The LMC is regularly involved in representing and supporting doctors who have been identified as having “performance” issues. The LMC has identified a number of themes which recur, and this regular feature will highlight these, so that our members can avoid these pitfalls.

A recent case involved a GP who documented parts of an examination that other parties present stated did not occur. In this case, the patient became unwell from a linked condition which may have been picked up if the documented examination had occurred.

The case was reported to NHSE and investigated.

This case highlights not only the importance of appropriate examination, but that making the examination being undertaken clear to the patient and other parties present. It also highlights that if a part of an examination is omitted, a reason and any remedial action required to complete any parts deemed necessary should be documented.

In line with GMC Decision making and consent content:

Keeping patients’ medical records up to date with key information is important for continuity of care. Keeping an accurate record of the exchange of information leading to a decision in a patient’s record will inform their future care and help you to explain and justify your decisions and actions.

And GMC Openness and honesty when things go wrong: The professional duty of candour:

Every health and care professional must be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that health and care professionals must:

• tell the person (or, where appropriate, their advocate, carer or family) when something has gone wrong
• apologise to the person (or, where appropriate, their advocate, carer or family)
• offer an appropriate remedy or support to put matters right (if possible)
• explain fully to the person (or, where appropriate, their advocate, carer or family) the short and long term effects of what has happened.