QUESTIONS

Question 1

how do you recognise potentially abusive or seriously

harmful sexual activity in a young person?when you should consider sharing information

Answer 1

Examples of when you should consider sharing information
are where (GMC 2011a: 28):
• The young person is too immature to understand.
• A big difference in age is ringing alarm bells!
• The partner is in a position of trust – e.g. the young per
son’s teacher.
• There is a force/threat suggesting emotional, psychologi
cal or physical pressure.
• Drugs and/or alcohol are involved.
• The child is under 13 years (under 12 years in Scotland

Generally speaking, a young person may feel more relaxed
about confiding personal information to you, as someone who
has been involved early in their treatment. Respect this and try
to get as much information as possible, as it may be the only
opportunity. If you suspect something untoward, it is often best
to get the parents involved – with the young person’s permis
sion of course. Beyond this, you may have to notify social
services. Remember to record your concerns and justify any
decisions made by your senior about the disclosure. You also
need to be honest with the patient about the information you
are disclosing.).

Question 2

What are the six princi
ples by which patient-identifiable information should be
utilised:

Answer 2

The Department of Health (DH 2010) devised six princi
ples by which patient-identifiable information should be
utilised:
1. Justified – what is the purpose of sharing the
information?
2. Necessary – how will sharing this information benefit
the patient?
3. Minimum – only share what needs to be shared. For
example, if you are referring a patient with a broken wrist
for physiotherapy, you don’t need to tell the physio that they
also are being treated for chlamydia. Be responsible and
think about what you share.
4. Need-to-know basis – as above, make sure you tell them
what they need to know and nothing more.
5. Be aware of your role – you are their doctor, respect the
fact that patients trust you and be aware that you have a duty
to uphold that confidence in the public eye. Doctors without
trust are like buckets with a hole in: not very good at all!
6. Legal – if you are unsure of a boundary, always check
it with a senior before you share anything.

Question 3

When should Caldicott guardians be involved?

Answer 3

These are typically board-level clinicians who resolve
local issues regarding information-sharing that go beyond the
level of a senior colleague. Typical situations in which Caldicott
guardians become involved include (DH 2010):
• police requesting information
• a patient requesting for their records to be deleted
• serious confidentiality breaches
It is enough simply to know about the existence of these
figures. You should get in touch with your foundation pro
gramme clinical lead or foundation programme co-ordinator for
all concerns involving the legal department. FY1s are not in a
position to handle such matters, nor are they expected to do so.

Question 4

What should you do if confidentiality is breached?

Answer 4

. If something does happen, the Medical Pro
tection Society (MPS 2010) argues you can best handle this by:
1. Establishing what happened and what went wrong.
2. Offering the patient an explanation and an apology.
3. Giving assurance that lessons have been learned.
4. Identifying how mistakes can be avoided in the future.

Question 5

What should you do if you think a patient is not fit to drive?

Answer 5

The Driver and Vehicle Licensing Agency (DVLA) are respon
sible for road safety and have strict guidance on health condi
tions and fitness to drive. Three things to note are:
1. It is the driver’s legal responsibility to notify the DVLA.
2. You are responsible for telling the patient that their condi
tion may affect their driving (see Figure 2.2).
3. Document in the notes what you have told them.
Some common conditions that patients will need to notify
to the DVLA are:
• Epilepsy or a seizure.
• Diabetes mellitus on any treatment that can cause hypoglycaemia.
• Acute psychosis.
• Severe mood disorders or neuroses: especially if they may
attempt suicide at the wheel.

Alcohol and drug abuse: especially if you suspect they may
drive whilst intoxicated.
Some common conditions where you would advise a period
of time off from driving, but they don’t need to formally notify
the DVLA are:
• Stroke/TIA
• Acute Coronary Syndromes (ACS)
The criteria for those with “group 2 entitlement”, i.e. lorry
drivers, differ from this. Make sure you enquire about occupa
tion so that the patient has the correct information.
If you are unsure what to do, your options are to (GMC 2009b):
1. Seek advice from a senior colleague.
2. Consult your local policy document or the DVLA (2011)
“At a glance guide to the current medical standards of fitness
to drive”. Here you should get the information you require
about a variety of disorders and conditions that can impair a
patient’s fitness to drive.
3. Seek advice from the DVLA or their medical advisor; prob
ably not your first port of call as this will take time.

Question 6

What happens if your patient disagrees with you?

Answer 6

Advise them to seek a second medical opinion but not to drive
in the meantime.
What happens if they ignore you and carry on driving anyway?
• Educate them about the consequences of driving against
medical advice to try and stop them; but be reasonable – you
cannot use force.
• Use persuasion of friends and relatives if appropriate.
What happens if that fails?
THEN you are advised to notify the DVLA – but tell the patient
that you are going to do this first.

Question 7

You are in A&E and you are notified that a patient is

coming in with a stabbing injury, what should you do?

Answer 7

Obviously your A to E approach and acute medical assessment
come first, but you need to take account of the following:

The history – you need to find out if this was self-harm or
an attack. The police need not be informed for the former.
2. In the case of the latter, inform a senior colleague. Advise
them you think the police should be informed in the interests
of the safety of both patients and staff.
3. If you are responsible for informing the police, DO NOT
disclose the patient’s information at this stage, it is unnecessary.
All the police need to be aware of is the incident.

Question 8

The police arrive and wish to see the patient, but you feel

the patient is not up to it. What next?

Answer 8

Your duty of care is to the patient and you should explain this
to the police. When you feel the patient is ready, you can then
ask them whether they wish to speak to the police.

Question 9

A crime has been committed, but the patient is
unconscious so you can’t gain consent to reveal their
details to the police. What should you do?

Answer 9

You can disclose confidential information as required by law
and in the public’s best interests. This is because others may be
at risk of injury and/or it may aid prosecution for the crime
(GMC 2009c). With any matters concerning confidentiality
you should be seeking advice from the consultant in charge.
Disclosing confidential information should never be rushed.
Finally, if you are required to disclose anything, you must
protect yourself by recording all the reasons for information
disclosure in the patient’s notes.

Question 10

You find out that this is a domestic dispute and the victim
does not want to press charges. What should you do?

Answer 10

Whilst it is appropriate to ask patients to disclose information
necessary for their protection, you should abide by a competent
adult’s refusal if the risk of harm is only to themselves and not
to others. However, you should warn them of the risks if they
do not consent to disclose. You should also give them ways to
seek help themselves, e.g. by informing them about domestic
violence support groups. If children were involved in this case
of domestic violence, however, you would be obliged to disclose the information to social services
Again, it is important to reiterate that, whilst you
should be aware of what to do in difficult situations concerning
confidentiality, you should always seek senior advice.

Question 11

Consent in under 18’s

Answer 11

If a child is having an operation, it is best practice to have consent
from both parents, but legally you only need one person with
authority to give permission to treat. In an emergency, you don’t
need permission at all, as you can operate in the child’s best
interests. If there is a conflict that cannot be resolved informally,
consult a senior as they may need to inform the legal department.
Your trust will have a local policy on this, so it is advisable to
familiarise yourself with it early on – or at least know where
to access the information. Any decision made to act in a patient’s
best interests must be able to stand up if challenged.

Question 12

Can a young person be seen without a parent?

Answer 12

deally a young person should have someone with them.
However, you would never want to give them the impression
that they could not get medical help – especially if it is some
thing important that they do not feel comfortable telling their
parents about (see Figure 2.3). You may also want to see them
on their own if you suspect there is something odd about the
family dynamics. Always offer a chaperone for any physical
examination if they are on their own and record whether they
accept or decline.
Note: divorce or separation does not make any one parent less
responsible for their child.

Question 13

What about a young person under sixteen years who
wants contraception, an abortion or an STI check without
their parents knowing?

Answer 13

This scenario is more likely to present working as a foundation
doctor either on a GP or GUM rotation. It is recommended that
you treat a young person in their best interests, provided that
you cannot persuade them to talk to their parents and that they
fully understand both the advice and the consequences. You
may be recognising a pattern here, but always seek advice from
a more experienced colleague; your job is to flag up situations
like this to them so they can be handled in the most appropri
ate manner. This does not make your role any less important
however as you do not recognise where issues can arise, then
problems may occur. Your job as an FY1 includes gathering as
much information as possible to pass onto your seniors.

Question 14

You have concerns about a parent’s ability to cope with

their child, what should you do?

Answer 14

This scenario is more likely to present itself in A&E. For any
patient who comes in with a serious domestic injury, mental
health issue or a history of drug or alcohol abuse, you must
check whether they have any children. It may be that you need
to put in a referral for social services as these children could
well be at risk and have fallen completely under the radar.

It is preferable that you gain consent from the parent when
disclosing information to social services. Agree with the parent
the information that you will share with social services. The
information you will need is all on the proforma but will
include:
• Patient details.
• Details of all the individuals in the household.
• What the problem is.
• Other agencies involved e.g. the school they go to, any health
visitors.
It is not always necessary to get consent to contact social
services. If you feel more harm would be caused to the child
by not disclosing the information – for example if the parents
would harm the child in some way – then you should not get
consent and inform a senior straight away. In this instance,
social services may be approached by telephone prior to sending
the report in writing. This assessment is made on a case-by-case
basis dependent upon the sense of urgency. Again, you would
flag this up to a senior as this decision should be made by a
more experienced colleague.

Question 15

Who would you seek advice from in situation when a child in danger?

Answer 15

For your reference, the GMC (2011b: para 60) advise the
following order of preference for seeking advice:
1. An experienced colleague.
2. A named practitioner for child protection – your foundation
clinical lead would help you with this.
3. A Caldicott guardian.
4. The GMC or another professional body (e.g. BMA, RCP)
or defence body (non-EU).
Only the first two points are applicable to the FY1 as the founda
tion school would liaise with three and four on your behalf.

Question 16

If social services call and ask for the medical records of

carers of the child, what should you do?

Answer 16

You should consider any specific requests for information very
carefully. Only very rarely would you disclose whole records. and this would not be your decision to make. It is most appropriate to get your consultant to review any records, for which
you would need the permission of the individual concerned.
With any case, you should be aware that information can be
disclosed if it is in the public interest. Although this is not your duty, it is important to be aware of it so that best practice is adhered to. If you see something wrong that could potentially breach confidentiality, you are expected to speak up: this is an
aspect of ‘integrity’ that is often mentioned.

Question 17

A young girl is diagnosed with cancer and her parents do

not want you to tell her, what should you do?

Answer 17

Although breaking bad news is not the responsibility of an FY1,
you should explore with the parents their reasons for not telling
their daughter. You should explain to them that you should
assess the capacity of the child and deliver information in a
way they can understand. This is because children and young
people usually want to know about their illnesses.
Exceptions to this are when:
• The information would cause “serious harm”.
• The child specifically requests that someone else makes the
decisions for them.
You should not withhold information unless the patient
refuses knowledge of that information. The exception to this
is if the information would cause “serious harm”, which is
more than making the patient upset or meaning that they
might refuse treatment (GMC 2010). For example, if a child
was particularly unwell, and the parents felt that giving the
diagnosis would cause the child more harm and distress, you
should get a senior to review the situation. However, you
should also go and see the patient yourself and make your
own judgement about the situation. If you agree that it would
cause further harm, record this in the notes. The decision to
withhold the information should be regularly reviewed and
the information shared at the earliest possible opportunity. As
a junior doctor, you should be aware of the patient’s prefer
ences at all times even though it will not be your sole respon
sibility to make these decisions. You are expected to advocate
for your patients, and get as much information as possible to
inform your colleagues.

Question 18

What to do if you have made a mistake?

Answer 18

• Apologise to the person it affects: patient, colleague, relative.
• If it concerns a patient, document the apology in the notes
and explain what problem was.
• The majority of mistakes that happen will be minor things;
you can simply fill in a Clinically Adverse Event (CAE) form,
learn from the mistake and move on.
• If the mistake is significant, inform your seniors.
• Complete a reflection piece within your eportfolio.

Question 19

How to deal with complaints against you?

Answer 19

If a complaint is made against you, obtaining advice and support from your consultant and defence union early on can help ease anxiety and smooth the process
Informing your consultant and defence union are the two most important things to do in the event that a complaint is put in against you. They can give you advice on what to do next. It is also useful to gain support from those close to you as you are likely to feel stressed until it is over with.

You do not need to talk with the GMC so early on in proceedings – hopefully it will not go that far. However, it would not be as damaging as to try and contact either witnesses or the patient himself. Doing either of these things would be seen as interfering with the process and this could reflect badly on you if anything comes of the complaint. Discussing the complaint with the patient is likely to aggravate him and the situation which makes it the worst option.
you?

Question 20

Most common drugs with prescription errors in NHS?

Answer 20

Prescribing mistakes cost the NHS £500 million annually in
England and Wales (DH, 2001). Nationwide, 5–7 % of acute
medical admissions are due to prescribing errors, 50% of which
are attributed to just four drugs: antiplatelets (16%), diuretics
(16%), non-steroidal anti-inflammatories (11%) and anticoagu
lants (8%) (Howard et al. 2007). P

Question 21

What if I am asked to gain written consent for something

I’m unsure of?

Answer 21

Being asked to gain written consent for a procedure that you
are not so comfortable with may be something you are faced
with as a junior. The way you manage this is important. The
GMC (2008a) recommends that the responsibility for consent
lies with the person doing the procedure. If someone delegates
gaining consent to you, they are still responsible. Thus, whoever
delegates the responsibility to you should make sure you are
familiar with and understand the procedure and the benefits and
risks involved. In this case you have two options:
1. Explain you don’t yet have the experience but that you
would like the opportunity to learn.
2. Begin the consent process and do what you can, leaving the
formal signing to a more experienced colleague.
Judgement in this situation has to be made on the basis of
your own knowledge, recognising where your limitations are.
If you feel comfortable explaining some aspects of the proce
dure, then the second option is preferable. This assists the
consent process but leaves the formalities to your more expe
rienced colleague.

Question 22

What should I do if a patient doesn’t want to know?

Answer 22

Sharing information and knowing how much to share is central
to good decision-making, but difficult to gauge. This can be
daunting at first. The GMC (2008a) recommends tailoring all
discussions to the patient without assuming the information
they want. Ultimately you should:

Find out why they don’t want the information.
2. Respect their decision not to have the information, BUT
3. Give them enough to gain consent: e.g. why you are doing
it, a brief description of the procedure, any serious risks
involved and whether they will have any pain afterwards.
4. If they won’t have even the basic information, write down that
this is what has happened and explain to them what that means.
For example, this may mean that their consent is not valid.

Question 23

What if a patient with capacity wants someone else

to decide?

Answer 23

If the patient has capacity, the bottom line is that no one else
can make the decision for them. The GMC (2008a) recom
mends that you:
1. Explain that it is important that they understand the options
and the implications of any treatment.
2. Find out why they don’t want the information.
3. Iterate that their consent won’t be valid if they do not have
this information.

Question 24

What about consent in an emergency?

Answer 24

The GMC (2008a) recommends that you should gain oral
consent in these circumstances but the patient should still have
all the information they need. Record this in their notes. If the
patient is unable to consent then you can act in their best inter
ests (see Chapter 4).
Ultimately you should recognise that, as a junior, you have
only been qualified for a short time. Issues of consent are
highly complex and the consequences of one decision over
another are largely beyond what you can see. You must share
this responsibility and find someone with more experience to
give you advice. If something such as a breach of confidential
ity happens because you have not gained consent, it cannot
be taken back. Nevertheless, the right actions can be sought
afterwards.

Question 25

Situations where its acceptable to silence bleeps?

Answer 25

During handover (see Chapter 6).
• When breaking bad news (see Chapter 4).
• During protected teaching time.

Question 26

When can anonymised medical images of patients can be shared?

Answer 26

The rapid spread of smartphones, digital cameras and related technology has brought new dilemmas to patient care. In response to this the GMC issued guidelines in 2011 - ‘Making and using visual and audio recordings of patients’.

There are however no problems with sharing anonymised patient images in certain situations. The GMC states: Consent to make the recordings listed below will be implicit in the consent given to the investigation or treatment, and does not need to be obtained separately:
Images of internal organs or structures
Images of pathology slides
Laparoscopic and endoscopic images
Recordings of organ functions
Ultrasound images
X-rays

Using medical images as in above scenario is extremely common and a normal part of teaching and patient care. The aim of the question is too tease out a combination of common sense, real-life hospital experience and knowledge of GMC guidance.

As there are no problems with using such images the best response is to do nothing (E). If you’re ever not sure then speaking to some one more senior is always a good first step (C). It is better (especially for you!) to speak to your consultant in private (A) rather than halt a meeting in front of everyone (B). Involving a patient’s relatives in your misunderstanding is likely to make them anxious about the quality of care their loved one is receiving (D).