AUTUMN 2014 SUMMONS AN PUBLICATION FOR MEMBERS

• Saying sorry • GDC responds • A most serious case indeed • essenT iaL MediCaL TexTbooks MddUs members SAVE 20% on all medical books when you order online at www.crcpress.com, enter discount code LBM25 at the checkout. FREE standard shipping worldwide. expires 31/12/2014

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MDDUS .indd 1 12/06/2014 11:38:41 CONTENTS essenT iaL IN THIS ISSUE WHY do doctors fi nd it diffi cult to say sorry? It’s a key question in this on top of a recent Professional Standards Authority review in a post-Francis NHS with calls for a statutory duty of candour on which the GDC failed to meet seven out of 10 good regulation MediCaL TexTbooks top of professional obligations to be open and honest in standards in fi tness to practise. On page 10, chief executive and admitting errors. registrar Evlynne Gilvarry addresses some of the criticisms. Psychiatrist Aaron Lazare – author of the book On Apology MDDUS case fi les contain numerous examples of negligence MddUs members SAVE 20% on all medical books when you – wrote: “We tend to view apologies as a sign of a weak character. claims resulting from failed joint and soft tissue injections – not But in fact they require great strength. Despite its importance just in technique but in poor consenting and explanation of risk. On order online at www.crcpress.com, enter discount code LBM25 apologising is antithetical to the ever-persuasive values of winning, page 16, Dr Lucy Douglas highlights new guidelines on best at the checkout. FREE standard shipping worldwide. success and perfection. The successful apology requires empathy practice from the Primary Care Rheumatology Society. and the security and strength to admit fault, failure and weakness. We also have Steve Ashton from Law at Work (p. 18) discussing expires 31/12/2014 But we are so busy winning that we can’t concede our dental practice health and safety. Do you have risks hiding in plain own mistakes.” site? And on page 14 Allan Gaw recounts a medico-legal case On page 12 of this issue Dr John Dudgeon – a medical adviser at dating back to the founding of MDDUS and involving the the Scottish Public Services Ombudsman – explores the need for a domiciliary use of chloroform. Would the outcome have been culture change in attitudes to acknowledging mistakes. diff erent if ruled on by a judge today? Quite possibly not. The GDC has being facing increasing levels of fl ack over proposals to raise the annual retention fee by 64 per cent – and Jim Killgore, editor

SAYING SORRY 12John Dudgeon – GP and medical REGULARS adviser with the SPSO – calls for a 4 Notice Board culture change in attitude among 6 News Digest doctors towards saying sorry 8 Risk: What are my chances, doc? 9 Ethics: An ethical ecology A MOST SERIOUS CASE 10 Q&A: Evlynne Gilvarry, GDC chief 14 14INDEED executive and registrar What began with a simple work- 20 Case studies: Lunchtime fracas, related injury in 1902 would end a Capacity to consent, Post-op year later with a death, a court case complication and a piece of medico-legal history. 22 Addenda: Fatal self-confi dence, Allan Gaw investigates Scarifi cator, Crossword and Vignette: Charles Hawkins Craig CLINICAL RISK REDUCTION Macmillan, medical publisher 16Lucy Douglas highlights new guidelines on best practice in joint and soft tissue injections HIDING IN PLAIN SIGHT 18Health and safety expert Steve Ashton considers some risk areas in dental practice so obvious they 16 become invisible

Cover image: Editor: Please address Design and production: Highland Landscape Jim Killgore correspondence to: CMYK Design by Denis Peploe Associate editor: 0131 556 2220 Son of Samuel Joanne Curran Summons Editor www.cmyk-design.co.uk John Peploe, the MDDUS noted Scottish Editorial departments: Mackintosh House Colourist, Denis MEDICAL Dr Jim Rodger 120 Blythswood Street Peploe inherited a DENTAL Mr Aubrey Craig Glasgow G2 4EA particular feeling for LEGAL Simon Dinnick Printing and distribution: the landscapes of the Highlands. This RISK Peter Johnson [email protected] L&S Litho painting depicts a landscape in the Scottish Highlands: Don’t forget to connect with us on social media to be the first to hear the sombre colour palette adds a melancholy mood to Summons is published quarterly by The Medical and Dental Defence Union about author news, discounts and offers the vast space depicted and is reminiscent of the style of Scotland, registered in Scotland No 5093 at Mackintosh House, demonstrated in the artist’s other Highland pieces. 120 Blythswood Street, Glasgow G2 4EA. • Tel: 0845 270 2034 • Fax: 0141 228 1208 Like us on Facebook www.facebook.com/CRCPressMedical Art in Healthcare (formerly Paintings in Hospitals Email: General: [email protected] • Membership services: [email protected] • Follow us on Twitter @CRC_medical Scotland) works with hospitals and healthcare Marketing: [email protected] • Website: www.mddus.com communities across Scotland to encourage patients, The MDDUS is not an insurance company. All the benefi ts of membership of MDDUS are discretionary visitors and staff to enjoy and engage with the visual as set out in the Memorandum and Articles of Association. arts. For more information visit www.artinhealthcare. The opinions, beliefs and viewpoints expressed by the various authors in Summons are those of the authors alone org.uk Scottish Charity No SC 036222. and do not necessarily refl ect the opinions or policies of The Medical and Dental Defence Union of Scotland. For more info, sample pages and to view the entire collection, visit: http://bit.ly/CRCMedical AUTUMN 2014 3

MDDUS .indd 1 12/06/2014 11:38:41 NOTICE BOARD

MDDUS wins eco award The success follows 18 months of hard led by our staff Carbon Group over the past MDDUS has been awarded the work by members of the MDDUS Carbon year and a half. prestigious Carbon Trust Standard for its Group which was set up in January 2013 “This reflects the Union’s commitment to success in reducing carbon emissions. with the goal of implementing more sustainable, responsible business practices A campaign spearheaded by the Union’s environmentally friendly business practices both now and in the future. staff Carbon Group achieved a reduction of in its Glasgow offices. “We hope this award will be valued by 3.2 per cent in carbon emissions at its Over this period, the company and the both our staff and our members and will be Glasgow headquarters between 2012 and Carbon Group have introduced a number of taken as a sign that we take our corporate 2013. Overall gas usage fell by 12 per cent new measures including the installation of social responsibilities seriously.” while energy costs were slashed by a energy efficient lighting, a heating system Darran Messem, Managing Director, quarter. MDDUS staff vehicles for the upgrade, improved insulation of windows, a Certification at the Carbon Trust added: “It Glasgow office also recorded a drop in fuel move to petrol company vehicles and a staff is genuinely impressive to see such a well consumption of almost four per cent. awareness campaign. It’s hoped the scheme mobilised internal team, focused on creating The Standard is a mark of excellence will be extended to MDDUS offices in and delivering reduction strategies to awarded by the Carbon Trust in recognition London in the near future. achieve the Standard. We congratulate the of a company’s efforts to reduce its carbon MDDUS Chief Executive Professor Gordon team at MDDUS for all their hard work, footprint. It is valid for two years and firms Dickson said: “I am very proud that MDDUS which serves to show other organisations who want to retain it must continue to cut has been awarded the Carbon Trust what can be achieved through a focused emissions year-on-year. Standard following a committed campaign approach.”

Caution advised over waiting list initiatives contract. However, it is not true to say that NHS-type indemnity THE NHS has been under increasing pressure to maintain “follows the patient”. Doctors must not simply assume that if and reduce the length of time patients wait for procedures. To these are patients undergoing procedures as NHS patients that this end many hospitals have out-sourced procedures to private they are automatically covered by NHS indemnity. hospitals. Others have used their own NHS staff to undertake Members who wish to undertake this kind of extra work must extra sessions within their own and other hospitals. be clear or have it made clear to them whether the procedures Patients within the NHS are protected by NHS indemnity under are covered by one of the NHS indemnity schemes. various schemes.In England, trusts contribute to the Clinical If the work is not so covered, members will have to check if Negligence Scheme for Trusts (CNST) and are thus covered by their current subscription is adequate and appropriate to allow NHS indemnity. Some other private institutions may also join the them to undertake this extra work. CNST scheme and so become indemnified through the same Members must ensure that they fully understand the terms on scheme.There are similar schemes in Scotland (CNORIS) and which they take on such work and, more importantly, carefully Wales (WRP), and Northern Ireland has a risk-pooling scheme. check the terms of the agreements or contracts for professional Doctors may be invited to undertake these waiting list indemnity requirements. initiatives and may be free to do so within the terms of their Contact our Membership Team if in doubt.

Dr Jim Rodger retires from MDDUS In 1980 Jim became MRCGP and later IN SEPTEMBER Dr Jim Rodger retired served on both the Scottish and UK Councils. It as head of professional services at MDDUS was through the RCGP that he met Bill after 21 years of providing advice and support Mathewson, who was then head of the medical to members. division at MDDUS, and Jim developed an Jim joined the Union in 1993 having practiced interest in the work of the Union. In 1993 a for 18 years as a GP in Hamilton near Glasgow. position became open at MDDUS and Jim His interest in medico-legal matters sprung in applied. part from his experience working as a police “It was difficult leaving clinical practice,” he surgeon. He developed this interest further by says. “But it seemed an exciting prospect in an earning a Diploma in Medical Jurisprudence area I was very interested in.” from the Worshipful Society of Apothecaries of In 2005 Jim was promoted to head of London. medical advisory services and later in 2008 he

l “NO” VOTE IMPLICATIONS be devolved to Scotland. MDDUS the interests of all our members l FORENSIC OR POLICE As all members will be aware, does not anticipate that there will are taken into account.The Union PHYSICIAN WORK MDDUS the outcome of the Independence be any great impact on our day-to- remains as financially strong today has revised the pricing structure Referendum was a vote in favour day operations. We will of course as it was before the referendum for those members who perform of Scotland remaining part of the watch developments closely and and will continue to provide a forensic/police physician work. UK. At a political level this marks consult as appropriate with key high-quality, expert service to all In the past we have included the start of a period of negotiation stakeholders both in Scotland and our members regardless of where cover for forensic/police physician on the added powers that are to the rest of the UK to ensure that they practise. work through the standard GP

4 SUMMONS NOTICE BOARD BLOG

opting out of on-call and we provided only one week postgraduate training a 24-hour cover, often on-call alone. The year so it was difficult to fit in all that nearest district general hospital was was needed and impossible to keep over an hour away, including 25 minutes refreshed in every procedure that might on a ferry which stops at night and then be faced. By Dr Colin we had to rely on helicopter transfers. In the ideal world we could arrange Boyd, GP at It was a very enjoyable if tiring role as drills in the hospital to practice Lochgilphead a GP/hospital practitioner. I was able to emergencies, for instance for CPR, Medical Centre do practical things such as suturing, postpartum haemorrhage, shoulder looking at X-rays and putting on dystocia, etc. We did this for CPR but it Rural practice and risk plasters, but I was also occasionally was difficult to schedule for all faced with complex emergencies. practitioners, including the ENPs as In a recent BMJ article (August 14) an Things that a main A&E department well as midwives. A&E specialist worries about deskilling might deal with on a weekly basis we The introduction of ERMS and loss of confidence in carrying out saw maybe once in two or three years. (Emergency Medical Retrieval Service) procedures that used to be routine, for For instance, from memory, during the has been a step-change for us. Not only instance in advanced airway 13 years I reduced three or four does it provide dedicated telephone management because anaesthetists are dislocated shoulders and two fracture access to an A&E or intensive care increasingly called in. dislocations of the ankle, inserted three consultant for advice, ERMS personnel It is accepted in The British or four suprapubic catheters, carried are also equipped to come out to our Resuscitation Guidelines that non- out a ventouse delivery for delay in the hospitals, usually by helicopter. They specialists should not waste vital time second stage of labour with foetal prepare patients properly for transfer attempting endotracheal intubation in distress, and put in an umbilical to mainland intensive care units, cardiac arrest, due to lack of practice, catheter in a baby born unexpectedly at including being able to anaesthetise to relying instead on simpler ways of 33 weeks to give glucose whilst waiting give full airway control. On top of this protecting the airway. This is a great some hours for the neonatal retrieval they provide feedback on our individual relief to GPs such as me who work in team. More frequently we saw seriously cases and run case analysis sessions, as community hospitals and may only be ill patients and a few seriously injured. well as practical training days. involved in CPR once or twice a year. Did I have the competence to do all In the end you have to judge your But there is a wider question of how to this? I felt I had even without any own competence against the need of maintain competence in infrequent supervised training in much of it, and the patient. By attending appropriate problems and procedures encountered apart from the shoulders they all had courses it is possible to maintain skill in isolated parts of the country. to be dealt with promptly and I was and more importantly develop Until four years ago I was a GP on a there. confidence. Working in a small place, Scottish island and with five colleagues Courses are a good way of developing your actions are discussed and judged looked after a population of 7,000. As and maintaining skills. The ATLS – and you still have to shop in the well as normal GP work we had 12 beds (advanced trauma and life support) Co-op! in the community hospital and an A&E course is one of the best for this type of If you can’t cope with that then department which had to accept all work, and I attended two courses eight isolated practice is unlikely blue-light emergencies. There was no years apart. But we allowed ourselves to suit you.

became head of professional services, managing both medical and graduate. That’s what I’ll miss most.” dental advisers as well as still advising individual members. And it Jim plans to continue with some of his RCGP and other is helping members in difficult times that Jim has enjoyed most professional commitments but also looks forward to spending about the job. more time with his golf and his family, including the grandchildren “I think of medical advisers as doctors to doctors. We discuss, (though not necessarily in that order). We will all miss him at reassure and support. Counselling is part of the job profile – no MDDUS. matter whether you’re dealing with a professor or a new medical Jim Killgore, editor, Summons

subscription rate, but depending l ‘focus on SPORTS SportPromote. Members can healthcare. Places are available at on your exact circumstances, MEDICINE find all our interviews in the Risk Heathrow on 6 and 7 of November you may need to increase your The latest MDDUS Risk Factor Management section - mddus.com 2014 and at the MDDUS Glasgow membership cover to include video interview addresses l LESSONS FROM AVIATION Office on 12 and 13 of March these activities. Please contact the topic of sports medicine Places are available at MDDUS- 2015. Costs are £470 plus VAT Membership Services at MDDUS with Dr Jonny Gordon, sponsored master class events and delegates can earn 12 CPD to check you have sufficient cover emergency medicine consultant being run Terema - who apply points. To register interest or book for this type of practice. and course director of principles of aviation risk to a place email [email protected].

AUTUMN 2014 5 News Digest

assumptions underlying the proposal to raise the ARF. This will focus in particular on the projected fitness to practise caseload. The GDC has said it will study all the consultation responses and a final report, including the findings by KPMG, will be considered by the Council on 30 October, at which point a decision will be made on the level of the ARF for 2015. In an interview in this issue of MDDUS Summons (p. 10), GDC chief executive and registrar Evlynne Gilvarry says: “The ARF was last increased in 2010. Since then fitness to practise (FtP) complaints to the GDC have increased by 110 per cent. Social media fuels rise in complaints have greater ownership of their health, “Without further significant investment in SOCIAL media and negative press are better informed, are developing higher our FtP processes we will be unable to deal coverage of the medical profession are expectations and are treating doctors effectively with the very large increase in helping to fuel a surge in complaints with less deference than in the past. our caseload and so we must make against doctors, a study by the General Lead report author Dr Julian Archer adequate provision.” Medical Council has found. said: “[The report’s findings] show that the Complaints to the GMC by the general forces behind a rise in complaints against Changes in death certification public about doctors’ fitness to practise doctors are hugely complex and reflect a in Scotland almost doubled from 3,615 in 2007 to combination of increased public THE first phase of changes in death certi- 6,154 in 2012. The dramatic rise awareness, media influence, the role of fication procedures in Scotland have been prompted the regulator to commission a social media technology and wider implemented. research team from Plymouth University changes in society. Doctors are now required to use the new Peninsula Schools of Medicine and “We found that while a better paper-based Medical Certificate of Cause of Dentistry to investigate the trend. awareness of the GMC has a role to play Death (MCCD). Old style MCCDs and However, the GMC made it clear there in the increase in complaints, it did not incompletely filled MCCDs will be rejected was no evidence to suggest the rise was necessarily result in an increase in by the Registrar of Births, Deaths, and due to falling standards. complaints the GMC were in a Marriages and returned to the certifying Researchers said increasing complaints position to deal with.” doctor or another doctor in the team to were a result of “broad cultural changes in complete and issue a new form. society, including changing expectations, Call for clarity on GDC fee rise The new arrangements are a result of The nostalgia for a ‘golden age’ of healthcare, A MAJORITY of dentists (66 per Certification of Death (Scotland) Act 2011 and a desire to raise grievances cent) responding to a consultation on the which is aimed at streamlining the current altruistically”. Complaints networks and annual retention fee (ARF) do not believe process, improving the accuracy of death social media were also making it easier that the GDC has provided a clear account certification and providing better public for people to complain. Clinical care of its resource needs for 2015. health information about causes of remains the largest cause of complaints, An overwhelming majority (97 per cent) death in Scotland. but there has also been a rise in concerns of respondents rejected the need for a 64 A second phase of the implementation is about doctor–patient communication. per cent rise in the ARF to £945 per year. scheduled for April 2015 and will introduce While attitudes towards medical The consultation on the ARF level closed further changes including electronic professionals are “positive overall”, on 4 September with 4,474 responses completion and transfer of MCCDs and negative press coverage was blamed for received. The GDC Council has met to scrutiny by Healthcare Improvement “chipping away” at their reputation, consider the outcomes and broader themes Scotland, along with a new electronic resulting in an increased number of people that have emerged about regulation and the system of reporting to the procurator fiscal. making so-called “me too” complaints handling of complaints in particular. NHS Education for Scotland has published to the GMC. The GDC has also commissioned the tools and training resources on their website The report also noted that patients now auditors KPMG to review the full range of to help doctors prepare for the changes.

l DOMPERIDONE potentially life-threatening effects vomiting. More details at www. reduce their chances of death or PRESCRIPTION ONLY on the heart. This follows advice mhra.gov.uk. disability. Fever is the second most Domperidone will no longer be issued by the MHRA in April that l UNEXPLAINED FEVER IN common reason that a child will be available to patients over the domperidone should no longer CHILDREN NICE has published admitted to hospital. The standard counter. The European Medicines be used for heartburn, bloating a new quality standard to help promotes the traffic light system Agency (EMA) recently reviewed or relief of stomach discomfort. healthcare professionals quickly for identifying risk of serious the safety and efficacy of the drug Indications for the medicine are identify and treat under-5s illness. Go to www.nice.org.uk/ and found a small increased risk of now restricted to nausea and seriously ill with fever and guidance/QS64

6 SUMMONS News Digest

GPs still prescribing unnecessary antibiotics A SURVEY of over 1,000 GPs has found that 70 per cent prescribe antibiotics because they are unsure if an infection is bacterial or viral. It also found that 90 per cent of GPs feel pressured by patients to prescribe antibiotics and 45 per cent say that they have prescribed them for a viral infection when they knew it would not treat the condition. The survey was conducted on behalf of the Longitude Prize, run by the innovation charity Nesta. In June the public voted for antibiotics to be the focus of the £10 million prize, the remit being “to create a cost-effective, accurate, rapid and easy-to-use test for bacterial infections that will help health professionals worldwide to administer the right antibiotics at the right time”. Last year over 50 million antibacterial items were dispensed in the community in the UK and antimicrobial resistance poses a “catastrophic threat” to health in the coming decades. Tamar Ghosh who leads Longitude Prize, explains, “Across the globe we need accurate point-of-care diagnostic tools to maximise the chances that antibiotics are only used when medically necessary and that the right ones are selected to treat the condition. In the next five years, the Longitude Prize aims to find a cheap and effective diagnostic tool that can be used anywhere in the world.”

CQC moves to targeted dental inspections practices after 2016. dying within a month of leaving hospital, DENTAL inspections by the Care Quality John Milne, Chair of the BDA’s General according to new research. Commission will be more targeted and focus Dental Practice Committee, said: “Time A study by the University of Leeds found on practices where there is “cause for and again, the CQC has shown dentistry to that this risk increased by 46 per cent while concern,” according to a recent “sign- be a low risk sector. But for too long it the risk of death within a year went up posting” statement on potential changes to adopted a costly ‘one size fits’ all approach by 74 per cent. the way it regulates primary care dental to dental inspection – and so we welcome The findings were based around nine key services in England. moves to a more targeted, risk-based elements of care identified as: pre-hospital The CQC is also considering whether approach. electrocardiogram, acute use of aspirin, every inspection team should include a “We are pleased that the CQC appears restoring blood flow to the heart dental specialist adviser and people with to have listened to reason, so we finally (reperfusion), prescription at hospital extensive understanding of dental services, see dental experts on the front line for discharge of aspirin, timely use of four types acting as “experts by experience”. dental inspections. It’s a simple, common of drug for heart attack (ACE-inhibitors, The statement comes ahead of a formal sense move that would be seen as positive beta-blockers, angiotensin receptor blockers consultation and the start of trial throughout the profession.” and statins) and referral for cardiac inspections in November 2014. rehabilitation after discharge from hospital. Dental services present fewer concerns Risks increased further for those who on the whole compared with other missed a course of treatment, such as an providers, according to the CQC. For electrocardiogram, within the first few hours example, between April 2011 and October of the onset of symptoms. They were much 2013, only one in eight dental locations more likely to miss other types of were found to fall short of regulations in care later on. some way compared with one in five in Researchers looked at outcomes for heart adult social care. The CQC proposes to attack patients discharged from hospital in inspect only 10 per cent of dental England and Wales between January 2007 providers, focusing attention upon those and December 2010. During that period, that are seen as “cause for concern”. Warning over care of heart attack patients around half of the 31,000 heart attack The CQC will also be seeking views on HEART attack patients who miss just patients discharged had missed a whether to provide ratings to dental one key element of care are at greater risk of course of treatment.

l NEW SEPSIS TOOLKIT FOR five times more likely to die from l ENHANCED SCRUTINY for complaints in relation to DOCTORS A new RCP toolkit has it than those with a heart attack IN DENTAL ADVERTISING marketing materials which may been launched to help doctors on or stroke. Symptoms are often The GDC has announced it will breach the Advertising Codes. All acute care wards recognise and not spotted meaning patients are be working closely with the enquiries regarding potentially treat sepsis more quickly. The not given lifesaving treatment in Advertising Standards Authority problematic marketing material condition kills 37,000 UK patients time. The guidance offers practical (ASA) to tackle misleading dental will be directed to the ASA a year and those admitted to advice. Access the toolkit at marketing. The two organisations complaints inbox. Go to www. hospital with severe sepsis are www.tinyurl.com/okhxe2d have agreed on a referral process gdc-uk.org for more details.

AUTUMN 2014 7 RISK

they can understand in order to make valid can be utilised as part of a range of wHAT ARE MY choices about their care and treatment. complimentary data formats together Gigerenzer describes how in a series of providing enough fl exibility to address the CHANCES, DOC? workshops in 2006 and 2007 he posed the needs of a variety of patients. same statistical problem to over 1,000 Alan Frame gynaecologists relating to the results of a There are other factors to consider in positive mammography screening. The communicating relative risk to patients: doctors in the workshops were provided • Guard against over simplifi cation of MOST doctors understand the concept of with additional relevant clinical information language: terms such as ‘common’ or relative risk, but what about patients? The to base their answers on and in a typical ‘rare’ can assume a shared majority will simply grow frustrated or session only around 21 per cent provided perspective, when in fact patients tune-out if a discussion aimed at joint the correct answer. Apparently this is a may judge risk by a diff erent order decision-making becomes a lecture in worse result than if the doctors had been of magnitude. statistics. Yet communicating risk is answering at random! • Patients may best understand absolute essential in obtaining and being able to The problem then may be two-fold. It’s risk expressed in natural frequencies, demonstrate valid consent. not only being unable to produce relevant i.e. 1:200 patients suff er a post- This requires meaningful dialogue with statistics for patients for every treatment operative complication. the patient, which includes a discussion option; it’s also about being unable to make • Presenting absolute risk fi gures alone about the chance or probability of things sense of those statistics when placed in has also been shown to lead to either going wrong. GMC guidance for doctors, front of you. an overweighting of low probabilities Consent: patients and doctors making Part of the diffi culty here may be in or an underweighting of high decisions together, states that when sharing setting out risk probabilities as percentages, probabilities. information and discussing treatment which apparently a lot of us struggle to options “you must give patients the understand. Possible alternatives are the One particular study looking at information they want or need about, use of simple fact boxes and tools such as probabilities of harm found that the term amongst other things, the potential option grids, which set out frequently asked ‘frequent’ was interpreted on average as benefi ts, risks and burdens, and the questions concerning a test or procedure equivalent to around 70 per cent. likelihood of success for each option”. and then off er likely outcomes for both However, the range of answers provided Entering a discussion about risk having and not having the test done. by participants was from 30 per cent probabilities I am always reminded of Mark Another alternative way of expressing through to 90 per cent. Twain’s quote about “lies, damned lies, and the relative risk uses numbers of people What is the law, and what do the statistics”. instead, and where possible with the aid of regulators say about all of this? A very public example of patients being diagrams. In Gigerenzer’s example of a The landmark medico-legal case Chester misled about risk probability occurred in positive mammogram, the reality looks v Afshar confi rmed a duty to warn patients 1995 when the UK’s Committee on Safety visually clearer if set out on a fl ow chart about risk. In the case, Ms Chester was left of Medicines decided to warn doctors that format: paralysed following surgery for a lumbar a new, third-generation oral contraceptive disc protrusion. The court ruled that Dr pill doubled the risk of thrombosis. This was Afshar was negligent in failing to warn her seized upon by a frenzied media and of the 1-2 per cent risk of the procedure resulted in thousands of women stopping going wrong. It’s interesting to note that their contraceptive pill, even though the the court’s chosen method of actual risk had merely increased from a communication here was in percentages, one-in-7,000 chance of getting the disease rather than 1:100 or 2:100 cases. to a two-in-7,000 chance. GMC guidance on consent is heavy on Are doctors confused by statistics? A what is required and expected from doctors new book by one prominent statistician and what they must ensure has been says they are – and this makes it hard for conveyed, but silent on how the actual risk patients to come to informed decisions probability and impact is communicated. No about treatment. Source: http://www.bbc.co.uk/news/magazine-28166019 two people are alike in the ability to Gerd Gigerenzer is director of the comprehend risk so it is up to the individual Harding Center for Risk Literacy in Berlin Other visual aids used to communicate risk healthcare professional to judge if a patient and in his book Risk Savvy he takes aim at probabilities include diagrams representing truly understands. health professionals for not giving patients percentages out of 100 stick fi gures. These the information they need in a way in which can off er a handy short-hand of risk which n Alan Frame is a risk adviser at MDDUS SUMMONS 8 ETHICS

first-line treatment to prescribe and how professional is devalued. much information to share at handovers, The capacity to be aware of professional AN ETHICAL are matters of discretion. Yes, there are discretion and to exercise judgement is ECOLOGY guidelines and standards but each inevitably diminished by a directive and professional will interpret those according controlling culture. What’s more, if those Deborah Bowman to his or her experience, values and directives and instructions assume that preferences. professionals are either doing or about to Although discretion is an inherent part of do “the wrong thing”, it is more than being a professional, it is not always undermining and demoralising, it is a THERE is a sign that I regularly pass. It considered to be an unequivocal force for fundamental challenge to professionalism, flashes, without exception, at drivers good. Indeed, professional discretion, considered practice and ethical instructing them to “slow down” particularly perhaps that of doctors, has engagement. irrespective of their speed. I confess that I often prompted suspicion and criticism, Some might argue that trust is earned always feel irritated by this instruction: I and sometimes with good cause. Since rather than an entitlement. Others may cite drive within the speed limit. While this may George Bernard Shaw wrote scathingly high-profile examples of trust in healthcare sound grumpy, I have tried to turn my about professions being “a conspiracy institutions and staff being misplaced or irritation to a better purpose. It has against the laity”, attention has been called abused. However, to create systems around prompted me to think about ethical to the power (and abuses of the same) that “worst case scenarios” or “bad apples” is to discretion and the contribution of systems. comes with professional discretion. Power disregard and potentially to undermine the What conditions or types of system make it and privilege will likely endure. Post- ethical commitment and professional likely that people will use their identity of the majority. Changes discretion well and flourish? “Professional discretion recognises and to governance and increased Sociologists have identified regulation may be understandable particular characteristics as specific allows for complexity and particularity.” reactions to failures of care, but to the “professions”, including there are significant risks to specialist expertise, admission by systemic changes made in the credentials, high social status and state- professionalism and de-professionalism are name of accountability. Ever-greater sanctioned self-regulation. One of the interesting (really) theoretical models, but instruction and surveillance represents a defining characteristics of a profession is they cannot eliminate the stubbornly diminution of trust that matters discretion. The law, regulators, professional constant imbalance that resides in clinical enormously if we want clinicians to reflect bodies and employers may set standards work. The patient has a problem and needs on their discretion and to make good and provide the framework within which the clinician’s expertise or skills. The patient professional judgements. that discretion is negotiated. However, on a is dependent in a way that the professional If reflection and discussion are replaced day-to-day basis, all professionals make is not in the encounter. The trick then is not by unthinking obedience (or even judgements about how to use their to seek to eliminate power, but to unthinking disobedience), we will all be discretion. recognise its inevitability and to facilitate ethically poorer. Environments in which Individual clinicians regularly interpret mutual trust. compromised standards are assumed and professional guidance to determine what is Most of the clinicians with whom I work increasing numbers of commands are the best – or at least the better – option acknowledge both the privilege and burden issued irrespective of individual given a particular set of circumstances or of discretion. In my experience, they are conscientiousness or performance are variables. That is how it should be. acutely aware of their responsibilities. damaging. Instructions that are unfeasible Professional discretion recognises and Many recount situations in which exercising or irrelevant are more than irritating; they allows for the complexity and particularity discretion has been difficult. Just as clinical reflect mistrust and disregard of clinical work. Sometimes exercising expertise and confidence develop with time professionalism. At worst, they create a judgement involves significant, even and experience, so too does skill in toxic environment in which people are momentous choices, such as whether to recognising situations of discretion and neither valued nor expected to behave well. proceed in a high-risk situation. Most of the exercising judgement. Yet if people are All communication has a moral time, discretion is enacted via a series of working in a system that is dominated by dimension, even road signs. apparently “routine”, perhaps even directives and instructions that are issued unnoticed, choices. Every-day questions, to everyone without appreciation of, or n Deborah Bowman is Professor of such as whether to give advice over the attention to, context and individual Bioethics, Clinical Ethics and Medical Law ‘phone, how to prioritise time, which circumstance, what it is to be a at St George’s, University of London

AUTUMN 2014 9 Challenging times at the GDC

The General Dental Council has faced recent criticism from various quarters – not least for proposed plans to hike its annual retention fee by 64 per cent. Here chief executive and registrar Evlynne Gilvarry addresses some of the issues

QUALIFIED lawyer and mediator, Evlynne Gilvarry became Large increases in three successive years have inevitably resulted in chief executive of the General Dental Council in 2010. Prior pressure on our teams and it has been difficult to recruit and retain Ato that she had been chief executive of the General staff in sufficient numbers to handle the load. Osteopathic Council and before that she held senior policy and Secondly and most unfortunately, we have not yet secured the management roles at the Law Society. legislative change that is necessary to improve our outdated procedures. We had hoped that new legislation, enabling wide-scale The GDC is proposing a 64 per cent rise in the annual retention change to our procedures would have been in the Queen’s Speech fee for dentists. Why such a steep increase and why now? earlier in the summer, but this was not the case. We have very clearly set out in our consultation document that The Department of Health recognises that our legislation is out of in the absence of an increase we will not have enough income to date. Indeed, by an accident of history, the GDC’s legislation is even undertake core statutory functions. The ARF was last increased more antiquated than that of other regulators, particularly in 2010. Since then fitness to practise (FtP) complaints to the regarding fitness to practise. Although wholesale change is some GDC have increased by 110 per cent. Without further significant way off we are working with the Department of Health on an investment in our FtP processes we will be unable to deal interim change – the introduction of case examiners – which will effectively with the very large increase in our caseload and so we help us to streamline and speed up the initial stages of fitness to must make adequate provision. practise. We hope to see the change in place by the middle of 2015. Fitness to practise is the most expensive area of our work. If a The introduction of case examiners will not only allow us to case reaches a hearing, the cost is around £19,500 per day and the improve the way we handle cases but will also save us up to £2m a length of a hearing ranges from a third of a day to 35 days. We year. have had to recruit more casework staff and more FtP panellists to clear a backlog of cases and to process new cases faster. How are you working to reduce the costs of fitness to practise procedures? Can you understand the anger among dentists with the fee rise We are doing a lot to reduce FtP costs, primarily through a two- given the recent Professional Standards Authority review in which strand strategy. We are achieving greater value and significant the GDC failed to meet seven out of 10 good regulation standards savings through tighter management of the contracts with our in fitness to practise? external law firms. We have also significantly reduced our reliance We regard failure to meet the PSA’s standards as entirely on external firms and correspondingly our costs through the unacceptable so we accept criticisms on this score. We want to appointment of an in-house legal team. This process started in reassure the profession that all our efforts are focused on tackling January 2014. We estimate that this team – by handling up to two the problems that have resulted in us missing standards. We have thirds of our legal work – will save £1.2 million per year from 2015. increased resources to deal with the continuing surge in caseload The next phase of the in-house development is to do advocacy in- and made other key changes to improve the performance of our house. We currently use an external team of barristers. This change teams. The achievement of a much better performance in fitness to will save even more money and we plan to have our in-house team practise is the number one priority. of advocates in place by the end of the year. This will result in a 44 per cent saving on barristers’ fees. What are the reasons behind the delays and other problems the GDC is encountering in the management of fitness to practise Why do you think complaints against dentists reported to the GDC processes? are rising? There are two key factors that have put pressure on our fitness to Firstly, I think the GDC, in common with other regulators and practise function. First, the very large increase in complaints we’ve public bodies, is experiencing the effects of a more informed and received. The scale of increase over the last three years – 110 per demanding public. We are doing more research with patients and cent – is a very significant departure from the patterns of the past. the public to learn more about motivation for complaining.

10 SUMMONS Q&A

Secondly, information on how to complain is more readily aimed at being an eff ective regulator. We hope that the profession will accessible. Th e internet plays a major role in this and we are seeing acknowledge the need for this extra investment, even though it an increasing number of complaints being submitted online. We are means a signifi cant increase in their annual registration fees. also seeing a greater proportion of complaints coming from sources Th e debate that has taken place since we began the consultation other than directly from patients – for example, from the NHS and on the ARF increase is an opportunity to clear up some other professionals. misapprehensions about the GDC’s role. Some of the commentary Th irdly there is evidence that the major structural change that seemed to confuse our role with that of the BDA. We are keen to resulted in transition from PCTs to NHS England left some areas have a more active engagement with the profession on regulatory of the country with many fewer performance managers. As a issues as we believe that this is the best way of building and result, we believe that some cases which might have been dealt maintaining trust. with in the past through local resolution are now fi nding their way It’s worth noting that the GDC’s 2013 registrant survey found to us. that confi dence in the GDC as a regulator remains high. More than Lastly, we are told by the defence organisations that a recent two thirds (67 per cent) of the dental professionals who took part change in the way lawyers are rewarded for handling claims against in the survey are confi dent that the GDC is regulating dentistry health professionals prompted a surge of referrals to the health eff ectively. A corresponding survey of patients and the public said regulators. regulation of dental professionals is very important and nearly eight out of 10 (77 per cent) are confi dent that the GDC regulates dental professionals eff ectively. “The GDC, in common with other regulators, is experiencing the eff ects of n Interview by Jim Killgore, editor of Summons a more informed and demanding public.”

A recent advert in the Daily Telegraph for the Dental Complaints Service was likened by the BDA to those favoured by “ambulance-chasing lawyers”. What was the intention behind the advert? Th e comparison with “ambulance-chasing lawyers” is mistaken and unfortunate. We have a duty as a regulator to ensure patients and the public, including those who receive private dental care, know where they can raise concerns if necessary. Promotion of the DCS is not a new development; we regularly run campaigns to ensure that the public and patients, as well as dental professionals and other advice bodies such as Trading Standards and Citizens Advice, are aware of the excellent service it off ers. At the heart of the DCS is the encouragement of local resolution and this happens in a large proportion of the cases it handles. Th e DCS consistently achieves very high satisfaction ratings with patients and with dental professionals. It is important to note that the DCS does not handle fi tness to practise cases. Some of the commentary in the wake of the advertisement clearly showed confusion on this point.

The BDA has reported that in a recent survey 79 per cent of dentists were not confi dent the GDC was regulating dentists eff ectively. Do you feel the GDC has lost the trust of the profession and how will you win back the doubters? We are determined to ensure that our performance as a regulator continues to improve. We have struggled to cope with unusually large increases in caseload in three successive years and we recognise that this resulted in our performance slipping. Th e measures we are taking – which include signifi cant extra investment which must be funded by the dental profession – are precisely

AUTUMN 2014 11

Why should I say

John Dudgeon– GP and medical adviser with the Scottish Public Services Ombudsman – calls for a culture change in attitude among doctors towards saying sorry

ORRY might seem to be the hardest What complainants want always act with integrity and have the word but for doctors it shouldn’t be. When something goes wrong or patients professionalism to shoulder blame when it SThe Scottish Public Services think something has gone wrong they want is theirs to take. Ombudsman (SPSO), the Parliamentary and to know that their doctor still cares and It would be naive to think this is always the Health Service Ombudsman, the NHS understands their concerns. They want case. Indeed some evidence suggests that Litigation Authority and the General Medical honesty and responsibility. They want to doctors avoid apologising up to 75 per cent of Council all advise on when and how doctors know someone is prepared to vindicate the time. Mindful of scandals like Mid should apologise. The language they use is their understanding of the error and ensure Staffordshire, I find it worrying that as a unsurprisingly formal. I wonder, though, how the same thing will not happen again. That profession we keep these barriers up. Doctors much resonance their advice has with doctors is not to say that we should accept blame have traditionally been the most trusted on the frontline in the UK today. For me the when the error is not ours but, even in individuals in their communities. The questions surrounding the importance of a no-fault situation, patients still expect approach to mistakes – and acknowledging sometimes saying sorry are simple: what sort their doctor to empathise. My hope is those mistakes with an apology – by some of of doctors do we want to be and how do we that doctors in the UK care about their our profession runs the risk of ruining this. want our patients to perceive us? patients (especially when things go wrong), Former SPSO Professor Alice Brown has

12 SUMMONS

HEALTHCARE PRACTICE

said: “Particularly in the health service, there profession like medicine. reviewer this, and often the complaint will is a resistance to saying sorry when things Doctors do not get sued (successfully) for not be upheld. have gone wrong. That is a great barrier.” making mistakes – they get sued for being A genuine apology when a mistake has There are many reasons for this resistance. negligent. So if you have made a mistake, happened is usually thought to be part of An overriding concern is that by apologising own up. Be honest and say sorry. It won’t do acting reasonably. To have not apologised you may be admitting liability. Section 2 of any harm and it may do a lot of good (apart properly will, at times, weigh the case against the Compensation Act 2006 (an act of the from being the right thing to do). Doctors do the doctor. Making a proper apology is a UK Parliament) says: “an apology, an offer of sometimes get sued for practising below an frequent recommendation from the treatment or other redress, shall not of itself acceptable standard of care – if that ombudsman. If this has already been done amount to an admission of negligence or substandard care results in harm to a patient then the ombudsman may feel there is breach of statutory duty”. for whom we have a duty of care. Remember nothing to be achieved by investigating the This particular section only applies in that if you have been negligent, evidence has complaint further. England and Wales. My understanding is shown that a heartfelt apology can reduce the In my opinion, until we change the that the law on this point is likely to be likelihood of legal action – but some form of perception of apology from an admission of regarded similarly in Scotland. The proposed intervention may be inevitable no matter failure that may ruin our reputation to a sign Apologies (Scotland) Bill – now under what you do. To my mind that is fair enough. of professional and emotional strength, we consideration by the Scottish Parliament – will still see patients pursuing complaints and covers similar territory and includes Apology – a reasonable response legal actions that would never have happened protection against admissions of liability. While many doctors have good had the doctor just said sorry and meant it. communication skills and make When a complaint comes in or a mistake is No such thing as perfect appropriate apologies, I think there needs noticed, I would urge my colleagues to act There are, of course, cultural barriers to to be a cultural change within the UK with integrity and professionalism. making an apology, particularly in the medical fraternity for apologies to be more Take a deep breath and try to see both medical world. The elitist and macho widely accepted. One change that may sides of the issue. If the patient has been culture that is at times present in our help is teaching our undergraduates the upset or harmed, acknowledge this and let hospitals and surgeries has always puzzled importance of being able to recognise their them know how genuinely sorry you are that me. If the reason for being a doctor is to mistakes and say sorry for them. they have suffered. If you can see that your help people (as we all said when trying As well as working as a GP, I am a medical actions have contributed to a mistake, to get into medical school), why do we adviser to the SPSO. The vast majority of acknowledge this and let the patient know maintain the culture of always having to be right? Why do we find it so difficult admitting mistakes? Psychiatrist Aaron Lazare, author of the “Doctors often don’t distinguish between making a book On Apology, wrote: “We tend to view apologies as a sign of a weak character. But in mistake and being negligent. We all make mistakes. They fact they require great strength. are an inevitable part of being human” “Despite its importance apologising is antithetical to the ever-persuasive values of winning, success and perfection. The complaints that are escalated to the SPSO, you are genuinely sorry. Explain what successful apology requires empathy and the having failed to be resolved at a local level, happened and how you plan to ensure it does security and strength to admit fault, failure would in my opinion never come to us if the not happen again. I am convinced that this and weakness. But we are so busy winning doctors involved had sat back and tried to empathic and professional approach will be that we can’t concede our own mistakes.” see things from the complainant’s point of more likely to result in the hurt and anger No doubt this will resonate with many view. If we could allow our defences to drop around a complaint dissipating without medical professionals. So can we learn to be and consider our patient’s position I am further action being taken. more rational about acknowledging convinced the number of complaints being NHS Education for Scotland and the mistakes? referred to the SPSO would reduce. SPSO have developed an online module When it looks like things have gone We understand that having a complaint about apology. I recommend taking the 20 wrong, correctly interpreting what has sent to the ombudsman is stressful for minutes required to work through it. It will happened is important for both sides. doctors. The ombudsman uses the standard leave you well informed about how to make Complainants are often unable to of reasonableness – what would we have an apology that your patient will appreciate. differentiate between poor service and expected a reasonable doctor to do? The negligence, and doctors often don’t ombudsman’s medical advisers all work in distinguish between making a mistake and the NHS and have good insight into the being negligent. We all make mistakes. They different perceptions doctors and patients n Dr John Dudgeon is a GP and medical are an inevitable part of being human, have. If an adviser finds that a doctor has adviser with the Scottish Public Services especially when practising a high-risk acted reasonably they will tell the complaints Ombudsman

AUTUMN 2014 13 A most serious case indeed

What began with a simple work-related injury in 1902 would end a year later with a death, a court case and a piece of medico-legal history. Allan Gaw investigates

N April 1902, Andrew Gillies, a joiner from the small Scottish town precedent, understandably decided that they could provide no further of Stewarton in Ayrshire, injured his left arm. He likely developed a assistance. Cunningham then chose to retain the Union’s law agents, I haemarthrosis with adhesions which his GP, Dr John Turnbull and Findlay, to represent him. Cunningham, advised needed manipulation under anaesthesia. Hesitant about this course of action, Gillies sought a second opinion Utmost propriety from a doctor in Glasgow who concurred with his GP. Two months later the case against Cunningham came to court Three months after his initial injury and with little sign of and revolved around three grounds of fault: that he should have improvement, Gillies agreed to the procedure which would be had a skilled medical assistant, that his method of chloroform performed in his own home under chloroform. Exactly what administration was outdated and dangerous, and that he had happened in the Gillies household that Sunday evening in July 1902 is anaesthetised Gillies without having resuscitation equipment at open to question as those present subsequently disagreed on their hand, including a hypodermic syringe and appropriate drugs. stories. What is clear, however, is that Gillies, then aged 52, did not These allegations were systematically addressed during the survive the procedure. His death certificate listed “syncope” as his two-day trial and a parade of expert witnesses were brought cause of death, which was most likely a cardiac arrhythmia induced forward to support Cunningham’s clinical approach to the by the chloroform. problem. Although these men often stated they might have done Five months later Gillies’ widow sued Dr Cunningham, demanding things slightly differently, they found his actions, by and large, to damages of £1,000 (approximately equivalent to 10 years’ wages of her be consistent with current practices. One expert witness, Dr dead husband). Dr Cunningham sought the support of the newly Joseph Bell from Edinburgh, who had some years earlier served as formed Medical and Dental Defence Union of Scotland (MDDUS), the model for a fictional detective created by his former student and indeed his was the first medico-legal case they considered at their Arthur Conan Doyle, even said Cunningham had treated the inaugural Central Committee Meeting in January 1903. patient, “with the utmost propriety”. The MDDUS had been set up in May 1902 in the interests of the The nature of Gillies’ death was scrutinised and a great deal of medical and dental professions in Scotland. Cunningham had emphasis was placed on the post mortem findings which showed submitted details of the action against him on 14 January 1903 – the no evidence of asphyxia, but which were consistent with syncope. same day he had also applied for membership. As he had not been a The method of chloroform administration used by Cunningham member when the patient’s death had occurred some six months had involved not a mask but a towel applied to the face doused in earlier, the MDDUS officers, concerned about the setting of the anaesthetic. Cunningham claimed to have used a method

14 SUMMONS MEDICO-LEGAL HISTORY

whereby his hands kept the towel above the face and allowed free suggested a modern jury, if presented with the same evidence and respiration, but others present refuted this account. the same allegations, would likely also fi nd in favour of Dr Th e relatively poor understanding of the toxicology of chloroform Cunningham. Th ere would, however, be some diff erences. Today, at the time was revealed by the testimony of another expert witness, such a case would probably take not three months to come to John Glaister, the Professor of Medical Jurisprudence at Glasgow court, but as much as three years due to the pressures of business University. He could shed no light on the exact cause of Gillies’ death in the Court of Session. and pointed out that “there was no subject which was giving rise to Th e same case today would also be heard by a judge alone, more controversy in the medical profession than the cause of death rather than the judge and jury that presided in 1903. And the under the infl uence of chloroform”. modern test of negligence would be whether the defender had Such was Cunningham’s personal belief that no malpractice was adopted a course of action which no professional person of involved that he claimed on the stand that he “would pursue the same ordinary skill would have taken if he or she had been acting with course again in similar circumstances”. ordinary care. However, as was the case with Dr Cunningham, the Th e judge instructed the jury at length and emphasised that this results of such a contemporary test would also depend upon the testimonies of other professionals in the same fi eld, to defi ne exactly what “ordinary skill” and “ordinary care” are. “What today would be malpractice may a Th e case of Gillies v Cunningham is notable for several reasons. Not only was it the fi rst medico-legal case laid before the new century ago have been standard MDDUS, it was also the fi rst medico-legal case in Scotland practice.” involving anaesthesia. It is also a useful example of how we might prejudicially review the past through modern eyes and with modern values. And fi nally, it should be a reminder to all was “a most serious case indeed,” especially to Dr Cunningham. In practitioners that it is too late to join your defence union aft er the conclusion, he informed the jury that in law “a person was not liable patient has died. in the exercise of his profession for a mere mistake...[t]here must be what in Scotland was called gross negligence, or in England crass n Dr Allan Gaw is a clinical researcher and writer in Glasgow negligence”. It was clear from his charge to the jury that he thought there was neither in this case. It took the jury only 45 minutes to ACKNOWLEDGEMENTS decide unanimously in Cunningham’s favour. I am indebted to Dr Iain Levack who has conducted much original research on this case and allowed me access to his fi les. Standards of the day Th e challenge at the centre of all medical history lies in the danger of judging past actions by present day standards. Th is is especially SOURCES true if those actions have an ethical or legal dimension. What • Levack ID. The fi rst anaesthesia litigation in today would be malpractice may a century ago have been standard Scotland – Cunningham Case (1902). Proceedings of the History of Anaesthesia practice. Th e use of domiciliary anaesthesia, for example, is now Society 29: 64-7, 2001 a thing of the past, but in 1902 it was commonplace amongst • Kilmarnock Standard April 4, 1903 pp 3&5 GPs. Chloroform was the most readily available anaesthetic and although its dangers were well recognised, its use was widespread. Indeed, Dr Cunningham had treated at least two other patients of his with the same orthopaedic problem as Gillies and had done so successfully using chloroform anaesthesia. Looking back at the details of this case it is easy to be critical of how the procedure was carried out. If Andrew Gillies was being treated today he might have been anaesthetised, but this would have taken place in a clinical facility fully equipped for modern resuscitation, the attending doctor would not have been alone and, of course, chloroform would not have been the drug of choice. But, if there is no understanding of cardiac arrhythmia and its eff ective treatment and if the standard and accepted practice of the day is to anaesthetise a patient on a Sunday evening in their upstairs bedroom using a towel and a bottle of chloroform, should we be so quick to condemn? A re-evaluation of the case by a contemporary judge in 2000

AUTUMN 2014 15 CLINICAL RISK REDUCTION

JOINT AND SOFT TISSUE Injections Lucy Douglas highlights new guidelines from the Primary Care Rheumatology Society

OINT and soft tissue injections are commonly used to help • injection into a prosthetic joint or surgical ease the discomfort and loss of function associated with metal work in situ Jmusculoskeletal disorders. Th ey are a safe and eff ective • imminent surgery at the site of or close to the treatment option for many patients and generally perceived proposed injection. to be a low-risk intervention. However, complaints and claims against doctors performing such injections are not infrequent. Anticoagulant therapy is not a contraindication to joint Th ere is little fi rm evidence on which to base best practice in injection but precautions apply. You should discuss the risks of this area and as a result there is variability regarding exactly how continuing or stopping anticoagulation with the patient and and when such injections are used in clinical practice. But there ensure a management plan is in place should a bleeding are certain considerations which can enhance patient safety and complication occur. help clinicians avoid some of the medico-legal pitfalls. Th e Several studies suggest that joint and soft tissue injections can following article is based on guidelines for joint and soft tissue be safely carried out provided the INR is within the therapeutic injections which have recently been developed by the Primary range. Th is should therefore be checked prior to the procedure. Care Rheumatology Society. For patients taking novel oral anticoagulants, given the shorter half-life, consideration should be given to avoiding interventional Before treatment procedures during peak drug activity – for example for As with all medical procedures, any clinician undertaking joint rivaroxaban this peak would be 2-4 hours aft er the last dose. and soft tissue injections must be adequately trained and have up- to-date clinical skills. Ensure all medication or other equipment is Procedure and associated risks appropriate for the intended use and in date. For example, some When positioning the patient, be prepared for the possibility steroid preparations vary in clinical indication yet the packaging they may faint during or aft er the injection. Ensure that they and constituents can be similar. will not get injured should this occur. When marking the skin, Ensure enough time is available to explain the procedure. avoid using an ink marker directly at the site where the needle is Consent for joint injection requires the same rigorous attention to to be inserted or a permanent tattoo may result. Potential risks detail as other interventional medical treatments. Th e patient associated with joint and so tissue injections include: must be informed about the nature of the injection, relevant risks • infection and benefi ts and alternative treatment options. A patient • soft tissue atrophy and local depigmentation information leafl et can aid patient understanding and decision- • tendon rupture making and also helps ensure that no important contraindications • nerve damage or adverse eff ects are overlooked. A suggested leafl et is available • menstrual disturbances on the PCRS website. • disturbance in glycaemic control in diabetics Clear documentation must be made of the above discussion • allergic reaction. and that the patient has consented to the treatment. Signed consent is not required in the UK but may be used in addition to Infection the above documentation. Further information regarding consent Infection is considered a rare complication of joint and soft can be found on relevant MDDUS and GMC web pages. tissue injection, however the consequences can be catastrophic. Contraindications to joint and so tissue injections include: Th e patient should be warned in advance about the serious • allergy to local anaesthetic, steroid, skin cleanser or dressing consequences of infection, what symptoms may occur and how to • local or systemic infection seek immediate medical attention if required. • active rash/broken skin at site of injection Dust covers on vials of medication are not necessarily adequate • uncontrolled coagulopathy to ensure sterility of the outside of the vial top. Th erefore • fracture/unstable joint swabbing the vial with a sterile alcohol swab is recommended for • tendon regions at risk of rupture some medications.

16 SUMMONS Skin preparation is generally recommended prior to surgical if this occurs. Avoid local anaesthetic at such sites if this may procedures to reduce the numbers of skin bacteria – although prevent the patient reporting symptoms of nerve irritation. there appears to be little published information on infection rates Consider image-guided injections. when no skin cleaning has been carried out prior to joint injection. Th ere have been rare recorded incidents of infection Menstrual disturbances resulting from contaminated topical antiseptics. All skin cleansers Eff ects on the hypothalamic-pituitary axis are thought to be should be used strictly in accordance with the manufacturer’s responsible for the menstrual irregularities or vaginal bleeding instructions. Consideration should be given to single-use skin seen in some women aft er steroid injections. It is important to preparations labelled as sterile. warn of this eff ect, which may persist for several weeks, to avoid Once the skin has been prepared, use a ‘no touch’ technique unnecessary alarm or investigations. when injecting unless full sterility is observed. Facial fl ushing may also occur follow a steroid injection. Th is is not an allergic reaction and does not preclude future injections. Soft tissue atrophy Th is side-eff ect generally aff ects women and can be dramatic and Soft tissue atrophy and local depigmentation are uncommon distressing, particularly if not forewarned. complications of steroid injection. Although these are predominantly cosmetic eff ects, at some sites such as the heel Glycaemic control pad, atrophy can be clinically signifi cant and may persist for Small increases in glycaemia lasting a few days may be seen aft er years. Atrophy may be due to the persistence of steroid crystals steroid injections in diabetic patients. Th e increase is generally in the tissues and seems less likely to occur with more soluble not clinically signifi cant but again it is sensible to warn patients. preparations, e.g. hydrocortisone and methylprednisolone. Th ese are therefore preferred for soft -tissue, small-joint and superfi cial Allergic reactions injections. Should concerning soft -tissue atrophy occur, referring Although allergic reactions are rare, full resuscitation equipment the patient for a course of local injections of saline may be helpful. must be readily accessible and staff available and trained to use it in all locations where injections are performed. According to Tendon rupture the Resuscitation Council UK website, cardiopulmonary arrest Th e risk of tendon rupture attributed to steroid injection, for resulting from injected medication predominantly occurs up to example at the shoulder, is somewhat controversial. However, it 20 minutes post injection. It would seem sensible therefore for has been demonstrated in animal studies that intra-tendinous patients to remain on site for this time. injections of steroid can result in collagen necrosis and weakening of the tendon, potentially lasting for several weeks. Th erefore if injecting in peri-tendinous regions where there is a risk of suboptimal needle placement, avoid injecting if resistance is PCRS guidelines encountered and consider the use of image guidance if available. Generally avoid injecting regions where concern regarding the Comprehensive guidelines on joint and soft tissue injections can be found in the Resources section of the Primary Care Rheumatology Society website: www. risk of tendon rupture is high, for example at the Achilles tendon. pcrsociety.org Nerve damage Ensure you are familiar with the anatomy of the injection site to avoid inadvertently injecting a nearby nerve. In neuropathies (e.g. carpal tunnel syndrome) the aff ected nerve may be swollen and therefore anatomical landmarks may be less reliable. Before injecting, ask the patient to report symptoms of nerve activation n Dr Lucy Douglas is a GP with special interest (GPwSI) in when the needle is inserted. Withdraw and reposition the needle musculoskeletal medicine and rheumatology

AUTUMN 2014 17 DENTAL HEALTH & SAFETY

Hiding in plain sight Steve Ashton considers some risk areas in dental practice so obvious they become invisible

ENTISTRY isn’t especially high risk. about it “tomorrow”? How oft en has the A fresh pair of eyes (sharing the Most of the things that cause injury splash of coff ee at reception been left to dry inspections with someone from another Dor ill health are reasonably well on the fl oor instead of being immediately practice, for example, or bringing in a understood within the profession. With a mopped away? It is so obvious it seems consultancy) may see far more where little bit of thought and eff ort, appropriate unnecessary to even think about. But familiarity has created blind spots. controls can be used eff ectively. Th e therein lies the problem. problem generally isn’t that the issues are If your practice does not have a culture Infection control not obvious; it’s that they’re so obvious embedded in the mind of every employee Th is is a key risk area for the dental those working in the environment to recognise and to do something about the profession. Very high standards of day-to-day tend not to think about them. small problems that arise each and every cleanliness and scrupulous procedures People become complacent and oblivious day then, sooner or later, somebody will for disinfection in the surgery are (quite to risks that only seem obvious with slip or trip. And the outcome can be rightly) expected and (generally) achieved. hindsight in the aft ermath of an incident. serious. While the most likely consequence Th e need for inoculation against hepatitis may be bruised pride, slip, trip and fall (and to confi rm the eff ectiveness of the Slips, trips and falls incidents in the UK cost 40 workers their treatment) for anyone undertaking invasive Th is is the easiest place to start in any lives in 2009 and cost society an estimated procedures is generally well understood. workplace and is the most overlooked area £800 million each year. In addition to the But when was the last time you of danger, causing injury (and sometimes fatalities, there were over 15,000 major reminded ancillary staff that they should death) to thousands every year. Patients, injuries attributed to this single hazard. stay away from work when suff ering from a visitors and staff walk into the practice A well-planned inspection programme simple head cold or perhaps a stomach every day. How oft en have you seen the will help you to remove the “blinkers” and upset? Are your reception staff aware of the damaged tiling just inside the entrance and control the most obvious hazards that may standards expected or are they waiting at promised yourself you would do something otherwise go unrecognised and unresolved. the desk with a welcoming sneeze for all

18 SUMMONS anaesthetics in dental practice there has away any time soon. However, regardless been an increase in the number of practices of any potential impact on health, what off ering relative analgesia. is your policy on waste segregation and It is important that gas scavenging management? systems are properly serviced and Th e Landfi ll Directive introduced in July maintained to prevent leakage and 2004 made it almost impossible to legally transient escape into the working space. dump mercury or mercury contaminated Exposure to nitrous oxide gas for patients products in the UK, resulting in a massive is intended to be at (relatively) high growth in recycling and consultancy concentrations for short periods of time. services. How accurately do you measure Exposure for staff at much lower your inventory – and how confi dent are concentrations for prolonged periods has a you that you are fully compliant with your completely diff erent impact – which may waste management obligations? cause problems especially for staff of childbearing age who could be at increased Clinical sharps risk and whose potential exposure must be It seems redundant to emphasise that assessed and managed appropriately. sharp blades and needles can cut or puncture staff as easily as they cut and Skin problems – occlusive gloves puncture patients undergoing treatment. How well do you manage skin care Yet sharps injuries do still occur, with all measures in your practice? Have you the consequential risks. Last year the UK or any of your staff suff ered problems introduced laws specifi cally requiring from itching, fl aking and reddening health workers to manage the risk. Do skin? Have you ever even asked the you know your obligations under the question? Severe allergic reaction to the Health and Safety (Sharp Instruments wearing of natural rubber latex gloves is in Healthcare) Regulations 2013? Have (thankfully) now far less common than you reviewed your policies and practices it used to be as manufacturers introduce to ensure that collection bins are never ever-safer unpowdered, low-free-protein overfi lled? And who handles these from formulations. Nitrile and vinyl gloves are fi rst opening to fi nal collection? Do you available that are suitable for some tasks need to do anything more to prevent but even these can cause allergic skin reduce or manage the risks of accidental Hiding in plain sight reactions for some people and are certainly inoculation or laceration? not the answer for all applications. Perhaps the bigger problem – the one more commonly overlooked – is the need Trivial hazards, serious incidents for a good skin-care regimen whatever Th ankfully, for most practices, these the incoming patients? Are your domestic glove is worn. Wearing any impermeable risks will never be realised. No one will cleaners routinely disinfecting the taps in (occlusive) glove for prolonged periods can be injured, there will be no catastrophic patient area washrooms or are they leaving cause hyperhydration and a predisposition fi res and everyone will assume the place a trap for the unwary? to subsequent skin problems including is safe. Unfortunately, the absence of If your standards are not communicated infection and/or physical damage. Th e consequence does not mean the absence eff ectively to everyone in the business there science of skin care is developing rapidly. of risk. If any workplace simply assumes it could be a risk of disease transmission. Th e How much time do you have to keep up is safe because no one has yet fallen victim British Dental Association (BDA) with developments outside your own to an unidentifi ed risk then it can only be recognises that all members of the dental specialism, and how do you ensure the a matter of time before the luck runs out. team have a responsibility to follow standards you are working to conform to Even apparently trivial hazards can cause infection control guidelines to ensure safe best practice? Access to an external advice serious incidents. practice. Th ey have published detailed and update service will oft en be easier and A specialist health and safety service, guidance, including topics such as surgery less costly. such as the one available at Law at Work, design, cleaning and disinfection. In can assist in the identifi cation and addition, the Department of Health has Amalgam toxicity management of a whole range of issues. published a technical memorandum on Th e debate over chronic toxicity of Dentistry does not need to be high risk, but decontamination. Th ese should be mercury dental amalgam may have sometimes things go wrong and it can be translated into clear, simple policies and some distance to go. With the increasing reassuring to know you have done all you staff guidance written in language your availability of social media, just two or can to prevent harm. whole team can understand. three vociferous campaigners can make (and have made) a huge impact on the Gas scavenger systems public perception – and it seems the calls n Steve Ashton is head of health and safety Following the cessation of general for removal of dental amalgam will not go services at Law at Work

AUTUMN 2014 19 These studies are based on actual cases from MDDUS fi les and CASE are published in Summons to highlight common pitfalls and encourage proactive risk management and best practice. studies Details have been changed to maintain confi dentiality

DIAGNOSIS POST-OP COMPLICATIONS

BACKGROuND: Ms T is 51-year-old HR and is sent home with a prescription elevated CRP, ESR and temperature manager with two teenage children. A for diazepam to ease anxiety. Next day are not uncommon after open heart recent echocardiogram has revealed she returns with worsening symptoms surgery. Clinical records show that Mr progressive ventricular enlargement and also nausea and vomiting. She is A had considered the possibility of due to long-standing aortic referred to the physician on-call. infective endocarditis and took regurgitation. A cardiothoracic surgeon Urgent blood tests reveal an elevated measures to exclude this diagnosis. – Mr A – advises aortic valve white cell count. Septicaemia and Considering all the evidence the replacement and Ms T elects to possible endocarditis are suspected. expert concludes that the post- undergo the procedure privately. Immediate treatment with IV operative management of the patient Ms T is admitted to hospital and Mr antibiotics is commenced. was reasonable. He does state that in A replaces her aortic valve with a Transthoracic echocardiography hindsight it might have been prudent bileafl et mechanical prosthesis. Routine reveals no vegetations but there is to give the patient temperature charts peri-operative antibiotic prophylaxis is severe regurgitation through the for home use after discharge from administered IV (fl ucloxacillin) prosthetic heart valve. hospital with follow-up in two weeks followed by gentamicin eight-hourly Ms T is transferred to the ITU and rather than six. Another expert on the for three doses. The operation is later that night suff ers a fatal cardiac case fi nds fault with the treatment Ms routine and Ms T is transferred to the arrest. Four months later both Mr A T experienced in A&E and concludes ITU for recovery. and the hospital are contacted by that had the prospect of endocarditis Next day the surgeon notes that Ms solicitors acting for the family of Ms T been acted upon with onward referral T’s vital signs are normal though with claiming clinical negligence in her to cardiology and appropriate a slightly elevated temperature. A few treatment. It is alleged that Mr A was antibiotics commenced then cardiac days later Mr A again notes the negligent is discharging the patient arrest could have been averted. elevated temperature and orders blood from the hospital with a positive blood Considering all the facts in the case cultures which yield coagulase culture and raised CRP and ESR in it is decided that there would be risk in negative staphylococcus from one combination with an intermittently taking the case to court. A settlement bottle in four. This is thought to be a elevated temperature. Suspected is negotiated and MDDUS contributes skin contaminant and not sign of infective endocarditis should have 10 per cent on behalf of Mr A. infection. been a clear concern. Seven days after the operation Ms KEY POINTS T’s temperature is noted at 38.2 and ANALYSIS/OuTCOME: MDDUS • Have a high index of suspicion in both her CRP and ESR are slightly provides support to Mr A in regard to possible post-operative infection. elevated. Mr A attributes this to the claim over Ms T’s private • Patient anxiety can mask more pericardiotomy. The next day she is treatment. Legal support for the serious critical signs. discharged with a follow-up hospital is provided via the NHS. An appointment in six weeks. expert report is commissioned from a Ten days later Ms T presents at the professor of cardiac surgery who local A&E complaining of shortness of examines the patient records and breath, tachycardia and severe other evidence associated with the backache. She is seen by an SHO who case. notes her history of valve replacement. No fault is found in the competence Ms T reports that she has been unwell with which the procedure was since the operation – tired, listless and conducted and with the use of sweaty with shortness of breath. Her prophylactic antibiotics – though it is pulse rate regulates and she is found to acknowledged that infection most be apyrexial. She is diagnosed with likely occurred at the time of the “panic attack”. operation. The expert notes there was Two days later she returns to A&E a positive blood culture in only one of again with backache and a racing pulse multiple bottles and also confi rms that

20 SUMMONS CONSENT: CAPACITY TO CONSENT

BACKGROuND: Mr D is a 73-year-old MDDUS for advice. man who was diagnosed with dementia several years ago. His condition has ANALYSIS/OuTCOME: Before deteriorated in recent months and an responding to the solicitor, Dr H is application to the court of protection is advised to speak with the patient to capacity then the disclosure can be being considered that would allow assess his capacity to consent to the made. If not, the doctor should proceed decisions about his fi nancial aff airs to disclosure of information. His capacity on the basis of the patient’s best be made on his behalf. may be impaired but it is possible he is interests which would normally involve His GP, Dr H, receives a letter from a still able to provide valid consent in discussions with a patient’s relatives or solicitor’s fi rm acting on the patient’s these circumstances. If Dr H determines carers. behalf seeking the doctor’s opinion as to the patient lacks suffi cient capacity to his capacity to manage his personal consent then, in the absence of a KEY POINTS aff airs. The request is accompanied by a welfare attorney/court appointed • Never assume a patient lacks consent form signed by Mr D. deputy, Dr H should discuss the matter capacity to make a decision based Considering Mr D’s dementia, Dr H is with an appropriate relative or close solely on a factor such as a medical unsure if this is valid and if the patient friend. It can be helpful to involve family condition or mental illness. fully understood the implications when members in these matters to ensure • Patients with diminished capacity signing it. The doctor is reluctant to they are not likely to object, but this may still be able to make simple discuss these concerns with the should be handled carefully as there decisions about their care, even if solicitors for fear of breaching patient may be confl icts of interest. they are unable to decide on more confi dentiality. She contacts If Mr D is deemed to have suffi cient complex matters.

COMPLAINTS HANDLING: LUNCHTIME FRACAS COMPLAINTS HANDLING: BACKGROuND: A receptionist sits at Ms ALunchtime shouts: “Please fracasdo!” the front desk of a dental surgery Later before treating Ms A the dentist reading a magazine in the last fi ve explains that the offi ce is locked over the minutes of an hour-long lunch break, lunch period for reasons of staff security. during which time the surgery is closed. The patient says she was not happy A few patients have turned up early and having to “wait outside in the cold”. The wait outside the locked entrance. One of dentist replies that this is no excuse for the patients – Ms A – starts to rap her aggressive behaviour. persistently on the glass door. The Later at a practice meeting the receptionist goes to the door and dentist learns the receptionist had been unlocks it and Ms A pushes angrily left frightened and in tears by Ms A’s passed her into the surgery. behaviour. It is decided by the practice She demands to know why the to write to Ms A informing her that she meeting but that the removal from the surgery is locked when she has an is no longer welcome at the surgery. A list still stands. appointment at 2. The practice manager few days later Ms A replies by letter The letter also advises Ms A that if hears shouting and comes out of her objecting to the practice’s “overreaction” she further objects to the decision she is offi ce and asks what is the diffi culty. Ms to the incident and further complaining free to take up the matter with the A complains that she came on time for about the inconvenience of the lunchtime ombudsman. Contact details are her appointment only to fi nd the door closing. The PM contacts MDDUS for provided. locked and what kind of customer advice. service is that? The PM asks her to calm KEY POINTS down and explains that the lunchtime ANALYSIS/OuTCOME: An MDDUS • Adopt a zero-tolerance policy to closing is practice policy. practice adviser discusses the issue with physical and/or verbal aggression Ms A shouts loudly that she “will not the PM and agrees that it is entirely against practice staff . calm down” and thrusts two fi ngers in unacceptable for practice staff to be • Immediate removal from the the PM’s face as she rants about the subjected to verbal and physical threats practice list is justifi ed if a patient “rude ****ing staff ”. The PM backs away by a patient – and that removal from the has been violent and/or verbally and tells her that the practice does not practice list is a reasonable response. abusive. tolerate such aggressive behaviour and The practice is advised to send a second • Ensure practice opening times are that she will be reporting the incident to letter informing Ms A that her complaint prominently displayed to avoid such the dentist. will be discussed at the next practice complaints.

AUTUMN 2014 21 ADDENDA

From the archives: Fatal self-confidence

A CENTURY ago prescribing errors no doubt posed a greater poison and this made the doctor angry. He insisted there was risk to patients than today – and sometimes even to doctors. An nothing wrong with it and to prove this he drank some. article in The Scotsman newspaper from Miss Catherine Dick – the doctor’s sister – September 1899 reports on an inquest into reported that on his return to the surgery he fell the death of Dr John Dick at Eastbourne in against the street door. She found him there Sussex. foaming at the mouth and staring wildly. He The doctor had been called out to the home gasped: “My God. I believe I have been poisoned.” of Mrs Greer. No reference is made to the Miss Dick brought out the stomach pump and pretext of the visit but he brought along a then ran to fetch a neighbouring doctor. On her liquid medicine that he had made up in his return Dr Dick said: “Tell him it’s strychnine dispensary. Later at a subsequent visit Mrs poisoning. I feel sure by the symptoms.” Greer complained that the medicine had made Efforts to save Dr Dick failed and the cause of her ill. She testified that on taking the solution death was determined to be “congestion of the she had felt like a “peg-top rolling around” and then had lost vital organs by the action of strychnine, probably on the nervous consciousness with her muscles “drawn up like a crowbar”. system”. In the time he was still coherent Dr Dick insisted he had Mrs Greer gave the medicine back to Dr Dick saying it was made no error in formulating the medicine. An expert witness later testified at the inquest that the deceased must have Crossword mistaken a bottle containing a solution of strychnine for another almost identical bottle containing chloroform water – a 1 2 3 4 4 5 6 constituent routinely used in some oral solutions. He added that the bottle dispensed contained sufficient strychnine 7 to kill 12 people. 8 9 9 The jury in the inquest returned a verdict of misadventure though Miss Dick still insisted that her brother had 10 made no mistake. 11 12 13

14 15

16 18 17 18 19

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ACROSS DOWN 1. Nags (8) 1. Inflammation of the liver (9) 4. Cause of infection (4) 2. Type of diabetes (abbr.) (5) 8. Latin American chaplains (6) 3. Solution introduced into 9. Painful swelling on toe (6) rectum (5)

11. Kettledrums (7) 5. Remov e hairs (7) LIBRARY PHOTO SCIENCE PHOTOGRAPH: 12. Memorise (5) 6. Males (3) 14. Pertaining to something that 7. Central parts (6) Object obscura: effects a closure (9) 10. In name only (7) 16. Sharp pains (5) 13. Recently married people (9) 17. Waste away (7) 14. Reproductive glands (7) Scarificator 20. ______scream, band (6) 15. Computerised axial 21. Mutate into new form (6) tomography (abbr.) (2,4) 22. Broad ribbon (4) 18. Default dog name (5) THIS six-bladed scarificator was made in France around 1900 23. Drugs used to treat 19. Insect sense organs (5) and used to create wounds on the surface of the skin for inflammation (8) 20. Purulent fluid (3) wet-cupping – a form of bloodletting. It employed a spring- loaded mechanism with gears to snap the blades out through See answers online at www.mddus.com. slits in the front cover. Blood-letting was still used by some Go to the Notice Board page under News and Events. doctors up until the early 20th century to treat a range of ailments by removing surplus bodily “humuors”. 22 SUMMONS ADDENDA

Vignette: Medical publisher Charles Hawkins Craig Macmillan (1902 – 1984)

TODAY it seems almost quaint to think of so well. The British Journal of Urology the keen student of the 20th century came later and was also a great success. carrying his heavy medical textbooks Macmillan made sure his authors had under one arm, or the consultant eagerly copies of the fi rm’s books and gained waiting for the latest journal to drop much good publicity thereby. He had even through his letter box. Print was the sent a copy of Child and Adolescent Life in medium of choice to convey Health and Disease to the Queen in 1946. information then and Charles He also went to book exhibitions and Macmillan was a publisher who grew medical congresses around the world, the Edinburgh fi rm of E & S and hosted and attended dinners. A Livingstone from small beginnings to particularly long trip in summer 1954 become a major producer of medical was to the USA and Canada where the textbooks and journals worldwide. publisher had sales agents. He summed Charles Hawkins Craig McMillan up his attitude to success: was born on 25 June 1902 – his “If you are a good publisher then, long name incorporating that of the like a good farmer, you can’t help doctor who delivered him. He later making money. If you publish to make changed the spelling to Macmillan, a money you can’t help losing and you can name better known in England. His almost smell a good manuscript.” parents were Plymouth Brethren and The fi rm grew with the turnover in Charles was taught the bible, from 1962 nearly 20 times that of 1944-45, of which he could quote or adapt phrases which foreign sales were more than half. A to suit most situations. new warehouse was built in West On leaving school Charles joined one of Crosscauseway to store some of the 400 his sisters at the printing fi rm of Nelson’s plus titles. So the fi rm had good reason to (a brother was a bookbinder). At age 17, celebrate its centenary at a dinner in the he moved to the medical publisher and North British Hotel, Edinburgh in 1963. bookseller E & S Livingstone, founded in Staff and authors including Professor John 1864 in a building opposite the old Macmillan became the sole managing Bruce and Sir Derek Dunlop were invited. medical school. Charles started at the director. Macmillan was more than a publisher. bottom but his abilities were obvious and Macmillan’s great skill was engaging Among other appointments he served as by 1935 he was appointed general with people. He toured England in chairman of the Edinburgh, Mid- and East manager and then joint managing director September 1941 to visit his authors, such Lothian Disablement Advisory Committee with Alfred J Scott. It was a very as Watson-Jones and Hamilton Bailey, and and was also on the Finance Committee of paternalistic organisation with annual to recruit more. He met secretaries, nurses the Princess Margaret Rose Hospital and outings for staff , widows and children. and booksellers. He chatted with doctors was director of the Edinburgh Chamber of “Blind children and motherless bairns” at their residency who found in him a Commerce and Manufacturers. were entertained and the needy received friend. He reported back: “This is the place Macmillan retired in 1967 and E & S Christmas gifts. where you get all the secrets about your Livingstone later merged with J&A The Second World War turned books, and these young doctors were very Churchill of London to form Churchill industries at home upside down, including ready to talk about a variety of subjects Livingstone, now an imprint of Elsevier E & S Livingstone. Even basic materials which I have carefully made a note of for which still maintains editorial offi ces in like paper and ink were rationed. future reference.” Ten years later a young Edinburgh. In 1970 Macmillan was Macmillan was in a reserve occupation but Stanley Davidson gave him his lecture honoured with an OBE for services to he lost staff to the services and authors notes which became a best seller: exports and to medical publishing. He had were committed to the war eff ort and had Davidson’s Principles and Practices of time to play as much golf as he wanted at little time to write. A bomb destroyed Medicine (1952). the Glenlockhart Club, and time for the stock in a warehouse of their distributor in In 1948 Macmillan agreed to publish nineteenth hole. He and his wife Isabella, London and 1943 and 1944 were full of two journals which were to prove very who predeceased him, had four children, disasters. A fi re at a printing factory successful: the British Journal of Bone and two girls and two boys. He died October destroyed 90 per cent of the company’s Joint Surgery (its American subscribers 25, 1984. illustrations, a promising young author’s made it a good dollar earner) and the ship was torpedoed on the way to South British Journal of Plastic Surgery, a brave n Julia Merrick is a freelance writer and

IMAGE: CHURCHILL LIVINGSTONE CHURCHILL IMAGE: Africa and Alfred Scott died suddenly. venture at the time and not expected to do editor in Edinburgh AUTUMN 2014 23 Factoring in risk Healthcare is a risky business… and to help you mitigate your own risks MDDUS Risk Management is working to develop new and innovative tools for members and their teams.

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