Raising and acting on concerns about patient safety (2012)

About the guidance

All doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity are being compromised.

Raising and acting on concerns about patient safety (2012) sets out our expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety.

Read the guidance online or open a pdf version of Raising and acting on concerns about patient safety (179kb, pdf).

The guidance is separated into two parts.

  • Part 1: Raising a concern gives advice on raising a concern that patients might be at risk of serious harm, and on the help and support available to doctors.
  • Part 2: Acting on a concern explains doctors’ responsibilities when colleagues or others raise concerns with them and how those concerns should be handled.

Use the tabs below to explore

  • a two part case study on putting matters right and raising a concern;
  • a GMP in action interactive case study;
  • a summary of the key points; and
  • how we developed the guidance.

Decision making tool

Decision making tool on raising concerns about patient safety

The decision making tool on raising concerns is an interactive web tool which brings the principles in our guidance on raising concerns to life.

We hope navigating through the tool and exploring the issues raised in the case studies will help doctors and others understand how the principles in the guidance may apply in situations doctors face.

The decision making tool illustrates the principles in the guidance, and is not a substitute for the guidance, or for specific advice from experienced colleagues, or a professional or regulatory body.

View the decision tool on raising concerns.

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Put matters right

What steps should a doctor take when patient safety may be at risk?

This case study highlights and explores some of the principles covered in Raising and acting on concerns about patient safety. We hope that it will help doctors and others to understand how the principles in the guidance may apply in practice. It is intended to illustrate the principles in the guidance, and is not a substitute for the guidance, or for specific advice from experienced colleagues, or a professional or regulatory body.

Read Part 1: Putting matters right below or Part 2: Raising a concern in the tab to the right.

Part 1: Putting matters right

Mrs Cole is 76 years old. She has been admitted to hospital for an elective knee operation for her chronic knee pain. Dr Higgs, senior house officer on a surgical firm, arrives on his morning ward round to see Mrs Cole for the first time before her operation and notices that her pre-operation baseline observations have not been completed, even though this is the standard protocol for the hospital.

Dr Higgs recalls that similar observations were not taken on one of his patients the week before last. He thinks that if this kind of lapse were to happen on a regular basis, patient safety would be put at risk.

For now, Dr Higgs decides that the best thing to do is to record Mrs Cole’s vital observations himself to ensure that her immediate care does not suffer (paragraph 2 and paragraph 20). Dr Higgs then goes on to liaise with the nurse in-charge to undertake follow-up observations.

Even though he was able to undertake the observations himself, Dr Higgs records the incident through the local system put in place by the hospital, as well as documenting in the patient notes to ensure that other members of the healthcare team involved in Mrs Cole’s care are aware of the incident (paragraph 11).

Dr Higgs also decides that, given the relatively low level of this concern and that it has been recorded through the appropriate procedure, it does not need to be escalated further at this stage. However, he commits to following up on the progress with the incident report in the next few days to see what action has been taken.

You can view the second part of this case study by using the tabs above.

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Raising a concern

What steps should a doctor take when patient safety may be at risk?

Part 2: Raising a concern about patient safety

The following afternoon, Mrs Cole goes in for her knee operation. The operation is a success, but a few hours post-surgery, Mrs Cole develops diarrhea and is transferred to a side room. Later on in the evening, the family informs the nursing staff that Mrs Cole is not looking well. After discussion and review, and in light of Mrs Cole’s history of diverticulitis, atrial fibrillation and high blood pressure, the nursing plan is to carry out two-hourly observations.

Dr Higgs conducts a ward round early the next afternoon and finds that no observations have been done for Mrs Cole since 6am. Dr Higgs undertakes an assessment and finds that she looks very pale with increasing difficulty in breathing, which has not been noted on the observation chart. Mrs Cole also complains of generalised tenderness in the abdomen, with evident signs of shock with cool peripheries.

Dr Higgs informs his registrar who arrives immediately, examines the patient and orders appropriate investigations, as well as informing the critical care outreach team. IV fluids are started and the surgical team are informed.

Having been reviewed by both the surgical and the critical care outreach teams, Mrs Cole responds to the initial fluid resuscitation and stabilises on IV antibiotics. Both teams work together to agree a joint management plan for the patient. Mrs Cole is transferred for close monitoring to a high dependency surgical ward.

Now that Mrs Cole’s condition has stabilised, should the doctor:

  • Record the incident through the local procedures?
  • Escalate his concerns to someone senior within the hospital?

Given the seriousness of the issue, and that it was the second time in a few days when issues arose in the care of Mrs Cole, Dr Higgs decides to record the incident through the hospitals reporting system for near misses (paragraph 11). But, after making the report Dr Higgs is unsure whether he should take further action.

He remains concerned about the incomplete pre-observation chart yesterday, and the apparent breakdown in patient handover and staff communication which led to scheduled observations being missed. Dr Higgs discusses the situation with Dr Ash, who is 10 years his senior at the hospital. Dr Ash advises him that he should probably tell someone about his concern formally (paragraph 18).

Although Dr Higgs does not know all the details of what happened to Mrs Cole’s management plan when he was not on duty (paragraph 10c), he decides that it was too close a call to be left as it is and discusses his concerns with the ward sister and Mr Green, the consultant in charge (paragraph 13).

Mr Green is responsible for clinical governance within the hospital. He orders an investigation be undertaken into the care provided to Mrs Cole and the issues raised by Dr Higgs in relation to handover and communication.

Throughout the entire process, Dr Higgs keeps a record of his concerns and the steps he has already undertaken in terms of reporting these through the hospital systems (paragraph 15).

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GMP in action

GMPia case study on raising concerns about patient safety

Good medical practice in action is an interactive web tool which brings the GMC's ethical guidance to life. 

Through the below case study, you can choose what Dr Singh should do when the receptionist, at the GP surgery, has informed him that she is concerned that patient's may be at risk as Dr Hargreaves continues to underperform, since his return to work.  

Please note that this case study refers to Good medical practice as well as our guidance on raising concerns.  

To view the case study, follow the link to the Good medical practice in action case study on raising concerns.

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Key points

Key points on raising concerns:

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Background

Development of the guidance

Raising and acting on concerns about patient safety (2012) (pdf) replaces Raising concerns about patient safety (2006).

In developing Raising and acting on concerns about patient safety we also consulted on Leadership and management for all doctors (2012) and Writing references (2012).

Read about the development of these pieces of guidance (371kb, pdf), which explains the process we undertook during the review.

This PowerPoint presentation also provides the background to the development of the guidance and highlights what is new within the revised version.

Please note - To view the speaking notes in the presentation, you will need to save it to your computer and open the presentation from there.

You can also read the results of an audit undertaken of the process for analysing the responses we received during the consultation.

 

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