Safety netting: A medicolegal defence
Dr Sara Sreih, Medicolegal Consultant and Peter J Mordecai, Claims Manager at Medical Protection, examine a recent case study where a failure to provide safety netting advice landed the doctor in a medicolegal dispute.
Safety netting advice is an extremely important part of medical practice. You will commonly be presented with a patient where there is more than one potential diagnosis and, whilst your provisional diagnosis may be the most likely diagnosis, it cannot be ruled out that one of the other diagnoses will be correct.
In addition, a number of conditions are evolutionary in nature and new symptoms will develop over the course of time. Safety netting allows for an opportunity for your diagnosis to be reviewed if new symptoms develop, thereby reducing the chance of a misdiagnosis.
The patient contacted Dr A for colorectal bleeding. Due to the COVID-19 restrictions, Dr A conducted a virtual consultation. After hearing the patient’s history, with no ‘red flag’ symptoms, Dr A diagnosed the patient with an anal fissure and prescribed a suppository. Dr A did not inform the patient to return if the symptoms persisted or worsened.
The patient’s symptoms continued for several months, and he sought a second opinion. A sigmoidoscopy was performed, and the patient was diagnosed with colorectal cancer. The patient was treated and a claim subsequently brought against Dr A on the basis that the delay in diagnosis led to more aggressive treatment being required.
Unfortunately, this case was indefensible because no safety netting advice was provided to the patient. The provision and documentation of safety netting advice would have assisted in defending the allegation of misdiagnosis, reasons being:
1. In a clinical negligence action, the patient must demonstrate that they have suffered harm as a result of the breach of duty. Had the patient been provided with safety netting advice and returned to the doctor, the correct diagnosis would have likely been made. This would have prevented any harm being caused to the patient, thereby preventing a claim. As no safety netting advice was provided, the patient was able to argue that there was a missed opportunity to identify the cancer thereby causing harm as more aggressive treatment was required.
2. If the patient had not returned despite Dr A’s advice, then Dr A would have been able to pursue a contributory negligence claim against the patient thereby reducing their liability.
Safety netting advice should be considered as a key part of a management plan agreed with the patient. Even if it is something that is done for every patient, the advice should be tailored to the specific patient and the clinical situation and communicated appropriately. The foundation of any shared decision-making is informed consent, and this is true not just in advising on treatment options, but also when advising a patient on when further help may be needed and what to do about it.
There are several factors to consider when assessing the degree of safety netting advice to provide to the patient:
1. Severity of a differential diagnosis – If there is a more serious, albeit possibly less likely condition in your differential diagnosis like cancer, then your safety netting advice may need to be adjusted to reflect this.
For example, a patient may not be aware of ‘red flag’ symptoms and if they are not particularly troubled by such ongoing symptom(s), they may not follow the doctor’s advice to return for follow-up. Empowering the patient with knowledge of all symptoms means that they can decide whether to attend a follow-up consultation.
2. Secondary complications – For example, if a patient presents to you with broken glass stuck in their hand, then there may be no requirement to provide safety netting advice to the patient for the primary injury. However, safety netting advice should be considered for secondary injuries or complications, such as infection.
3. Guidelines – If there are guidelines regarding a particular diagnosis, consider incorporating that into your management plan, along with safety netting advice for the diagnosis you are making.
4. Limitations – Are there any limitations in your ability to diagnose the patient? If so, safety netting advice should be tailored to compensate for these restrictions. This may be particularly pertinent when consulting remotely.
5. Patient factors – Bear in mind the level of understanding, vulnerabilities, social set up and clinical concerns relating to a patient. For example, if there is a risk that the patient may develop sepsis, and if they live alone, it may be preferable to be proactive in scheduling a follow-up at the appropriate time to review and check their progress, rather than relying on the patient to book an appointment themselves.
If there is an expectation that the patient should be taking action in certain circumstances, you should be extremely clear on whether they understood and explain why you are advising as such. Specify the division of responsibility between yourself and the patient and document this in the medical notes. For example, note down who is tasked with arranging a follow-up appointment.
6. Time frame – Wherever possible, consider and communicate the time frame clearly by which time you would expect an issue to resolve, or after which point the patient should seek further help.
7. Communication and documentation –The safety netting advice should be communicated in a manner that is appropriate for the patient. Written materials or leaflets may be used to further assist and the provision of these should be documented in the medical notes. The patient’s records should reflect the safety netting advice, what was communicated to and agreed with the patient, as well as any actions that the clinician is taking, such as scheduling a follow-up within a particular timeframe. It is not sufficient to just say, for example, that safety netting advice was provided.
Finally, you should contact your medical defence organization for further advice if you are unsure about giving safety netting advice.