Escalating concerns to a higher level


Dr Gibbs works as a GP partner in a rural practice in Wales. He gets a letter from the local hospital about an elderly patient, Mr Brown, who has severe rheumatoid arthritis which has not responded well to treatment.


Mr Brown's care in hospital is managed by Consultant Rheumatology Physician, Dr Goodwin.

The letter explains that Dr Goodwin has put Mr Brown on a course of azathioprine for his severe rheumatoid arthritis. He wants Dr Gibbs to continue the prescription. The letter states that Mr Brown will have a blood test when seen in the follow up clinic four weeks after discharge.

Dr Gibbs notices the clinic appointment date was four weeks ago but the letter was only sent in the last week. Dr Gibbs knows that azathioprine can reduce white cells in the blood, leading to an increased susceptibility to infection. Some of his patients are on azathioprine so he knows local Health Board guidelines recommend weekly blood tests for the first two months of use. He also notes that the hospital's shared care protocol is missing and should have been included with the letter.

What the doctor did 

Dr Gibbs tries to call Dr Goodwin's secretary and then Dr Goodwin directly but cannot reach them. He immediately rings Mr Brown to check how he is doing and learns that he has not had a blood test since starting azathioprine. 

Dr Gibbs explains the importance of the test to Mr Brown, who becomes upset and explains that he is scared of going back to hospital. He is concerned about getting an infection and says he will be worried sick waiting for test results. Dr Gibbs tries to reassure Mr Brown and arranges an urgent blood test at the local centre. Fortunately the results of the test are satisfactory.

Dr Gibbs worries that Dr Goodwin hasn't followed the shared care protocol for patients on that drug. The risks for Mr Brown are greater by the delay in sending the letter. He fills in a significant event audit form and sends the details to the National Reporting and Learning System (NRLS). He knows that they can consider if a national alert about the importance of weekly blood tests for patients on azathioprine should be issued.

Dr Gibbs also raises his concern with the Senior GP partner at the practice and the manager of the Health Board. After an investigation by the Medical Director, the hospital updates its discharge processes. Immediately relevant clinical information is passed on to patients' GPs without delay. All doctors are reminded about following the shared care protocol for patients on azathioprine.