opinion malpractice as would be blister from new orthosis.

the word accident is not possibly the right one I think we should call it a clinical risk when using sharp instruments.

yes in this case the pod should have possible not debrided but having made the clinical decision to do sharp debridement I feel it then become a clinical risk.

I understand that in the legal proceedings it may be the case that sharpe debridement is deemed to have been a to great of a risk but again it is a risk and the malpractice in this case is again on
risk + benefit = outcome ( bad outcome for both patient and pod)

I understand were you are coming from but cuts in podiatry I feel are mostly clinical risk as if infection from pna tna as is blisters from new orthosis

what do you think

 

I think I've said all there is to say and that you're still confusing or interchanging types of outcomes.

In this type of work there will be many times when you're out of your own 'comfort zone' and all the attempts at justifying one's position will be of no use when litigation looms !

Regards

 

WDD

It's worth pointing out that 'informed consent' is not recognised in English Law !

Regards

(I'm writing this in France also)

 

that's interesting

the subject of consent seems a little vague

example is when you attend a dentist what form of consent do you give for quite invasive things involving use of local analgesia?

or for example when my dad had his hip replaced the consent form included risk of death why would anyone consent to death!

I think in this case the legal issues were around was the podiatrist negligent and by been negligent did it result in malpractice?

In my opinion the podiatrist set about to do a plan of care for the high risk patient that the patient had been on for some time.
the high risk status had not changed from when the previous cal reduction was done and had been the established care plan.

was the podiatrist negligent ? in my opinion no was it malpractice as far as i remember it was deemed to have not been the podiatrists fault as----
and here is the legal crux the disease process the patient had was the main factor involved in the failure to heal from a minor injury during a podiatry procedure.

I have seen many patients lose toes and limbs and not heal from surgery to reduce bone necrotic tissue and what ever, and the underlying state of the vascular reduction has been the main factor for the loss

I think if you treat every patient as if they were going to sue you the development of trust and respect will be very hard.
again leaflets and consent forms are a tool in the plan of care and help the patient understand that risks are present

 

In order for negligence to be proven a Claimant (usually the patient himself) must show that the doctor owed a duty of care to the patient, that the doctor was negligent in his management, and also that the patient suffered harm as a result. The Claimant has to succeed on both liability and causation to obtain compensation:
Liability to show that the doctor or nurse must have been found to have acted in a manner that no other similar professional would have done.
Causation that harm has resulted which would not otherwise have occurred (on the balance of probability, ie the action of the doctor or nurse was more than 50% likely to have caused the harm).

Is the management in this case negligent?

due to the pre-existing vascular condition was the podiatrist more then 50% to blame for the loss of limb?

 

I really was going to leave this thread but when dealing with legal matters (on which others have greater expertise than I), it is necessary to be fully accurate in your own defence.
In order for negligence to be proven a Claimant (usually the patient himself) must show that the doctor owed a duty of care to the patient, that the doctor was negligent in his management, and also that the patient suffered harm as a result. The Claimant has to succeed on both liability and causation to obtain compensation:
This is correct.
Liability to show that the doctor or nurse must have been found to have acted in a manner that no other similar professional would have done.
This is incorrect. What you are referring to is the Bolam principle which holds that the practitioner (not necessarily a doctor or nurse) must have acted in a way that the average practitioner would not have done - not in a way that no other similar practitioner would have done. There's a very big difference there.
Causation that harm has resulted which would not otherwise have occurred (on the balance of probability, ie the action of the doctor or nurse was more than 50% likely to have caused the harm).
This is correct, although it would not be possible to argue that (as others have pointed out) causation was not the responsibility of the podiatrist ie., on the balance of probability the limb loss was caused by the cut, which would not have been there if the podiatrist had not cut the patient, so the 50% is, in this case, a non sequitur.

Bill Liggins

 

My opinion given, nothing more to be said.
Ros

 

time to call it a day on this this

good debate
thanks guys

 

Outside of this particular case 'informed consent' seems to be an area that could do with some clarification.

What's it's purpose?

If the patient is informed of a risk does that mean that they forfeit their right to sue for medical malpractrice if the risk becomes a reality - a kind of get out of jail free card?

It seems to me that in many cases so called 'informed consent' could and would be reinterpreted as bamboozled consent.

You may have informed the patient but that certainly doesn't ensure understanding. Perhaps after they have signed the informed consent form they should take a short written examination to test their understanding of the consent they have given?

One thing I am sure of is that all high risk patients are at a deep viceral level aware that they are at risk and that in clinical settings, where they are to undergo some procedure that increases their level of risk even more, their anxiety levels make it impossible for them to give genuine informed consent.

Bill

 

WDD

As I replied previously, 'informed consent' does not exist in English law.
It would better be described as 'medical consent', which requires that the patient has a general understanding of what they are agreeing to, not such a level of understanding as required by informed consent !

Informed consent exists in the USA and many other countries but not in England.
Theoretically the patient's interests are protected in a similar way as burden of proof varies also.

We all talk about getting 'informed consent' but as it is not embodied in our law we are wrong and because of different burdens of proof we are confused; as demonstrated in this thread !

 

Hello John

Absolutely. I recall when this nonsense of 'informed consent' began in the NHS (just ignorant managers again) I pointed out that not only was it meaningless in law, but would have to include the potential for death as an element of the information provided to the patient. The response worried me in that a) I thought that some senior managers might expire with cardiac arrest b) they refused absolutely to include death on the list of potential adverse reactions. Hence, the consent was not 'informed' and did not even include all adverse reactions!

All the best

Bill Liggins

 

bit confused, as just been reading the nursing times on informed consent seems real in nursing?

 

what form of consent do we need for routine work in the uk?

 

For those of you who think the situation re-informed consent, is still too clear try this one on for size.

www.nursingtimes.net/after-bristol-the-importance-of-informed..

Now you will know why you seek informed consent and just how to go about it, I don't think?

Still a bit of confusion can't be all bad can it? There must be some winners, mus'n't there?

Bill

 

hi bill are you working in France or just taking in the veno!


S LEARNING
OPINION
STUDENT NURSING TIMES
JOBS
SUBSCRIBE
After Bristol: the importance of informed consent
6 December, 2001

VOL: 97, ISSUE: 49, PAGE NO: 32

Ann Gallagher, MA, RGN, RMN, PGCEA, is a PhD student at the University of Central Lancashire

Jean McHale, MPhil, LLB, is professor of law at the University of Leicester

The final report of the Bristol Royal Infirmary Inquiry (Kennedy et al, 2001), which was published in July this year, is arguably the most extensive and comprehensive critical review of clinical practice undertaken in England. It provides a thorough critique of the conduct of paediatric cardiac practices at Bristol Royal Infirmary between 1984 and 1995.
The final report of the Bristol Royal Infirmary Inquiry (Kennedy et al, 2001), which was published in July this year, is arguably the most extensive and comprehensive critical review of clinical practice undertaken in England. It provides a thorough critique of the conduct of paediatric cardiac practices at Bristol Royal Infirmary between 1984 and 1995.

In an article by Dinsdale (2001), Rebecca Howard, a nurse and member of the inquiry team, is reported to have said: 'We heard some very good things about nursing at Bristol, but what came through clearly is that there were big gaps in what people were communicating with each other.'

The report sets out a wide-ranging series of recommendations under a number of headings:

- Respect and honesty;

- A health service that is well led;

- Competent health care professionals;

- The safety of care;

- Care of an appropriate standard;

- Public involvement through empowerment;

- The care of children.

The first category, 'respect and honesty', focuses on partnership, keeping patients informed on treatment and care, communicating with them, support services for patients, consent to treatment and responding to the patient when things go wrong. This article focuses on the implications of the inquiry's recommendations for nursing practice in relation to consent to treatment.

Keeping patients informed
In the past doctors took responsibility for providing information to patients/clients and gaining their consent, while nurses played a subsidiary role. Today the situation is quite different.

Given the ever-expanding scope of professional practice and increasing professional autonomy, nurses may be the sole or main clinical practitioners dealing with a particular patient. Patients may also turn to nurses for advice and clarification after a consultation with a doctor or another health professional. It is therefore vital that nurses are aware of their professional and legal obligations regarding consent to treatment.

As treatment choices/options increase, so does the range of methods of conveying information to patients. The NHS promotes the greater availability of patient information through initiatives such as NHS Direct. In the future there is also the prospect of new bodies, such as the Patient Advocacy and Liaison Service, playing a role (Department of Health, 2000).

Health care professionals cannot be regarded as simply imparters of information, while patients are not simply passive recipients. The internet and the media have contributed to patients being far more aware of the choices available to them and more fearful of the risks that may arise from clinical procedures.

The Bristol inquiry report and its recommendations need to be seen in the context of these developments. The report makes a number of specific recommendations in relation to patient information. It states, for example:

'4. Information about treatment and care should be given in a variety of forms, be given in stages and be reinforced over time.

'5. Information should be tailored to the needs, circumstances and wishes of the individual.

'6. Information should be based on the current available evidence and include a summary of the evidence and data in a form which is comprehensible to patients.

'7. Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.'

What then are the implications of these recommendations for nurses in practice?

The legal and professional context
In English law there is no right to full disclosure of all information concerning the nature and risks of treatment. To avoid liability in battery (non-consensual touching, which amounts to trespass to the person), health professionals must disclose the broad nature of the procedure to be undertaken (Chatterson v Gerson, 1981).

They are also obliged to disclose certain consequent risks of clinical procedures, and failure to do so may result in liability in negligence. However, English law has never recognised an obligation of informed consent as is recognised in other jurisdictions, such as the USA and Canada (Reibl v Hughes, 1980; Canterbury v Spence, 1972).

In Sidaway v Bethlem Royal Hospital Governors (1985), Lord Diplock stated that the level of information disclosed should follow the Bolam standard or test, which is used to determine whether clinical practice is negligent. The standard was defined in a famous case (Bolam v Friern Hospital Management Committee, 1957), which held that a doctor is not in breach of a duty of care if he or she acted in accordance with a practice accepted as proper by a responsible body of medical opinion. The standard also applies to other health care professionals. While the other members of the majority of law lords in Sidaway v Bethlem Royal Hospital Governors (1985) took slightly differing approaches, Lord Diplock's approach was followed in Gold v Haringey Health Authority (1987).

Over time, however, the professional practice standard itself has begun to alter and the trend today is towards enhanced disclosure of information to patients (General Medical Council, 1998).

At the same time the judiciary is increasingly willing to scrutinise the responsible body of professional practice and the information that body of practice provides (see, for example, Bolitho v City and Hackney Health Authority, 1997; Smith v Tunbridge Wells Health Authority, 1994).

Recently Lord Woolf stated that where there is a significant risk which would affect the judgement of a reasonable patient then it is normally the doctor's responsibility to inform the patient of that risk (Pearce v United Bristol Healthcare NHS Trust, 1999). This is an important statement towards enhanced disclosure.

Consent can be regarded positively as facilitating a partnership between the practitioner and the patient. But providing large quantities of information in itself does not necessarily mean that a patient can give truly informed consent to treatment. There is a difference between making information available and communicating it effectively to the patient. The Bristol inquiry's recommendations address this issue.

Consent as a process
The Bristol inquiry report emphasises that consent can be best regarded as a process. It states that:

'24. The process of informing the patient, and obtaining consent on a course of a treatment, should be regarded as a process and not a one-off event consisting of obtaining a patient's signature on a form.

'25. The process of consent should apply not only to surgical procedures but all clinical procedures and examinations which involve any form of touching. This must not mean more forms: it means more communication.

'26. As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives and about the likely outcome, to enable them to make a choice about how to proceed.'

The recommendations can be regarded as enhancing and reinforcing good practice. Section 3 of the UKCC draft of an updated code of professional conduct (UKCC, 2001), which is currently under consideration, emphasises the principles of consent and adds the helpful directive that 'patients' treatment decisions must be recorded and communicated to all members of the team'. It also states that 'patients have a right to make informed choices about their care' and to receive 'information about their condition'.

The Bristol recommendations remind us that consent is not just applicable to surgical procedures, but relates to all activities that involve 'touching'. This includes many nursing procedures, such as assisting with washing and dressing, taking blood pressure and applying dressings.

Providing quality information and responding to questions
Recommendations 4-7 of the Bristol inquiry report suggest that information given to patients should be based on evidence. It should also be presented in different ways, at the appropriate time and with supporting materials designed in partnership with patients. Providing evidence-based information in 'a form comprehensible to patients' (Recommendation 6) requires a high level of competence on the part of the nurse.

It was suggested in the House of Lords in Sidaway v Bethlem Royal Hospital Governors (1985) that while there was no doctrine of informed consent in English law, patients who ask questions about their treatment should be provided with information in response to their queries. But subsequently, in Blyth v Bloomsbury Health Authority (decided in 1987, reported in 1993), the Court of Appeal took the view that a patient - ironically herself a nurse - who had asked questions about the risks of an injectable progesterone-only form of contraception was not required to be given full information in response to her queries. It was simply the case that she should be given information in accordance with the approach that a responsible body of professional practice would take in such a situation.

The Bristol inquiry report states that 'patients should be given the opportunity to ask questions' (Recommendation 11). The corollary of this approach is surely that they should be provided with answers. It would appear to be difficult for professionals to justify withholding information in the future.

This potential movement towards greater transparency has implications for nurses. Are they best placed to provide information and answer questions, and what skills do they require to do so? This clearly depends on the context and the particular nurse's knowledge and experience. For example, specialist nurses are likely to have a particularly high level of knowledge and expertise in their own area of practice. As with any other area of practice, nurses should consider carefully before undertaking an expanded role. In this context, clause 6.1 of the UKCC draft code (UKCC, 2001) states: 'To practise competently you must possess the skills and abilities required for lawful, safe and effective practice without supervision. You must acknowledge the limits of your professional competence and only undertake practice and accept responsibilities for which you are suitably skilled and experienced.'

What appears most challenging is the statement in the Bristol inquiry report that 'information should be tailored to the needs, circumstances and wishes of the individual' (Recommendation 5). This approach confirms the move towards greater openness and has further ramifications. It implies that nurses have a good knowledge of the patient, perhaps knowing what she or he does and does not want and/or need to know.

This is aspirational, and in principle should be applauded, but what of the practice? Nurses generally spend more time with patients than any other health care professionals and are more likely to get to know them. However, when the time available to spend with patients is limited by shorter hospital stays and staff shortages, an approach that is tailored to the individual patient may be difficult to achieve. Also, although nurses receive theoretical and practical input on developing effective communication skills in the preregistration curriculum, is this enough to satisfy the demands of the Bristol recommendations?

The report also recommends other methods to promote improved communication, such as tape-recording 'when a diagnosis, course of treatment or prognosis is being discussed' (Recommendation 10). While tape-recording will provide the patient with a record of what has been said, will it lead to more self-conscious and inhibited practice on the part of nurses? Tape-recording will also require the provision of 'quiet rooms'.

There are also particular challenges in areas of health care where the information on treatments is uncertain. This has been discussed elsewhere (for example, Logan and Scott, 1996).

The Bristol inquiry report acknowledges the sometimes burdensome nature of information. Recommendation 14 states: 'Patients should be supported in dealing with the additional anxiety sometimes created by greater knowledge.' And recommendation 15 states: 'Patients should be told that they may have another person of their choosing present when receiving information about a diagnosis or a procedure.' This will require careful application.

It is undoubtedly true that certain information (for example, about a life-threatening diagnosis) may distress patients, and some may benefit from having a friend or family member present for support. However, we need to be wary of treating patients as less than autonomous individuals. What may be seen as supportive and respectful in one circumstance may be seen as patronising in another.

Conclusion
This article provides only a brief overview of some of the implications of the recommendations of the Bristol inquiry on consent to treatment. Clearly, other aspects of the law and professional guidelines also impact on this area. The most significant is the Human Rights Act 1998. This does not make health care rights explicit, but a number of articles are relevant to consent, such as the right to privacy in relation to information (Article 8) and to freedom of thought and expression (Article 10).

The practical ramifications of the Bristol inquiry can already be seen in government and professional guidelines. In a statement to the House of Commons in response to the Bristol inquiry, health secretary Alan Milburn commented that 'informed consent must be a cornerstone of a modern health service' (Department of Health, 2001a).

The recent 'Good practice in consent' guidelines from the Department of Health (2001b) provide additional general and specific advice on the practical implications of consent. The RCN's (2001) response to the Bristol inquiry also contains examples of good practice in relation to consent and information-giving in health care. There are further issues associated with imparting information to, and gaining consent from, children and those who have diminished capacity. However, these are beyond the scope of this article.

The provision of information to patients is a cornerstone of good practice in health care. Professor Ian Kennedy has said (Donnelly, 2001): 'It doesn't take any say-so from Whitehall for a nurse or doctor to treat a patient with courtesy and dignity. It doesn't take Alan Milburn to do that.'

Nurses need to ensure that they have the necessary knowledge, skills and attitudes to do this competently. They also need to be able to refer patients to the most appropriate source of further information.

Enhanced and additional training is undoubtedly necessary to ensure that the inquiry's aims with regard to the provision of information to patients are taken forward. The Bristol recommendations are to be welcomed as an important statement reminding us how crucial it is that we effectively communicate with patients.n

- The Bristol inquiry report is available on the internet at: www.bristol-inquiry.org.uk

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hpc standards of prifisioncy section 1 2.6 states we must understand informed consent?

ahhhhhhh



1 be able to practise safely and effectively within their
scope of practice
1.1 know the limits of their practice and when to seek advice or refer
to another professional
1.2 recognise the need to manage their own workload and resources
effectively and be able to practise accordingly
2 be able to practise within the legal and ethical
boundaries of their profession
2.1 understand the need to act in the best interests of service users
at all times
2.2 understand what is required of them by the Health and Care
Professions Council
2.3 understand the need to respect and uphold the rights, dignity,
values, and autonomy of service users including their role in the
diagnostic and therapeutic process and in maintaining health and
wellbeing
2.4 recognise that relationships with service users should be based
on mutual respect and trust, and be able to maintain high
standards of care even in situations of personal incompatibility
2.5 know about current legislation applicable to the work of their
profession
2.6 understand the importance of and be able to obtain informed
consent
2.7 be able to exer:bash:cise a professional duty of care
3 be able to maintain th

 

I spoke to the president of the largest malpractice carrier today at a Podiatry conference in the USA. He is a Podiatrist and board certified in foot and ankle surgery. He is also a past president of the APMA. I asked his opinion regarding this hypothetical case.

He told me that in the USA, going a bit too deep in debriding a callus on a PVD patient is not malpractice even if an amputation was the result. He told me that All podiatrists have at times cut a bit to deep when trimming deep seated calluses or mycotic incurvated nails. It happens, but it is not malpractice.

He also said that the patient could sue (he is not aware of any case like this ever happening either) and his company would defend it as in his view it is a normal risk but not deviation of care. People can sue for anything, but the chances a jury would deem a guilty verdict is very slim.



Steven

 

Patients may also turn to nurses for advice and clarification after a consultation with a doctor or another health professional.

Now what does that mean? Does it mean that if the doctor didn't inform the patient it becomes the duty of the nurse or other professional who may or may not have been present at the original interview? Does it spread responsibility or deflect it from the doctor or just generally muddy the waters because it sure doesn't make anything clearer, although it must contribute significantly to the income and job interest of the legal profession?

The report makes a number of specific recommendations in relation to patient information. It states, for example:

'4. Information about treatment and care should be given in a variety of forms, be given in stages and be reinforced over time.

'5. Information should be tailored to the needs, circumstances and wishes of the individual.

'6. Information should be based on the current available evidence and include a summary of the evidence and data in a form which is comprehensible to patients.

'7. Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.'


So that reduces the number of patients you can see to one per three hour session, ie 20mins for the treatment and the rest of the morning or afternoon to take them through the informed consent/consent to treatment bus trip. Sorry of course it's the other way round. Bus trip first and then treatment hopefully all nicely rounded of with a clotted cream tea (and I think to myself, what a wonderful world)?

What then are the implications of these recommendations for nurses (or anyone else in practice with thepossible exception of doctors) in practice?

Increase your dose of anxiolytics and carry on as before secure in the knowledge that you 'never died a winter yet'.

Bill

PS
Hi Tony. I took early retirement just over eleven years ago and moved to France full time a few months later. In the last year we (my wife and I) have changed to six months (the winter months) in England and six months in France. So far it's working well although at the end of each six month period it is very difficult to leave which ever country we are in and you also live with a permanent vague sense of being a refugee. It leaves you with a sense of not quite being British any more and not being French. Some people are never happy.

 

hi bill
my brother is the same but has a place in spain.
sometimes i feel he just goes coz he has a place there.

still i am very jealous!

Big thanks to Lab Guy for this its is really appreciated as is you good advice in this bill.

so if I have a patient sitting in my chair and as part of the assessment I explain that "ok mrs smith i will drill the fungal nail down so to give better penetration of the topical treatment and i will reduce the nails.
and reduce some of the hard skin under your foot and we will try an offloading insole is that ok with you"

And she said yes that's fine.

Is this informed consent?

thanks again guys brill comments
tony