Case type 5: clinical concerns

155. Good doctors make the care of patients their first concern, work effectively with colleagues, provide a good standard of practice and care and are open and honest when things go wrong. They work within their competence, keep their knowledge and skills up to date and demonstrate leadership within their role.⁵⁸
     
     
156. Doctors must provide a good standard of practice and care.⁵⁹ They must recognise and respect every patient’s dignity and privacy.⁶⁰ They must treat patients with kindness, courtesy and respect⁶¹. Doctors must listen to patients and encourage an open dialogue about their health, asking questions and responding honestly to their questions.⁶² They must work in partnership with patients to assess their needs and priorities,⁶³ giving them the information they want or need in a way they can understand.⁶⁴
     
     
157. To develop and maintain effective teamworking and interpersonal relationships, doctors must listen to colleagues, communicate clearly, politely, and considerately, recognise and show respect for colleagues’ skills and contributions and work collaboratively.⁶⁵
     
     
158. Doctors must contribute to continuity of patient care.⁶⁶ When delegating tasks or duties, doctors must be confident the person they are delegating to has the necessary knowledge, skills, and training to carry them out.⁶⁷ If a task is delegated to them but the doctor is not confident they have the necessary knowledge, skills and training to carry it out safely, they must prioritise patient safety and seek help.⁶⁸
     
     
159. Documents that doctors make to formally record their work, including patient records, must be clear, accurate, contemporaneous and legible.⁶⁹
     
     
160. Doctors should be familiar with, and use, the clinical governance and risk management structures and processes in the organisations where they work or are contracted to.⁷⁰ They must act promptly if they think patient safety or dignity is, or may be, seriously compromised⁷¹ and be open and honest with patients if things go wrong.⁷² Doctors in a formal leadership or management role must take active steps to create an environment in which people can talk about errors and concerns safely.⁷³
     
     
161. Patient safety may be affected if there is not enough cover. A doctor must therefore take up any post they have accepted, work any shift they have agreed to, and work their contractual notice period before leaving a job, unless the employer has reasonable time to make other arrangements, or their personal circumstances prevent this.⁷⁴
     
     
162. Doctors must be competent in all aspects of their work, including, where applicable, formal leadership roles, management, research and teaching. They must recognise and work within the limits of their competence and keep up to date with guidelines and developments that affect their work.⁷⁵
     
     
163. Doctors with additional leadership and management responsibilities must make sure that systems are in place to give early warning of any failure, or potential failure, in the clinical performance of individuals or teams and must make sure any failure is dealt with quickly and effectively.⁷⁶ They should also make sure systems are in place to monitor, review and improve the quality of their team’s work and that teams are appropriately supported and developed.⁷⁷

164. Clinical concerns can include a wide range of matters relating to a doctor’s behaviour and/or performance at work. A view will need to be reached about where on the spectrum of seriousness the concern or allegation lies with reference to the nature and extent of the departure from the professional standards and considering the presence of any features that increase seriousness. An expert opinion may be available to assist with this depending on the stage of the fitness to practise process the matter has reached.
     
     
165. Very rarely, a clinical concern will relate to a doctor’s role in encouraging or assisting a person to end their own life or amount to gross negligence manslaughter. This behaviour, even if a single act, may be so serious that it can have a significant harmful impact and pose a risk to public protection.

In cases of clinical concerns, the different parts of public protection might be engaged as follows:

166. Where the concern or allegation involves a series of failures to provide a proper standard of care amounting to a departure from the professional standards, or one particularly serious departure, the interim orders tribunal (IOT) should carefully consider the impact on patient safety if the doctor were to continue working unrestricted pending resolution of the fitness to practise process.
     
     
167. Detail about when an interim order is likely to be appropriate in a clinical concerns case can be found in the specific case types section in Section 2: IOT hearings.

168. Allegations relating to clinical concerns can fall at the lower, mid-range or higher end of the spectrum of seriousness depending on the circumstances of the case. This means the starting point for assessing current and ongoing risk to public protection could be low, medium or high.
     
     
169. Where the starting point for assessing risk is low, evidence of relevant context known about the doctor and/or their working environment and evidence of insight and remediation that decrease risk, will usually have more impact. This is because the risk to public protection, including the impact on public confidence, arising from clinical concerns falling at the lower end or mid-range of the spectrum of seriousness are generally easier to address.
     
     
170. However, where the starting point for assessing risk is high, evidence of relevant context known about the doctor and/or their working environment and evidence of insight and remediation that decrease risk may have less impact because allegations falling at the higher end of the spectrum of seriousness can be more difficult to remediate. The medical practitioners tribunals (MPT’s) decision on risk should reflect this and a conclusion the doctor poses a current and ongoing risk to public protection may be needed. If so, this will result in them finding that the doctor’s fitness to practise is impaired.
     
     
171. Where an allegation about a clinical concern leads to a finding of impairment, it may engage one or more of the three parts of public protection. Whilst the MPT must consider the individual circumstances of the case, it will be unusual for a proven allegation about a clinical concern not to impact on patient safety.

172. A wide range of behaviour and/or poor performance is frequently seen in these cases. However, where there is a wide range of clinical concerns, a conclusion that the doctor poses a current and ongoing risk to public protection will often have been made.
     
     
173. However, where the specific type of behaviour or poor performance amounting to the clinical concern just fell short of a conclusion that the doctor poses a current and ongoing risk to public protection, and there are no other concerns requiring restrictive action, a warning may be required to maintain public confidence in the profession and uphold professional standards.

174. The proportionate sanction in response to an allegation relating to a clinical concern will depend on the extent of the doctor’s behaviour and/or poor performance and the impact it’s assessed to have on each of the three parts of public protection.  
     
     
175. Where the level of current and ongoing risk to public protection is low or medium, conditions will often be the proportionate response.  
     
     
176. Suspension or removal are only likely to be needed where the assessment of risk is high based on the case falling at the higher end of the spectrum of seriousness, there being relevant context known about the doctor and/or their working environment that increases risk and/or because the doctor has shown a lack of insight and/or is not willing or able to remediate. 
     
     
177. When deciding on sanction, the medical practitioners tribunal (MPT) should consider the sanctions banding for clinical concerns cases in Part C of Section 3: MPT hearings. 

178. For those rare clinical concerns cases involving a criminal conviction or caution, the medical practitioners tribunal (MPT) should also refer to the specific case type section Criminal convictions, cautions, court sanctions and determinations. Where there is more than one type of proven allegation, the MPT should impose the sanction that addresses the most serious findings.