Features: Blank prescriptions
25 March 2009
A GP pre-signs blank prescriptions and sickness certificates for use by his unqualified Nurse Practitioner.
A Fitness to Practise Panel erased a GP’s name from the medical register after finding that he had pre-signed a large number of blank prescriptions and sickness certificates for use by his Nurse Practitioner, who was not qualified or registered as a supplementary Nurse Prescriber.
A PCT investigation found approximately 2,000 blank prescriptions and five blank Med 3 sickness certificates, pre-signed by the doctor at his GP practice when he was on holiday. During his absences the doctor engaged a locum GP to provide limited medical cover. The Nurse Practitioner undertook home visits and provided medical and emergency cover in the absence of the locum. She also conducted morning
surgery, including examining patients, writing up patient notes, issuing presigned prescriptions and Med 3 sickness certificates. The doctor did not provide her with any adequate training, appraisal or clinical supervision for this role.
The surgery had been a two partner practice until the resignation of the senior partner and had a list of approximately 5,000 patients. As a single GP the doctor could not provide the necessary level of medical cover. He should have appreciated this and taken appropriate action.
Good Medical Practice (May 2001) states: ‘If you have good reason to think that your ability to treat patients safely is seriously compromised by inadequate premises, equipment, or other resources, you should put the matter right, if that is possible. In all other cases you should draw the matter to the attention of your Trust, or other employing or contracting body.
'You should record your concerns and the steps you have taken to try to resolve them.'
The doctor did not seek the PCT’s assistance or take steps to recruit additional GP resources or engage sufficient locum cover. Instead he used his Nurse Practitioner in a role which was akin to that of a GP. This led to the development of dangerous, illegal and unacceptable practices and to the creation of a dysfunctional regime which undermined the ability of staff to work as a team and provide effective healthcare.
The Panel found that the doctor had seriously failed in his duty of care towards his patients who were regularly seen by the Nurse Practitioner. It was particularly concerned about the number of presigned prescription forms, which left no room for doubt about the doctor’s intention that the Nurse Practitioner should play a substantial and improper part in the delivery of medical services.
Good Medical Practice states: ‘You must be satisfied that, when you are off duty, suitable arrangements are made for your patients’ medical care’.
The doctor did not put in place arrangements to provide cover after his partner resigned, nor did he provide adequate temporary cover when he went away on holiday.
Good Medical Practice states: ‘Delegation involves asking a nurse, doctor, medical student or other health care worker to provide treatment or care on your behalf. When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved’.
The doctor told the PCT that the Nurse Practitioner was competent in performing the role she undertook at the practice. This indicated a lack of insight and understanding on the doctor’s part; his belief in the Nurse Practitioner’s competence could not excuse the fact that she should never have been given such a role.
Good Medical Practice states: ‘You must be honest and trustworthy when writing reports, completing or signing forms, or providing evidence in litigation or other formal inquiries. This means that you must take reasonable steps to verify any statement before you sign a document’.
A sickness certificate is accepted by employers as evidence of a person’s inability to work on the basis of a doctor’s examination. There was no such examination by a doctor in cases where the Nurse Practitioner completed the Med 3 sickness certificate which had been pre-signed by the doctor. He therefore connived in the presentation of dishonest information.