Case study 1: General practice

Baby Anthony was born via normal delivery at term. He was breastfeeding well and he and his mother, Belinda, were discharged the next morning.

Later that day, Belinda became concerned that Anthony’s skin tone was beginning to develop a yellow hue, so she asked her mum what she thought. Belinda’s mum suspected that Anthony was mildly jaundiced, but knew from her experience of Belinda developing jaundice as a newborn baby, that it is common and usually harmless in young babies, especially breastfed ones, so she reassured her.

Two weeks went by and Anthony’s jaundice had failed to resolve. He was not feeding well or gaining weight. Belinda took him to the GP, Dr Visconti, to ask his advice.

Dr Visconti examined baby Anthony and advised Belinda that the jaundice was mild, probably due to breastfeeding (as is the case in approximately 10% of breastfed babies for up to one month post-delivery) and would likely go away in the next few days. He reassured Belinda there was no need to worry, and said that she should come back if Anthony’s colour didn’t improve in a few days.

Two days later, Belinda returned to the GP surgery, anxious because Anthony had become floppy and had lost all interest in feeding. Dr Visconti realised that Anthony was far more jaundiced than he’d previously thought, and that he should have referred Anthony to Paediatrics for measurement of his blood bilirubin concentration when Belinda had brought him to the surgery two days ago. Dr Visconti sent Anthony to the local children’s Accident and Emergency unit for urgent evaluation.

It transpired that Anthony had developed a dangerous concentration of bilirubin in his blood, which means he needed a prolonged admission to hospital, phototherapy treatment and a blood transfusion. It is possible that exposure to this high concentration of bilirubin may have caused long-term damage to Anthony’s brain.

What should Dr Visconti do?

  • Should he assume that the paediatricians who are now treating Anthony at the hospital will explain what happened? They will be in a better position to explain the likely course of baby Anthony's treatment and the possible outcomes, especially as he seems to be getting better?
  • Should he contact Belinda and apologise for not measuring the bilirubin concentration when she brought Anthony to the surgery the day after he was born?
  • Should he wait to see whether Anthony experiences any developmental delays and, if so, apologise to Belinda at that point?

Who should apologise?

In paragraph 9 of Openness and honesty when things go wrong we say that when you realise that something has gone wrong, after doing what you can to put matters right, someone from the healthcare team must speak to the patient or those close to them. Paragraph 9 also says that the most appropriate person to speak to the patient or those close to them will usually be the lead or accountable clinician. This is because that person will usually have an ongoing relationship with the patient, and will be in the best position to know the details of what went wrong and what the effects are likely to be.

Because Dr Visconti has realised that he ought to have carried out the bilirubin test earlier, either he or the paediatricians should explain this to Belinda and apologise.

It doesn’t necessarily have to be the person who is responsible for the adverse incident who apologises for it: much of the time it won’t be clear who or what is responsible. From the patient’s point of view, however, they’ve suffered harm or distress because of something going wrong, and they have a right to expect an apology and explanation. In paragraph 16d we suggest that saying ‘I am sorry’ doesn’t mean taking personal responsibility for someone else’s mistakes. But it is likely to be more meaningful to the patient than a general expression of regret.

Dr Visconti shouldn’t assume that the paediatricians will offer an explanation and apology to Belinda. As paragraph 5 says, while we don’t expect every team member to take responsibility for talking to the patient or their family, we do expect doctors, nurses and midwives to make sure that someone has taken on that responsibility, and to support that person if necessary.

Does the duty of candour apply if no harm is immediately apparent?

In paragraph 8, we say that this guidance applies not only when something goes wrong with a patient's care and they suffer harm or distress as a result, but also in situations where the patient may yet suffer harm or distress as a result of something going wrong. Although Anthony is showing signs of improvement now, there’s a chance that he may show developmental delays in the future as a result of the high concentrations of bilirubin he was exposed to. This might have been prevented if Dr Visconti had ordered the test when Belinda first attended the surgery with Anthony, and so the duty of candour does apply.

When should I speak to the patient or those close to them?

As paragraphs 8 and 9 make clear, the point at which you realise that a mistake’s been made is the trigger for the duty of candour to come into effect, not the point at which harm or distress is apparent. So Dr Visconti shouldn’t wait to see if Anthony has developmental difficulties, he should speak to Belinda – or make sure that someone is going to speak to Belinda – as soon as possible.