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Article 5. Strategic decision making, motivation theory, and junior doctor interviews
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  1. Correspondence to: Mr Wardrope (Jim.Wardrope{at}northngh-tr.trent.nhs.uk)
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Wardrope J, McCormick S
Article 5. Strategic decision making, motivation theory, and junior doctor interviews

Publication history

  • First published November 1, 2001.
Online issue publication 
November 01, 2001
  • SIMS ARTICLE 5: INTERNET PAGES

    The Internet pages are divided into "feedback" and "in tray". Feedback gives some of the actions taken over the previous management problems.

    Article 5 - FEEDBACK

     

    LETTERS

    Dear Dr York,

    Welcome to St Jude's hospital and I hope you are settling in well. I understand that as A&E departments go this one is quite busy and you are going to have an interesting time here. I hope I can start our working relations off on a good foot by giving you a pleasant task rather than a problem. I have just seen a young lady in clinic with a dentritic ulcer that was referred on to us by one of your SHOs. Apparently the patient gave a vague history of having a FB blow in to her eye but when the cornea was stained the SHO was suspicious of the corneal damage seen. Unfortunately our on-call SHO advised, over the phone, the use of a mixed antibiotic/steroid eye drop and suggested discharge. Your SHO has recorded: ???dendritic ulcer. Plan - Hold off on the drops for tonight and Ophthalmic review in the morning. I need not explain to you how badly wrong this could have gone. Pass on my thanks to your SHO and please remind them all that we are more than happy to review any ophthalmic patients the following day if they are unsure of a diagnosis.

    Welcome once again.

    Yours sincerely

    Mr U V Itis
    Consultant Ophthalmic Surgeon

    P.S. We did agree with your department 5 years ago to remove all steroid eye preparations from the A&E eye room stock. Could you please check that this is still the case? I think this case shows the value of our joint SHO teaching sessions and I will be happy to continue to help.

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    STATEMENT OF STAFF NURSE JENNY HOLLY

    On the 20th of December of last year I was at the staff Christmas party and was the subject of an unpleasant advance by Dr Philip Wales.

    During the last few months I have worked with Dr Wales in the A&E department and found him quite pleasant but unfortunately he thinks that I have some feelings for him. He has often made suggestive remarks of a sexual nature to me but he also directs comments of a similar nature to other female members of staff. I am not against this behaviour necessarily but recently I felt that I had been the subject of these comments more than others.

    At the Christmas party he had clearly been drinking and whilst I was on my way to the toilet I encountered him in the hotel lobby. He once again made suggestive comments saying that he fancied something really sweet for dessert! I was a little scared as I was alone and he was standing to close to me for my comfort. As I backed away from him I stumbled against a cloakroom door and fell backwards in to the room. When I got up I discovered that Dr Wales had entered the cloakroom and closed the door behind him. As I tried to push past him he reached down and put his had up my skirt on to my thigh. Just then there was a banging at the door and Dr Wales stopped suddenly. He turned around and walked out as if nothing had happened. I just sat down and cried as I was scared by what had happened. When I had gathered my thoughts I went across to the ladies toilet and fixed my make up as my crying had spoilt it. While I was there I spoke with Sister Ash who helped me gather my thoughts. Following this incident I avoided Dr Wales but noticed that he continued in his normal behaviour with other women at the party. Unfortunately I could not get the incident out of my mind and again became tearful. At this time Sister Ash helped me again and organised a lift home for me with Mr London.

    Recently Dr. Wales has again made some suggestive comments that I feel are inappropriate and unwelcome. I am most upset by these incidents and whilst it would be easier to ignore this situation, I feel that a stand must be taken against such behaviour.

    Staff Nurse Jenny Holly

     

    STATEMENT OF SISTER LISA ASH

    As a Sister at St Jude�s A&E department I was at the staff Christmas party last year. Like many people I had been drinking and at one point needed some fresh air. As I left the party and walked through the lobby I became dizzy and stumbled, bumping my elbow on a door. I decided to run my bruised elbow under a cold tap so went to the ladies toilets. When I was there Staff Nurse Jenny Holly entered the room and seemed very distressed. When I asked her what was wrong she was reluctant to say but admitted to having had a disagreement with Philip Wales. I saw her again later when she was upset and she explained to me what had happened. At this time I asked Mr London for help and he kindly gave Jenny a lift home.

    It is unfortunate that such an incident has occurred in our department. Our staff work closely together in a stressful working environment and this is unlikely to help the situation. It is unsurprising to me that Dr Wales is involved in such an incident. His behaviour and risky comments, whilst generally tolerated by those of us who know him, are open to misinterpretation and whatever the outcome of this investigation I would hope he changes his manner.

    Sister Lisa Ash

     

    STATEMENT OF MRS VERA WATSON

    I am a receptionist at St Jude�s A&E department and was at the Christmas party on December 20th 2000. Whilst I was there I needed to check on my babysitter and left the main hall to use my mobile phone. As I returned, Jenny Holly was just leaving the hall and held the door open for me. As I turned to say thank you to her Dr Wales pushed past me and followed her in to the lobby. They then began talking and I went back to the party. I understand that some people claim that Staff Nurse Holly initiated this conversation but it was clear to me that Dr Wales started it.

    Mrs Vera Watson

     

    STATEMENT OF DR JACOB IRELAND

    As a Specialist Registrar in A&E I was at the staff Christmas party on 20th December last year. I understand that an incident occurred between Dr Philip Wales and Staff Nurse Jenny Holly. Whilst I did not see anything of the actual incident I was with Philip for most of the evening and at no time did his behaviour give me any cause for concern. Philip is popular with most of the members of staff in this unit and obviously spent time with many of them that night. It is unsurprising that a single man would spend much of that night with female colleagues, especially one with Philip�s charm. He is acutely aware of the attraction a successful man like himself can be and would never abuse this position for any form of sexual gain.

    I am aware that Philip has a reputation amongst some of the female staff in this hospital, one that I feel is undeserved. It would appear that there may be bad feeling rooted in past indiscretion but more likely it is an unwillingness to accept the lifestyle that Philip has chosen, that of a single man who wants to enjoy himself.

    Dr Jacob Ireland

     

    STATEMENT OF DR HARRIETT BROWN

    I am an SHO working at St Jude�s A&E department and as such attended the Christmas party for staff at the Golden Hotel. Whilst I was there I noticed Jenny Holly and Dr Philip Wales talking in the lobby when I was on my way out for a cigarette. Jenny did seem a little unsettled by Dr Wales� presence but then people at a Christmas party often end up having conversations with people they don�t really want to! I went outside for my cigarette and when I returned later they had both gone. I saw nothing else that night that I feel was relevant.

    Dr Harriet Brown

     

    STATEMENT OF DR PHILIP WALES

    I was at the St Jude�s Hospital A&E department staff Christmas Party on December 20th 2000 and whilst there spent time with a number of the nursing staff, male and female. Unfortunately one of the junior staff nurses became enamoured with me and tried to get me to go out with her socially. Whilst I have never felt the need to avoid relationships based within the department I was not interested in Staff Nurse Holly�s advances. It would appear that she felt the Christmas Party would be a good chance to try again and regrettably as I had consumed a fair amount of alcohol I was in a more receptive frame of mind. The incident that Staff Nurse Holly refers to occurred shortly after deserts were served. I was leaving to go to the toilet when she approached me from behind and whispered "Fancy something a little sweeter" in my ear. She then guided me towards the unattended cloakroom and began kissing me. One thing lead to another and whilst we were there I began to slip my hand up her skirt. Suddenly there was a noise as someone banged in to the cloakroom door and this brought me to my senses. I explained that we shouldn�t really do this and that when Staff Nurse Holly sobered up she would regret the incident. She was very annoyed at my rejection and then suddenly became tearful. At this point I left her and continued on my way to the toilet but I remember that as I was entering the toilets she was leaving the cloakroom and looked to be heading for the ladies. I had no further dealings directly with Staff Nurse Holly that night but do remember her looking upset when she saw myself and Fiona Smith dancing together later that night.

    I am shocked at the allegation being levelled at me and can only say that Staff Nurse Holly was a more than complicit party in what was a regrettable drunken fumble. I can only assume that this is sparked off by some wish for revenge at her rejection by me.

    Dr Philip Wales MRCP

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    NOTES FROM EXAMINATION OF MRS S SMITH

    Name Mrs. Susan Smith

    DOB 29.2.55

    Address 16, Plane View, Jamestown

    Occupation Shop Assistant.

    Right handed

    Married. Two children

    Date of accident 2.2.01

    Date of interview 1.11.01

    Mechanism of injury Mrs. Smith was the driver of a Fiesta car. She was wearing a sear belt and a head rest was present and correctly positioned. The car was not fitted with air bags. She was stationary at traffic lights when her care was struck in the rear by another car. Mrs. Smith was thrown forward by the impact, restrained by the seat belt and then recoiled backwards. She did not strike the steering wheel or any other part of the car. She was able to get out of the car and exchanged details. Her car was still driveable.

    Injury She did have some aching in her neck at the time of the accident but the following morning the pain was much worse. She had some pain in the right arm and hand with tingling in the fingers.

    Treatment She attended her general practitioner who advised her to take pain killers . She was certified as unfit for work. She had continuing pain and saw her GP again and physiotherapy was organised and was signed off work for another two weeks.

    Work Prior to the accident Mrs. Smith was a full time shop assistant. She was off work for 4 weeks. When she returned to work she was unable to do any heavy lifting. It took about three months before she was able to do her job normally. She has had no further time off work.

    Activities of daily living The neck was very painful initially. Her sleep was disturbed for 4 weeks. She took regular painkillers for 4 weeks. She was able to dress/wash/eat and cook. She required help with heavier household tasks for a six week period. She still has some problems in doing her shopping. She was unable to drive for a five week period and when she did return she was very anxious and would avoid driving if possible.

    Hobbies and Leisure Mrs. Smith went to the gym once a week and swimming once a week. She was unable to do these for 4 months. She has returned to the gym but is still not doing all her normal exercises.

    Progress and present positionThe neck was very painful initially with pain across the base of the neck, shoulders and down the right arm. The neck was very stiff. The symptoms improved after physiotherapy and after about 6 weeks she was able to do most things apart form heavy lifting. It took about 3 months before she could lift/hoover/shop although these did cause an increase in aching in the neck.

    At present the neck is much improved. She still has aching in the neck on most days and this is worse if she has been doing a lot of activity the day before. It is stiff in the mornings. The pain is at the base of the neck and between the shoulders. There is no longer any arm pain or parasthesia.

    She is still anxious when driving but this is mostly at traffic lights. She is has no flashbacks/nightmares and she does not avoid driving.

    Past Medical History Mrs Smith has been fit and healthy in the past, no previous neck problems. No medication at present. No other bone/joint problems.

    Examination
    Mrs. Smith is 1.67 meters tall and weighs 74 Kg. She appears a pleasant and straightforward lady.

    General She can talk freely about the accident and the injury with no evident distress or anxiety. She walks normally, sits normally and moves normally.

    Neck There is no swelling or deformity. There is tenderness over C6/7 in the midline, the right paraspinal muscles. Flexion is full. Extension is full with pain at end point. Rotation to the right is reduced by 20 degrees and is painful. Rotation to the left is to 85 degrees. Lateral flexion to the left is painful and reduced by 10 degrees.

    Neurological examination shows normal power/tone/reflexes and normal sensation. Balance and gait are normal.

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    INDEPENDENT REVIEW

    Report of Independent Review Panel.

    Mr. R. Bristol, Consultant A&E, St Elsewhere.
    Dr. F. Whitehaven. Consultant Physician, Dunromin District General.
    Convenor. Mr. S. Wheelright. Non Executive Director. St. Jude's.

    Documents examined

    Accident and Emergency records
    Medical records, St. Jude's
    Complaint correspondence from Mrs. Green, Dr. York, Dr. Canterbury, Mrs Penny and Ms Butcher
    Statements of A&E SHO, Medical Registrar, Dr. York, Dr. Canterbury, A&E nurse

    Interviewed

    A&E SHO
    Medical Registrar
    Dr. York
    Dr Canterbury
    Mrs. Green.

    (The first eight pages of this document deal with the factual context of the complaint and no-one disputes the facts and therefore they are omitted from this summary.)
    For details of previous correspondence see SIMS articles 1, 2, 3, and 4

    Conclusions

    1. The staff in the accident and emergency department carried out a reasonable assessment and rightly came to the conclusion that meningitis was in the differential diagnosis as was a urinary tract infection.
    2. They correctly referred the patient to the General Medical team.
    3. The communication between the A&E doctors and the medical registrar could have been better. Specifically they should have emphasised the concerns regarding possible meningitis.
    4. The A&E junior doctor handbook does emphasise the important of proper hand over and communication to the inpatient teams.
    5. The medical registrar was faced with a difficult clinical problem. The diagnosis of meningitis can be difficult. A urinary tract infection was a possibility. The medical registrar cannot remember the A&E staff informing him that they though meningitis was a possibility. If he had been made aware of this he says he would have admitted the patient.
    6. The nursing staff in A&E were correct in questioning the registrar's decision. It might have been wise for the registrar to review the patient in light of the nursing concerns.
    7. We found no evidence that any of the staff regard patients with learning difficulties in a negative light. Indeed the A&E department has a very positive attitude and the junior doctor handbook highlights the problems of diagnosis in patients with learning difficulties.

     

    Recommendations

    There should be even more emphasis placed on the handover of patients to inpatient teams when a referral is made.

    Clear differential diagnoses should be made in A&E notes.

    Relatives should be fully informed of treatment plans for patients.

    If a relative questions a treatment then it is good practice to fully review the patient and seek a more senior opinion.

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    Dear Ms. Butcher,

    Thank you for a copy of the Independent Review. I do not think this report answers my questions fully. I have taken advice and I am writing to the Ombudsman for Health too ask that this complaint has a more thorough investigation.

    Your sincerely

    Mrs. Green.

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