COVID-19, consent and accessibility in GP practices

Weightmans recently acted in a case which involved a patient mistakenly receiving a contraceptive injection instead of a B12 injection. A contributing factor was the treating nurse’s facial covering led to a miscommunication with the deaf patient. Whilst the facts of this case are unusual, it holds valuable lessons for all GP practices.

PPE may limit a patient's ability to communicate

In this case, the fact that the nurse was wearing a mask hindered the communication between the parties. Unfortunately, it led the patient to believe that she was being called for her appointment when in fact a different patient was being called.

Because patients were queuing outside due to the COVID-19 pandemic and social distancing guidelines, the patient’s name was not displayed on an electronic board which may have prevented this mistake.

However, if the treating nurse had asked the patient to confirm their name and date of birth before the assessment began, the mistake would have been caught at that stage. Unfortunately, the error was only realised after the patient had left the surgery.

Wearing personal protective equipment can impact communication in healthcare environments. Therefore, efforts should be made to remind staff about this burden and to utilise alternative communication methods.

The National Healthcare Communication Programme has produced guidance entitled Communication skills for staff wearing PPE which has suggestions for clinical staff to overcome the obstacles presented by PPE and ensure good communication between clinician and patients. Some key points include:

• Building the relationship by making good eye contact and using body language to communicate information;
• Listening carefully to questions and concerns and summarising the patient's problem. Use verbal empathy and clear open-ended questions;
• Speaking clearly and at a slow pace. Check the patient's understanding and ask questions.

In addition, patients should be asked to confirm their name and date of birth before the assessment begins to avoid any patient mix-up as occurred in this instance.

If these steps had been taken, the error may not have happened. Therefore, it is important that staff are made aware of the specific difficulties of communicating whilst wearing PPE and how they can adapt the way they communicate with patients to ensure the proper standard of patient care is achieved.

Whilst the consequences for the patient in this case were not severe or long lasting, a breakdown in communication could potentially have fatal consequences. Communication between patient and clinician is key and it is essential that any barrier to communication, including those presented by the COVID-19 pandemic, are overcome. 

Informed consent should be taken even for minor procedures

In this case, the practice nurse had not obtained the patient’s informed consent to perform the injection. If she had, the patient would have not consented to receiving the contraceptive injection and the error would have been avoided.

As GP practices increasingly perform more procedures, it is crucial that staff are made aware of their duty to obtain informed consent prior to any treatment being provided. This involves providing information about all material risks, which includes any risk to which a reasonable person in the patient's position would attach significance.

The GMC has published guidance on decision-making and consent (2020). Doctors must be satisfied that they have a patient’s consent or other valid authority before providing treatment or care. The purpose of this guidance is to help doctors to meet this standard. Some of the key points include:

• Clinicians should explain what they are going to do and why, make it clear that the patient can refuse, stop immediately if they refuse and be alert for any sign that they may be confused or unhappy;
• Doctors should find out what is important to a patient so they can identify the information they will need to make the decision. The discussion should be tailored to the individual patient in a way they can understand;
• Clinicians should discuss recognised risks of the treatment, any effect on the patient's individual circumstances, risks of harm and any benefits.

If informed consent had been taken before the patient was injected, the nurse would have realised the mistake before it was too late. Failure to obtain adequate consent can result in patient harm and may result in future claims. It is therefore important that all staff in GP practices who have patient contact are aware of the importance of taking informed consent and are given training on the subject if necessary.

Practices and practitioners need to be accessible for patients who are deaf and visually impaired

It is very important that GP practices are accessible for those with visible and invisible disabilities, visual impairment, and sensory loss. Since 1 August 2016, all organisations that provide NHS care and/or publicly funded adult social care are legally required to follow the Accessible Information Standard.

The Standard sets out a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients and their families.

The guidance indicates that GP practices should have:

• An accessible communication policy which is in line with the Accessible Information Standard and an agreed approach to identifying individuals with information/communication needs relating to a disability, impairment or sensory loss and processes for booking longer appointments.
• Clear processes for recording individuals’ information/communication needs in line with the standard and flags, alerts or prompts established to highlight/make individuals’ information/communication needs ‘highly visible’ to staff, supported by relevant prompts to action.
• A range of ways for individuals with communication needs to contact the service, and for the service to contact them.

The CQC will assess practices on the criteria, as described in the guidance, by looking at how the service assesses for disability-related information and communication needs, how they record this and what systems they put in place to ensure these needs are met.

They also look at how the service flags patients’ information and how that information is shared within other health and social services.  

Arguably, if these standards had been followed then the error in this case may have been avoided. It is essential for practices to meet this standard to ensure that they are accessible and accommodating for all their patients.

Failure to do so may have a negative impact on patient care, result in criticism by the CQC, negatively impact the reputation of the practice and possibly result in legal challenges. Training should be provided to staff to explain the Accessible Information Standard and the detailed processes to be followed.

Conclusion

As well as concluding this matter within three months of receiving instructions, Weightmans provided the GP practice with some recommendations to help them learn from the incident and prevent future incidents from occurring.

Whilst this was a rare and unusual case, it serves as a timely reminder to ensure policies and practices relating to consent and accessibility are followed. Also, it highlights the challenges that practices continue to face because of the COVID-19 pandemic.