A talk by the MDU regarding the importance of having medical indemnity. One not to miss for any new NHS doctors - this is a crucial aspect of working in the NHS.
IMG Webinar Series 5 - Indemnity Essentials: Safeguarding Yourself and Your Career
Summary
This is a Medical Defense Union session hosted by Dr. Nandor Sermon, a Medical Legal Adviser at the MDU. During the session, Dr. Sermon aims to discuss practical medical legal challenges such as patient confidentiality, medical prescribing, professional boundaries, chaperones, consent, and mental capacity law in the UK. He also hopes to discuss the multiple lines of accountability a medical professional may face, including civil claim, complaints, investigation by a regulator, inquest, medical quality review, and criminal investigation. He also intends to explain the GMC’s multiple roles, and provides guidance and resources that medical professionals may find useful. Finally, Dr. Sermon will provide a scenario to demonstrate how medical regulation extends beyond the workplace. Professionals of all levels of experience are sure to gain valuable insight and knowledge from this session.
Description
Learning objectives
Learning Objectives:
- Identify the different lines of accountability and regulatory bodies to which medical professionals must adhere in the UK.
- Describe scenarios in which an action could result in multiple legal repercussions.
- Outline expectations of medical professionals regarding patient confidentiality, informed consent, and professional boundaries.
- Describe the role of the GMC in setting standards of medical practice and licensing of medical practitioners.
- Highlight the importance of following cannabis legislation, even in a personal setting.
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Okay, nobody looks like, you know. Um So um sorry everyone for the weight, we experienced some technical issues with showing the screen and so on, but now we've overcome that. So, um how much further adu thank you very much for joining um the lecture series number five for the IMG series this time in partnership with the Medical Defense Union. And we are proud to present Doctor Nandor sermon today who will be giving the lecture or webinar. Um He's a medical legal adviser at the MDU and has been since 2008 and that was very knowledgeable about indemnity and the cover they provide at the MDU. Um So just as a layout, well as I'm sure you'll have questions that you want to ask throughout the presentation. Um If you could absorb mute, the mites, I'm assuming that's already happened. Um The comment, comment box section can be used for any questions that you have throughout the lecture and we'll try our best to keep an eye on that and uh appropriate sections. We'll get doctor number soma to address those appropriately. So I think without any further of you, let's uh get started you ready? Yeah, ready to go. Okay, let's get uh please let us know service second and I think it was a bit slow. Mhm. Okay. Have a great Alvin. Will it, will it go into a slideshow? Yes. So like this and everything BC I can see it's, it's still in the kind of protective you. I think it's not going into a slide show yet, but never mind. I think we can read them. Well, first of all, thank you everybody for your patience and thank you to uh you guys that mind the bleep for inviting us to talk. Um Now you'll probably see from the, the kind of learning point on the presentation there seems to be a kind of heavy sell on, you know, joining the MDU or joining the defense organization. And I'm certainly not going to take up to an hour of your time on that. I wanted to do something a bit more productive today and talk to you about about the kind of medical legal landscape in the UK, talked with a whole range of topics that, that touch on the things that you come across in day to day practice and Alvin and Devia hopefully can hold me to account on that where there are things that you come across. Um The intention is not that you go away with a complete knowledge of, of how medical legally things work in the UK, but just an awareness of the things that you might come across sources of information and advice and how to, and, and, and how to deal with that. So, um is it possible to start the slideshow? And I've got some commentary about buzzing. So I don't know whether trying to new uh your might might help with that. So, could you repeat that again? Um There's a comment about loud buzzing on the, on the chat. So uh could you try muting your microphone at Alvin? And then uh so just a second and I mean, just stop. Oh, yes, I appreciate that to stop. Share screen. Thank you. Yeah, that's, that's worked. Alvin, that's, that's work. So it's obviously feedback at that end. Pietro. Thank you for flagging that up. That, that's great. So we'll get back on shortly and, and we'll either work through the slides if we can, if it can go into slideshow mode, that'll probably make it a bit easier to, to read. Um Alvin, can we sort of go on slideshow and start with that? Will that will that work? No, we'll, we'll work with this. Well, look what I'm going to talk to you about is first of all, a couple of practical medical legal challenges. So we're going to talk about patient confidentiality a bit about prescribing professional boundaries, chaperones, and a comment about consent in mental capacity, the law in the UK around that it can be quite complicated and the concepts there are things which I think is helpful to introduce um um uh introduced early on to anybody thinking of working in the UK. So if we go on to the next slide, the multiple jeopardy slide, sorry, I think we're still on the first slide. Um Have it if I can yet, we've got on to the next one. That's, that's great. So this is not intended to be a scary slide, but it's something that I think that will surprise people who have not worked in the UK that if a single clinical incident happens, there are sometimes instances where lots of different things can arise from it. So in every country in the world, doctors can be sued typically. And this is what we mean by a civil claim, a doctor being sued by uh a patient or another organization for what they've done if there said to be negligent in care. However, there are other that used to be the thing that 20 years ago the uh doctor would have found more most threat threatening. But now it's possible for a doctor to face complaints. Now they are quite common. Uh, in, in practice, we'll all have complaints over the course of our career. I've certainly had them from clinical practice. A doctor can face investigation by a regulator. And I know worldwide regulators vary greatly in terms of how interventionist they are, how much they involve themselves in, in day to day life. And I would say the GM see in the UK, do are quite interventionist and do get involved in a lot of cases when a patient died. If it's an unnatural death, we have the coroner system whose purpose is to work out who died where they died and how they came about their death. And some of those inquests are really straightforward. Others can be really difficult for doctors. We also have organizations in England, also in Wales, Scotland and Northern Ireland that look at the quality of healthcare in organizations and sometimes doctors drawn into those processes. Very occasionally doctors face criminal investigations. I'm talking about chaperones today because the commonest one is that a doctor is accused of uh an inappropriate Axion during a clinical examination, say for example of sexual assault, doctors are sometimes investigated on manslaughter charges where there are significant sort of clinical incidents that I would say though is still very rare, extremely difficult if you happen to be involved. But, but but rare. So the first, if I have the next slide, please, I know it will take, take a bit of time to, to, to adjust. So it's not moved on to slide seven as yet. Maybe it's a bit of lag. Yep. Here we go. So the first concept I want to introduce is that doctors have multiple lines of accountability. So it's, it's not just the medical regulator, the gm see the doctors have to follow the law of the land like every other citizen and I'm sure that's the same around the world. Doctors are also held to account by their employer. So if you're employed by a hospital or work in a GP practice, um, those who kind of pay your wages will have expectations of you and policies about confidentiality, dealing with certain things in the workplace that will expect to be done in a certain, when you're held to account. We've got the coroner who looks at deaths and you saw lots of other things on that slide. So I guess the first thing to say is there's, there's quite a bit to think about in these situations. So, um if we go on to probably on to slide nine makes most sense here. Great. Thank you. So, I'm going to talk about the GMC 1st. 1st of all, if we go on slide 10, what, what does the GMC do? So it has a number of purposes, the GM see, set standards for medical education. It helps that some syllabus as it sets expectations for medical schools, it deals with registration and licensing. So it holds the list of doctors who are of people who are medically qualified and are registered with the GMC have, have a license to practice medicine. It deals with a process called revalidation and this is what allows you to maintain your license to practice the license to practice is essentially what let's you see, treat and prescribe for patient's and the process in the UK for maintaining that is having a system of appraisal most typically done through your employer uh and having a recommendation made by a senior doctor term, the responsible officer at that organization that allow that recommends the GMC that you maintain your license. Now, there are other ways to doing it. They are usually much more complicated, but that's the basic way that works. The other thing that the GMC does is produced guidance, an awful lot of guidance in fact, and the relevance of that is not only that, it's um you know, sometimes helpful in terms of practice, but it is also a standard that you can be judged against if you deviate from it. And that's their other role, which is what often hits the press the most is the regulation of doctors and fitness to practice procedures where you here, if a doctor has been erased from the register, has their ability to practice medicine taken away, it will be usually following a fitness to practice process that the GMC has run. So in terms of preparation for UK practice, if you did one thing in the medical legal sphere, it would be to read this document. This is the GM C's core guidance in good medical practice. It was updated in 2013 and it's going to be updated and published later this year again. So there will be changes to it. The core of it looks very similar to what it is now. But that's the one thing I would do if we have the next slide. If you're feeling really enthusiastic, I would look at these other documents. They provide guidance on confidentiality and that's a really common thing you'll come across there's issue that they also have guidance on consent. And that's again a common cause of dispute and a really important thing to think about. And they also have guidance about treating Children that's relevant to all doctors. They produce vast amounts of guidance. There are hundreds and hundreds of pages of it in different things. I think these are the key documents that you'd read and the other things you can access online or look up if you have a particular question. 0, 17. Now I'm going to put forward a scenario. The point about this is really to show how medical regulation can extend beyond the workplace. So this is a doctor on a night out visiting friends in London. Is it has a little bit too much alcohol to drink and ends up in an altercation to nightclub. The police are called this situation de escalates, but the doctor accepts a fixed penalty notice of 90 lbs for being drunk and disorderly in a public place. Now, many of you might be thinking what on earth has this really got. It's a bit bit ill judged and perhaps it's, it's, you know, it's, it's not how we'd all want to be in our best state. But you know what's this got really to do with care of patient's. But um if we have the next slide, um the JMC do require that doctors tell them if anywhere in the world they have been charged, let alone convict ID, but charged with a criminal offense or if you have registration in two different countries, a lot of doctors in the UK have registration in another country, often Ireland, perhaps India, etcetera. If there is a finding made against them in that other jurisdiction, the GMC puts an obligation on us as practitioners to, to tell the GM see that we've been the subject of those findings. So that the only point I'd make across here is is that medical regulation of the UK can also reach into your personal life. You can have circumstances on, on things such as this, you can have, you know, other driving offenses, particularly driving under the influence of alcohol. I can do that but also issues arising from personal family life, particularly things relating to say, neglected Children, domestic violence, etcetera, all our things, the regulator can take seriously and they will communicate with registration bodies overseas. So be mindful of that, check out that guidance and B and really the message is is that the burden of registration actually goes beyond the workplace for doctors. And that's a really important thing to remember. So the next topic I'll talk about is confidentiality. And again, most of us intuitively know that medical services are intended to be managed um in a confidential way and that the information that, that we are in a privileged position to receive about patient should be treated in that way. But there are subtleties to this and, and there are things where I've seen doctors who are just trying to be helpful, run into problems because of that. So think about this scenario, you're, you're a doctor training, working in general surgery. One of the teams secretaries is worried about their mother who had had an echocardiogram a few weeks ago under the cardiology team, they have not had an appointment or the result and says, can you look this up and tell me what the result is because my mother's worried, this is the sort of request I got, I would say not all that infrequently. Um And you've got to be mindful of things that things like this here. You might say, well, I've got the permission of, of, of the relative to look at it, but I'd say you need to go back to first principles here. Do you have the consent of a patient? This this person's mother to look at the records in some instances, you might. But is that still okay? Because when you access um computer systems at, at work, it's usually only for the care of patient's that you have a direct responsibility to most hospitals in the UK. In that situation would say what you should do is perfectly reasonable for you to advocate for that person by contacting the cardiology team and saying, look, I've had this inquiry. Can you look at it but that you shouldn't be using your own access to the system to look at your own results that are relatives or inquiries in that in that way, unless you had a direct interest in the care of that patient, so there can be subtleties to this that can catch people out trying to do the right thing. So when you, when you look at this, when you're, when you're asked for information about a patient, think about, do you have that person's consent? Is there a mandate by the law to disclose the information or have you been asked to do so by a court's or is there a public interest, that information must be disclosed? Public interest is a really odd term terminology. It doesn't really mean what the public are interested in. It doesn't really mean that at all, what it means is, is there a wider public purpose in you share in that information? And that can most commonly be if say there is a direct threat of violence to somebody um that, that you have to disclose, to protect that person from death or serious harm. So again, if we have the next slide, again, I can't in an hour sort of equip you with everything there is to know about confidentiality, that would be a kind of probably a series of webinars. But again, there's GMC guidance, there is an NHS code of practice which is really detailed and I flagged this up for any of you who come to work in pediatrics or general practice. One of the commonest inquiries our members get doctors working in sort of general practice or in hospitals is often requests for practitioners to provide information to social services who were involved in safeguarding Children or child protection. And there is specific guidance available. It when some detail about about uh on how to do that. So if you have the next slide, that's just a visual of uh of where you can get information about where, where those pieces of guidance are. I'd say that the JMC guidance is by far the most sort of accessible point. But the other main messages is that look if you have an inquiry and you're really not sure how you should respond to it, get advice from a senior colleague because almost certainly they would have come across that situation before. And you know, for, for doctors who are members, we always say look, ring us, we're very happy to talk about these things and it's the commonest sort of inquiry we get. So if we move on to the next section on, on chaperones, um as I said, I'm going to talk about these because um the specific requirements about chaperones are I'm kind of misunderstood sometimes and I'll run through those and run through what should be in your mind when you're undertaking an examination that requires a chaperone, as I said, that, that and I don't want to sort of say to you that allegations of sexual assault against doctors are common. They are rare but they're extremely difficult for all concerned if they arise. Uh And they can take years sometimes to investigate and that's incredibly stressful for the practitioners in those circumstances. So if we move on to the next slide of the scenario, um this is really based on a case I had a number of years ago, patient was, wasn't uh suggesting that they've been sexually assaulted at all. They complained they felt violated and it was during a diving medical examination, anybody has it. If you, if you put a chat message in any, anybody hazard a guess as to why that was. So I'll give you a second or two before I talk about. Uh we'll come back to that. So put a message in the chat if you've got any ideas and I will talk about chaperones generally and we'll come back to that in a minute. So if we have the next slide, um So this is the GMC guidance on why on when chaperone should be offered. Remember, the role of a chaperone is, is somebody who is an impartial observer wherever possible for an intimate examination. And the GMC defines an intimate examination as an examination of breasts, genitalia rectum or another examination where the patient may feel particularly vulnerable. A chaperone should usually be a health professional is what they say. I will, I will sort of put that in context. It doesn't mean that the person has to be a doctor or nurse. What it means is it should be somebody who is sufficiently trained to know how the procedure should be done and, you know, would be able to raise a concern if something untoward happened and equally should be able to give reassurance that it was conducted appropriately. If it was, you know, um, the other thing is put a note in the record about chaperones. If a chaperone was offered and declined, then do make sure you include that. Um So yeah, if we go on to the next slide, um So in terms of key tips about chaperones, giving patient's privacy to dress and undress, remember, it might be appropriate for other types of examinations rather than intimate examinations if you have a particularly vulnerable patient. Um Communication is really important occasionally saying things intended to put the patient at ease can have the opposite effect. So being professional giving clear communication, particularly about why that examination is important and the rationale for doing it. Uh As uh I I up until earlier this year, still worked in Hepatology. I've seen a lot of people with gi bleeding in my time, but until I started working for the MDU, I did not kind of think about, you know, actually I explained I was going to do a rectal examination, but obviously often wouldn't explain that if they had hematemesis iss why I was doing a rectal examination. You know, so somebody was vomiting blood, the patient won't necessarily understand why you're, you're doing a rectal examination to look for alter blood melena. Uh So explaining those things can help the patient understand why that should be appropriate. Uh Remember the chaperone should be trained. The other point I would make here is that the gender of the doctor and the patient doesn't affect whether it's a chaperone should be offered. When I've spoken about this before. I've often had comments such as well if it's a male patient and a male doctor or a female patient and a male, a female doctor or even a male patient in a female doctor, you know, essentially if the doctors feel well, it doesn't really matter. I would say that that really isn't our experience when we looked at this even around 10 years ago, about a quarter of the allegations were where the gender of the, of the patient and the uh the doctor were the same. And we're certainly seeing every combination of doctor patient gender uh being the subject of allegations of inappropriate examination. So, you know, remember it is contingent on the needs of the patient and the type of examination. So returning to the first scenario and we asked about why that patient felt, felt threatened or felt violated. And I've got over suggestion here, maybe the patient was forced to remove face coverings for the fundoscopy. That's a good point. That wasn't, wasn't the issue on this occasion. This was simply because the patient had got undressed for a general examination. And in this case, the fundoscopy had occurred um with the doctor, you know, obviously close to the patient as you need to be for the fundoscopy, but the patient hadn't redressed between the general examination having the fundoscopy undertaken and they found that uncomfortable. Now, you may think that's reasonable or unreasonable, but just remember everybody reacts differently to these situations and, and sometimes people are uncomfortable in situations to us which are really familiar. So if you're mindful of that, it'll, it'll, it'll kind of help you through, through this sort of think your way through these sorts of issues and how to approach them. So the next slide um on professional boundaries, um I'm going to talk a little bit about this. Yeah, thank you. 27 will be, be great here. So a few questions that I that were often ask is like, you know, is it legal for me to prescribe for myself? Can I prescribe to my family, can prescribe for someone that I work with? And again, I'm conscious that in, in, in, in a lot of, you know, in a lot of circumstances, if your doctors, you will get requests from family. Um and it's almost expected that you will be able to help and, and it's, it's maybe seen as bad when you can't. But again, we have very clear guidance and precedent from the GM, see about this. If we go on to the next slide, um, you know, that they kind of talk about, you know, if you're ill, then you're not your own doctor. You know, that you, if you think you've got something, um that you can pass on to patient's or if you've got something that affect your ability to, to work, well, you've got to take independent advice about that. So that's, that's plain. And I guess that would be obvious if you think you've got a condition that could be transmitted to patient's or impair your judgment. Well, you should get independent advice. Of course, you could, I don't think we'd, we'd argue about that. Now, they also suggest that we should be immunized against serious communicable diseases. And this bit is the bit that it's important is it should, you should be registered with the general practitioner outside your family. And I'm sure most of you will know, but essentially that general practitioners are in primary care in the UK and at the present are the gatekeepers for most other services. Um And the idea and, and typically, you know, when I came to this country in about 1980 78 80 you, you know, it was really common for um parents who were doctors to register Children at their practice or a family members, you know, or a friend's practice. That's, that's really discouraged. Now, it's, it's intended that all medical care should be, should be independent and that we access medical care in the same way that other patient should so be mindful of that as well. So yeah, next slide please. Um and again, there's also very clear advice that we should avoid providing medical care to ourselves or any bomb. We have a close personal relationship. Now, wherever possible is again, need to put this in context. Wherever possible means that we apply really high threshold for that. It doesn't mean it wasn't possible for me to see my GP because I was on call tomorrow or it was inconvenient. I'd have to miss work or I'd have to arrange time off work. That that's not really what it's talking about. What it's talking about is circumstances such as if you're in an isolated setting, you're working, you know, you're a doctor or an oil rig or you're a doctor on a remote island in the, in, in the north of Scotland where, you know, you're the only doctor, your family also live on the island. You may be compelled to give treatment in that situation. But it's not intended as, as, as as as a convenience that and similarly with prescribing. If we go on to the next slide, there's also really clear guidance about avoiding prescribing for yourself or anyone else, you have a close relationship to put this in context. This really stems from cases spanning over decades in the UK, where there are issues with doctors, um prescribing inappropriate prescription medicine, sometimes uh dependence inducing medication for themselves or family members. And this sort of has become a stricter and stricter sort of prohibition over, over time. Um So to the next thing, next slide, so I think, you know, that, that, you know, around the world and it will be frowned upon for a doctor to have an improper relationship with a patient or anyone close to them. Um So I'm not gonna labor that. I think it's also important to remember that in terms of relationships with patient, there is also guidance about things like gifts. Uh and that is exist from the GMC, usually you can have it from your employer's as well. And it's usually the, the point is that you shouldn't accept a gift where there is a chance that there's even a perception that you know, that that gift could affect that the treatment that, that the patient gets. Now, um It's not banned for you to accept a small token of, of, of appreciation from the patient, but for anything more substantial, most organizations have a process where you can declare that. Um and, and have it registered as a gift and get advice on whether you can keep it or not. We are also sometimes called for advice when doctors get unwanted attention from patients' and how to manage that. And it's usually best to, we generally say if, if, for example, if it happens in a GP surgery that ideally that, that doctor should be shielded from having to interact with that patient and instead somebody else should do the communication to say, look, you wrote to dr so and so in these terms, you know, ask them out on a date or whatever that's not appropriate and you really shouldn't do this again. And if these reasons, the other thing to be mindful of is social media, again, it goes back to the point that doctors aren't ever really fully off duty. So, you know, you've got to conduct yourself reasonably and respectfully on social media. And the JMC also say that if you use um social media and you're commenting on something as a doctor, you should identify yourself by name. That's not really so that you can be held to account. It's, it's really to try and stop people who aren't doctors at all. Um, you know, purporting to be on social media because if someone puts their name on social media and say, look, I'm Doctor X, it's, it's actually quite easy for a patient within a few seconds to look you up and see whether you are a doctor or not, you know. So I know that's as a double edged sword but, but be mindful of that. But your standard of behavior on there is expected to be similar to, to how it would be in, in other settings. So, thanks for that. If we go on to the, yeah, to the next slide from that, I'm going to talk briefly about consent. And again, the idea of this is not at all to make you experts in this in one session. Um It's really to say, look, this is uh this is a really big topic and it's something that, that when you're getting consent for procedures for treatments or even examining patient's etcetera, these are things that you should think about. Typically, when we get questions about this, I can break them down into consent in adult patient's, when people ask about what risks should we explain, you know, etcetera that there is also issues in relation to consent in Children, the stage of which they're able to give their own consent or which parents can, can, can give consent in that setting. And there's also another big and complicated area about who can give consent for somebody lacking mental capacity or how do you make decisions about patient's who lack capacity? So think of it in, in that framework. So if we have the next slide, so in the adult patient, the basic position is of course, us as adults, we're free to decide what we want. We can make unwise decisions, we can refuse treatment. Um You know, even when that puts our life at risk providing, we've been appropriately counseled. Um So essentially in some ways, this is very straightforward, but much of the debate in the UK and law really since, um for, for, for the last sort of, you know, 70 years has focused on the question typically of what does a patient need to be told to give properly and sort informed consent for a procedure or an intervention um before, probably about seven years ago, 78 years ago, the view in the UK, certainly by the law, though not by probably most, how most doctors approached it or, or, or the GMC as the regulator was that, you know, we as medical experts would be in a reasonable position to decide what information a patient would need to, to make decisions about their care that's really changed over the last few years. And the focus is very much on a patient centred approach. So if there's ever a legal question about whether valid consent was in place, the focus is really on whether a reasonable patient in that person's position got the information they would have expected. So it's kind of, you know, there may be a lot of overlap in the information, but the concept has moved from something where we as the experts know what a typical person should need to know about this procedure to what a reasonable patient might, might expect in this setting. Um So if we go on to the next slide, so I apologize. This may be a little, a little small, but this is um the guidance that's been in place from the GMC for about three years. Um It doesn't say anything else shattering, but it has these principles which essentially say that you should involve patients' as much as possible in decision making. You should share information about serious complications or what a reasonable person in the patient's position would want to know that if you want, if you come to know that something is really important to that person, say they have a particular occupation that would make a complication of surgery, particularly difficult for them or, or a particular lifestyle that, that would be affected by a complication. Then there's an onus on us to kind of share that information that where somebody might struggle to make a decision, you've got to support them as best as possible in, in that using communication aids or whatever ever adaptations they need to, to do that. And, and this point where they say the choice of treatment or care for patients who like capacity must be of their overall benefit or otherwise terms best interests. That's really an expression of the law in the UK about how you make decisions about patient's who like capacity, which will come onto to later. So I'd say that's a reasonable source of information because it does do a brief review of the law as well. But then I'll go and talk to one of those complicated areas which is Children. Um So think about this scenario, a seven year old attends the any department of fractured ankle suggest sustained during a football match. Parents are divorced and the child normally lives with their mother. Child needs an operation. The father gives his consent that you cannot reach the mother. Can you proceed? So uh answers in the comments but will will go on to the next slide to do do the background and I'll return to that at the end. So, yes, I have 37 please. So you can treat a child if that young person has the capacity and is consented to treatment. So this is to do with their level of maturity, etcetera. There isn't a cut off age but you know, typically Children much under 11 aren't typically able to give their independent authority, but it will still really depend on a case by case basis. Certainly as they get older, the expectation is that they will have more involvement in their decision making occasionally. And you may read about these in the international press sometimes when, when this comes about. But if a doctor is, if there's an intractable distribute between the medical team and uh parents, sometimes the court's intervene uh to, to make treatment decisions, also authorized treatment decisions about patient's who are, who are Children occasionally. Um you know, you can provide treatment and emergency if it's needed to really preserve life or serious deterioration in the condition of the patient. So immediately necessary treatment you can certainly give when you can't reach the patient's. So, um we've got an answer here saying if it's not urgent, you can wait until the mother is reached or maybe depends on who has legal custody. There's lots of important points. Then I'll come to those, the, the concept in the UK of, of, of, of parents being able to give consent rest on a legal concept called parental responsibility. That's again, something I think that might be distinct from many other countries in that it isn't exactly paralleled with who has custody of the Children or who is even responsible day to day for the Children. Um It's a technical term that has a definition. So if we move on to the next slide, um So a person, you know, these individuals, these are the classes of people who granted parental responsibility. So here the birth mother, married father's, even if there is subsequent divorce, unmarried fathers, if they're named on the birth certificate, it's possible to enter into a parental responsibility agreement with, with a person who has parental responsibility to acquire it. I've not ever seen one, but that's possible. Adoptive parents have parental responsibility. So if you adopt a child, of course, are granted this legal status for them. Uh Other bodies merit who may have parental responsibility as well as parents. So if a child is taken into care by local authority, local authority will typically share parental responsibility for that child. If you give your child up for adoption, you no longer have that. And parental responsibility can sometimes be removed by a court. Tibbetts decided that you are effectively an unfit parent. Typically. Go go sorry, go back a slide. So typically it's the scenario that we've got, I think there's a lot of, of, of important points there. And I think the one that's sensible here is that if, if you've got non urgent treatment, there is no harm at all in um in, in trying to get the agreement of both parents. Technically, for most treatment decisions, you can rely on the authority of one parent who has parental responsibility. If you know that there is a dispute, then I really advise against proceeding with one authority. I would typically suggest that, you know, clinicians do their best to say to the parents, particularly for non urgent treatment that they sort out the dispute amongst themselves in the interest of the child and come back, those situations can get messy. And we always say, look, call us for advice if these aren't resolved. The other thing is that there are some treatment decisions which are said to be of a particularly contentious nature that, that require the authority of both parents are. Uh and an example of that can be some sort of vaccination. It can also be nontherapeutic circumcision. So typically, for say religious circumcision, they would need to be the authority of both parents, both individuals, parental responsibility to proceed. And of course, if, if there is no only one parent with parental responsibility, you can rely on that. So, um next slide, please. So again, I'll talk about this for no better reason than actually, it's quite a common scenario that comes up and exams and questions. It's about whether you can provide abortion, um sexually transmitted infection advice and treatment without parental or knowledge or consent to young people under 16. And these are the conditions that have to be fulfilled. They understand the treatment that they should have been persuaded that you should make attempts to persuade them to tell their parents or allow you to tell them that they're likely to continue to have exposure to risk without the treatment and they're likely to be adversely affected if they don't get it, get the treatment they need. And it's therefore in their best interest to proceed. This is expressed in what you might think is quite an old fashioned way because it's really based on a case called Gillick from the 19 eighties where a mother tried to challenge the local authorities position in terms of putting forward people for treatment. In, in this context, she failed in that challenge and forever has had a judgment named after as a Missus Gillick. Uh and, and these are the characteristics of a childhood has tend to be Gillick competent to consent to their own treatment in this context. So the next thing I'm going to move to if we go on to the next slide is um refusal of treatment. Now, this is um one of those situations which is difficult because the law is unclear. Okay. Now, although you'd think we'd be getting calls about this all the time, we really get very few calls about this. So essentially people tend to work things out in pragmatic terms. Either a child who is refusing treatment that they need will kind of be taught around to do that or people will take the view that actually if somebody who is um you know, a teenager wants to, to, to do something, you know, that they can't really, can't really force them to have it without perhaps causing further injury. But it's one of those areas where the refusal of the competent child as it's called. So somebody who's between 16 and 18 but refuses treatment. It's an odd position of law in the UK. So a 16 year old by law and the default position is they can consent treatment. Unfortunately, the position about whether they can refuse, particularly if their parents want them to have the treatment is confused. Now, we seem to have lost the slideshow. Alvin, I'm not sure where that's gone. I've just got a black screen maybe if you, yeah, stop sharing and re share. I don't know whether that might, might work guys. Can you see the slideshow? It may just be me. In which case I could just continue with my own sort of presentation open or are you seeing a black screen as well? All right, I think we're back on. Thanks Alvin. Uh So we're gonna really wrap up with a couple of topics. I've got a couple of slides I think with social media at the end. But when we talk about mental capacity and again, um now guys, can you see the presentation again now? Because I, I can, yeah, fixed. Perfect. Thank you so much. So we're gonna do mental capacity next. So if we move on to the next slide, so mental capacity is essentially whether somebody has the kind of, you know, mental ability to make decisions for themselves. Now, the complexity of this is that England and Wales Scotland and Northern Ireland each have mental capacity legislation. Uh Northern Ireland has had this in draft form for some time that they have had uh problems with their assembly and forming a government so that the only parts of this are, are in, in, in, in, in progress. Now, the questions we had a webinar at the MD you on this a couple of weeks ago and the questions that people often ask me is look, how do you, what questions do you asked test whether someone's got mental capacity? And I would say that I entirely understand why that question has been asked. But you need to think about this in a fundamentally different way. There isn't a standard set of questions you can ask uh to determine someone's mental capacity. The questions that we asked in things like a mini mental state examination or tests of orientation and cognition might be relevant to whether you ask yourself whether the patient has capacity or not, but they never fully determine it. And I hope to be able to communicate why here. So the starting point for law is that that as adults, we basically start off with the law saying look, you've all got capacity, you know, you've all got the capacity to consent or refuse medical treatment or make other decisions. Unless the people you're seeing have reason to think that you, you don't okay. And if there are things that make you think that the person's capacity may be impaired, then you know, the onus is on us as practitioners to, to make that assessment. Why I say that that you can't make assessment of assessment of capacity based on a string of standard questions is that capacity is time and decision specific. So for example, it might mean that if you've got a retired, uh you know, uh a retired business mogul with, you know, millions and millions of pounds of assets and they get a degree of cognitive impairment, they might have capacity to manage their day to day finances, but not to decide what to do with their investment portfolio, etcetera. And it's similar for medical care, people might be able to make decisions about more minor things but may not have the capacity to make bigger decisions. So essentially when we assess capacity, we're assessing whether they can understand the information, at least the basic information, they would need to be able to make the decision they need to make at that time. Okay. Um and as I say, the decision to um you know, the inability to, to make complex decisions doesn't mean you can't make other decisions. Okay. So this is how the act in England and Wales estates, it states that someone um may lack capacity if they're unable to do one of the following. I'll go through those. I will say though that this must arise from a disorder of brain or mind, it can't just be safe. For example, if someone's asleep, that's a physiological state, they won't be able to do those things, but that's not a disorder of mind and mind and brain. So it has to happen for that reason. So they need to understand the information relevant to that decision, you know, and they should be able to understand also that if they fail to make a decision, what what, what the impact of that be and that might be particularly relevant for urgent situations, they've got to be able to retain the information in their mind for long enough to let them to use or to weigh the information as part of a decision making process. So they've got to retain it for long enough for them to kind of work out in accordance with their own priorities, what that should be and they should have a means of communicating that decision. Now, this may be typically bye bye bye speech in sign language where it might for people with significant neurological conditions be with augmented communication or simple muscle movement. Okay. Now, this is on the balance of probabilities. So if you think it's more likely than not, they can't do one of these things, then um then they may lack capacity. There's a very interesting variation to this in Scotland which had mental capacity, legislation before England did where they also say that the person should be able to remember the fact they've made a decision which in practical terms is probably a sensible thing, but that's not a requirement in England. Um Next slide, please. Um So if a patient fails the test on, on those criteria, then essentially we have to make a decision in their best interests. The person to whom that decision falls is really the person who is planning the intervention. Okay. Best interest is a term defined in law. It's not just medical best interest. It essentially requires us to consult widely with all of those people who might have a, an interest in the person's welfare and try and work out what's best, what's in their, their best interest. Now, this might be really typical, if you know, easy. If somebody has had a road accident is unconscious, they need to go for a laparotomy. You know, that's a reasonably easy decision. It may be much more difficult. Say, if you've got a patient with multiple comorbidities who's elderly, who's always prioritized, living at home, who might need to go into hospital for investigations and often that that's resolved by having a group of people have a best interest meeting, including their family care workers, where their residents, etcetera and come into that. Now, I can only really touch on the concept of mental capacity. Here. There's lots more about advanced refusals of treatment. There are particular requirements about serious medical treatment when the patient doesn't have anybody that paid carers to sort of speak for them. Um, we've really not also touched upon the fact that if you're, you know, in that context, say the unconscious patient, you would typically, you know, if you're making decisions in the best interests, you do what's least restrictive of their future options. And what that means is that you're going to do the most limited treatment that's still compatible with the purpose of saving them or saving a limb or what have you. But that doesn't necessarily, you know, that gives the most uh scope from making decisions in the future. And if you can safely defer some other steps in their care until they may recover, then that's what I would do. It is a complicated area, but I just want to introduce that, that concept and there is, there's some e learning on our website, but there's also a webinar recorded from a couple of weeks ago on the, on the, it's on youtube on the MDU video channel that you can check out if you're, if you're interested. Um So I'm going to wrap up with some comments about social media. Um So yeah, next slide after that and I say this because I think it's one of those very, very avoidable causes of difficulty for doctors. I wouldn't say doctors getting themselves into trouble all the time. It's not that it's banned or you can't express yourself. It's just that sometimes you can see that things have developed, that really need, that would cause trouble. And sn actually the fundamental thing to remember is look, if you, if you wouldn't communicate in the way that, that you would with uh an individual, like, you know, it's gonna face to face interaction, don't, don't do that on social media. So if we go on to the next, next slide, so the risks of social media as we've seen them is that candler personal and, and professional boundaries, you know, I've got a colleague who's very switched on with this and with minimal amount of information and access to a social media profile, she, she has again where she can tell us all sorts of things that we didn't really know about ourselves or things about our life that you didn't think would be obvious from what you put on Facebook or whatever patient's can contact doctors directly that can be difficult. They can leave negative feedback on forums that it's usually only appropriate to deal with offline. You can raise issues of respect for colleagues. If, if you, if you, if you do that, you've also got to be careful about straying into individual medical advice. It's not saying that you can't express a view or a comment about a medical condition or procedure or innovation or what have view. But it's really easy in conversations online to stray into giving specific individual advice about, about a patient, you know, to a patient about condition or to a colleague about an individual patient and that can be very difficult, raise very difficult issues, you know, um practicing across jurisdictions, indemnity, all sorts of things. Um The other thing to be mindful of particularly of unusual cases is that accumulated information, saying a case report or something put on social media can lead to identification of a patient or it or, or just as difficultly, it can lead to somebody thinking that it's about then when it's not okay and those things can be difficult. So the next slide um so, you know, and remember this is a very long way of saying, look, it's remember it's there forever and remember that, you know, you see this with, you know, whenever somebody gets a a position of prominence. You know, we know it seems a ritual that we bring up their tweets from when they were 16 and, and scrutinize them and remember that as a doctor that can be extremely difficult. So next slide, please, again, this is just simply to say there's a lot of, there's a lot of GMC guidance again about this, not because it causes a huge problem, but actually because there was a call for some degree of clarity from the profession as to what they could or couldn't do. So, the next slide, um so the final things I'd come to, sorry, um is really the kind of strap line we talk about what do defense organizations do? Why might you want to join one? Uh And it's ideally that you can, that, you know, I think the most useful thing we do is to give some support before things go wrong. When people ask us a question of, look, I've got a tricky situation. How should I handle it? What we always want to do is to try and prevent that situation, getting worse or esca or escalating. Uh So next slide for that, um in terms of what we do of who we are with 40 doctors and a range of specialties from general practice, clinical genetics, neurosurgery, etcetera were spread over the UK. Um We get more than 20,000 calls to the medical legal telephone advice line that's, you know, doctors and dentists calling us about medical legal questions, you know, anytime day or night and we get approximately 10,000. That's just in the medical side, new case files a year where a doctor, what has a serious, more and more serious issue where they want written advice a about complaints. Gm see case occasionally police investigation. Um and the next slide please. And so when things go wrong. Yep. Sorry. Next, next slide. Um, you know, there is a thing called the duty of candor across across now all you UK jurisdictions. Um that, that kind of requires NHS organisations to be open and honest with, with patient's when things go wrong. And actually, this is quite a clumsy piece of quite bureaucratic legislation. And our real point about this is that doctors since, um, you know, for about 30 years have had an obligation to do that through their GM see obligations to be open and honest with patient's when things go wrong. Um And that often helps diffuse things if it's done in the right way. Next slide, please, it can be quite difficult and to do. Um and to phrase appropriately and we can certainly give advice on that. It's often sensible to apologize. There's been a lot of fuss about that given a case that the GMC had last week. But as much as their approach to that was clumsy, the other thing that can often go wrong is an apology for, you know, an apology of clumsily phrase can worse, worsen the situation. You don't have to say sorry when you've not done anything wrong. In that case, you can offer empathy an explanation, but where something has gone wrong, giving a meaningful apology is more likely to defuse than not. So if we move to the, to the next slide, so I've put their, the last slide have the, the kind of professional duty of candor what the GMC expects, which is straightforward. There's a duty of candidate organizations have, which is more bureaucratic requires more record keeping in general terms. From your perspective, what you need to do is to be able to flag up uh an incident, an issue, an adverse event, wrong prescription or whatever. So the organization and look at that and see whether they need to follow this process for the next slide, please, you know, the problems we see can be if there's a failure to report an error, amendments to records are really, really difficult. If you ever make an amendment, don't sort of cross stuff out, right it again, right. It, you know, make clear it's a retrospective amendment include why you made that, that why you're making the amendment to make sure it's timed and dated with the current date and time. Because otherwise when, when patient see amendments to records, you know, if, if they have suffered harm, but all sorts of thoughts come into their head that there's been some malice behind this and and why it's happened. It can be very, very difficult to undo the other avoidable issue is about not taking enough care when completing reports. The thing I would say is, although I've been doing this job for 15 years and had literally thousands of cases when that case first comes in. Yes, there are one or two you can tell are going to escalate others. It's, it's actually very difficult to predict whether something will be resolved or something won't, it doesn't always relate to the severity of harm that came to a page. Join at all. It can depend on how motivated the complainant is etcetera. And if you, if you, you know, and, and you guys, when you're busy, you'll always be asked to write a report and send it back this evening when you've not had access to the notes, etcetera. Often taking a breath saying, look, I'm, I'm really happy to help with this process, but I want to see the records. I want to have a think about it. I want to take advice and I want to do a proper job so that if this escalates everything that's in my first report is accurate, I'm not having to backtrack on it. That's really, really important. So for the last few slides I'm talking about, you know, kind of the common things we see. Um you know, often clinical management is, is often they're often something has happened that's, that's not been kind of not been the outcome the patient wanted. So there may be issues relating to clinical management but often these other things, communication, chaperones, dealing with confidential information, the content of the records, either with it being uh the accuracy of them being disputed or being inadequate or indeed adults having written something without kind of thinking that actually patient's essentially can access all their records. They all they have to do is ask and it may well be proactive and online in future, you know, being frank when things go wrong and also consent because of the changing approaches is really important as well. So the last section so recovered, the substantive work is well, why join the MDU or a defense organization? If we go to the next slide and say, look, it's not that you should practice, been fearful of medical legal consequences. It's really you should just do your job but have somewhere to go to. If you face any of these sorts of issues, you may hear that the indemnity provided by the NHS is enough, but actually, it only covers this process. Civil claims. It can sometimes support you with a complaint or in a coroner's inquest, providing your interests are aligned with your employer. If you're somebody who, who's, you know, if they say, look, we think you did this wrong and you don't agree with that, that does put you in a more difficult position. And the next next slide, please. Um And this is simply to say, look, these are the sorts of things that we can uh we, that, you know, that a defense organization would tend to support you with, whereas the NHS only would, would do. And as I say, these things in terms of complaints and uh and Inquest really depend on how well your interests are aligned with that organization. Um So next slide, please. So of course, look, I'm the head of the advisory department at the MDU. Of course, I would say come and join us, we're the best, etcetera. Uh And this is kind of why we say that in all seriousness, I, I would say, look, I, I'd far rather you joined somebody than nobody. It's ultimately your, your decision. If you're, if you don't have any work that is effectively private, but work, if it's all within the NHS, you might not need indignity for claims outside what you're giving in the NHS. The only thing I would say is there are two really bad reasons for not joining an MD. Oh, the first really bad reason for thinking I don't need it is that this will never happen to me. It may well not, but you really can't tell or I'm a good doctor. So I will avoid these problems. You know, it really doesn't quite work like that. I've seen a lot of really excellent doctors find themselves in considerable difficulty. The other thing to say is that, you know, the other, the other reason is thinking, you know, that, that the NHS is cover is, isn't enough for those other processes because it, because it, it isn't. So, you know, I'd say, look, yeah, you know, we are the MG, you were here to help. Um, you know, and of course we'd love to join you. But it, on a more serious note, look, think whoever you pick, um, uh, you know, think carefully before saying, look, I don't think I need this because you might do so, I'll stop there. I'll go in and hand over to you. Okay. Well, thank you so much and for such a sort of overarching and actually quite in depth um webinar on sort of indemnity cover and quite common legal scenarios that you may encounter. Um sorry for all the technical difficulties. Oh, no, thank you. Thank you for your help with that. I think that I hope it was, you could see it on there and I was just trying to see whether and if, if anybody in the answer any questions in the chat, I'm very so you have some time for questions if any would like. Yeah, way. Um otherwise I can start with some. So specifically there, the, the MG you provide sort of bone services and online services that you can gain some I guess uh legal input from. But during work in the sort of more acute setting where you actually encounter this also retrospectively you might be able to about these scenarios, but within a hospital or even in primary care, what sort of resources are available for, perhaps some doctors. So, I guess, um, the first thing I'd say is it's always sensible to talk to a senior colleague. They, you know, that I, I'm, it's obviously the case that sometimes there are a gent, you know, I, I love this job because it's like medicine, you get an infinite variety of the same thing you've seen 100 times. There's a subtle difference that makes it unique and you see that in the medical legal sphere, but actually, you also see the same thing over and over again and a lot of your colleagues will have, you know, will, will have, have done that. Um So there is that, um, you know, trusts have legal departments, um etcetera. But I would say that actually look, you know that during the daytime, we typically answer our phones within about a second. So if you, if you need to talk to us, we try, you know, I'm not saying we can do that every single time, but we try and be available because we know that sometimes, you know, I've had calls when they say, well, the patient's in the room with me or the police are at the surgery, you know, and they want to know this and, and often actually that those scenarios aren't actually that complicated, they're stressful for you. But they're not, you know, but often the medical legal part is straightforward and often what that person needs is, look, you know, this is what they're going to say to you. You might perhaps just want to say to the officer. Look, I'm very happy to help, but I need to think about these things. Can you give me this information? Could you please give us this, this request, etcetera and, and, and do that. So I'd say look, senior colleague call, call the defense organization, bigger organizations may well have people charged with doing uh certain things if you've got a bit more time, particularly in a big hospital with a complex issue, save mental capacity, they will often have a whole team that can help you work out how to maximize the patient's capacity, what helped to give them, etcetera. So, so that that sort of thing is, is all completely possible. Okay. Thank you very much. We actually have some questions in the chat. So yeah, yes, you can see them curtains. Yes, I've got petrol sort of asking. Could you tell us a nutshell? What would constitute punishable negligence for an fy doctor? And what's the rationale behind it? So I wish I could have my multiple jeopardy slide up again because um the concept of negligence relates to civil claims and there isn't an element of punishment in that, you know, a patient souza doctor Souza, an organization typically sues the NHS um and essentially that the standards are that, you know that there was a duty of care from that doctor to the patient or the organization to the patient. That's almost always the case in medicine, but it was a breach of that duty. So the treatment fell below what a reasonable body of a medical opinion of uh of opinion would have supported that, that failure to give treatment caused harm to the patient and the punishment or the compensation is not really there to be punished. Certainly not in the UK, there's not really a concept of punitive damages of gosh, this person did something really bad. So we're going to compensate you much more. It's really to try and put the person back in, in the condition they were. Um but for the harm they've suffered. So it's why I say for some example, that's why spinal claims are so great because the compensation is not to, to punish the surgeon. But to say, look, this person may be paralyzed for the rest of the life. There'll be all sorts of adaptation needs, etcetera that goes on. And that's what, what amounts to the compensation built now. Um So in a nega in the context of negligence, look think of that. That's a civil claim. It's, it's about compensation, not punishment in the context of where people are punished. Well, you know, the the processes that do that can either be affairs a police investigation and that's, you know, rare and a complicated sort of scenario. So it's hard to sort of do that in a nutshell. The other communist thing we talk about is a regulator and they have the ability to punish because they can suspend the doctor's registration, stops them working for, you know, a month, two months a year, which is a huge fine effectively, as well as the personal stress of all of that. All they've got the ultimate sanction of removing a doctors registration for that to be engaged. The the standard that should be applied is that the doctor has fallen seriously below the standard of a doctor of a similar stage of training. So it shouldn't be that you've got a really difficult clinical call wrong. It should be that that foundation doctor has repeatedly and seriously been below the appropriate standard for an fy one doctor. I would also say that typically where its clinical performance, particularly if you're an F one doctor, it's likely the outcome is not likely to be punishment of that type of suspension or ear asia. It's much more likely to be that you have to agree a specific plan of working with within a remediation program, either through agreeing to do that or being forced to do that at the end of the process. But it's much more likely to be something that, that is done through a kind of, well, you need to show us that you're working under supervision, you're doing these things etcetera. Um, so, and, and, and of course, that's often why for more senior doctors it can be even more serious because in order for them to return to fully unrestricted practice, if they've gone through a GMC process, they have to show that they are able to function independently. Whereas really for a doctor in training, they have to show they've got to the appropriate, you know, so they can be managed as any other training doctor with a monitoring annual reviews, etcetera that they would get through training otherwise, so Peter, I know that's a bit of a roundabout answer, but I hope that's got somewhere near that. Okay. And then you have the question. Would you go? Oh, do you? Oh, thank you. So I've got, what's the process of joining the MDU? I'm sorry, the slides didn't project fully. We did have QR codes on the slides to, I can just share the last slide actually. Yeah, that should have a QR code on you otherwise if you go to www dot the MD you dot com, um I'll stick back in the chat. Um then you should be able to, to, to, to follow the links on there to, to join. Oh, sorry. Yeah, so there's a QR code on there. If that, if you scan that, that should take you through to, to a web page that, that lets you follow through on that. So I can't see any other questions in the chat so feel free to shout out. Okay, looks like we don't have any more questions. Um So thank you everyone for joining and thank you very much for watching on the SOMA for uh such a great uh webinar. Um If so, we've just post in the chat if you can provide some feedback. Um That'd be amazing. Um And I hope you've enjoyed just webinar. I hope to see you all soon. Great. Thank you very much, guys. Have a good evening. Thanks.