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Violent patients – a step-by-step guide to safeguarding staff

After a mental health inpatient made a death threat against a GP in a London practice. Londonwide LMCs' medical director Dr Vicky Weeks shares the advice she gave the team.

“The practice has followed correct process in terms of removing this patient from their list. They have contacted the police, obtained a crime reference number and carried out an immediate removal in accordance with the contract regulations and BMA guidance.

Things the practice could be reasonably expected to do to safeguard the doctor and the other staff –

Write this up as a Significant Event (or Near Miss, as it didn’t happen on practice premises) including all the actions they have taken as a result.

• Share the Significant Event Audit report with all the staff at a practice meeting and document this. Ensure all reception staff are aware of the situation and know that they should call the police if the patient attends the practice
• Ensure the doctor (or any other clinician for that matter) never practises without anyone on reception
• Ensure there are two people on reception at any one time and if that is not possible ensure that the practice has an up to date lone working policy and that the entire practice team is familiar with it
• Check that the patient does not have any personal contact details for the doctor, e.g. mobile number, home address etc
• Discuss the incident with the doctor and ask what if any support he or she would like on a personal level
• Recode the patient appropriately and document their removal and the reasons for the removal in the patient’s notes.
• Flagging the death threat in the notes and the fact that this patient could potentially be a risk to other clinicians or staff will be helpful information to the practice that will end up receiving this patient.

Continuity of care for the patient

The practice should inform the hospital and the local mental health team (if the patient is under the mental health team) that they have removed the patient from their list, as they also have responsibility towards the patient and their continuing care.

The practice should also inform NHS England and the local Clinical Commissioning Group (CCG) of the removal and the reasons for the removal and find out if there is a Violent Patient Scheme (VPS) available locally (all CCGs are obliged to commission a VPS scheme) and ask that NHS England or the CCG allocate this patient to one of the participating practices.

Notifying the patient    

The regulations state that the patient should be notified of their removal unless in the opinion of the practice it would be detrimental for the patient to do so. Acknowledging that this is a vulnerable patient with mental health issues, the practice needs to make a judgement call about what would be worse for the patient:

a) not to be informed that they have been removed, turn up at the practice for an appointment, be turned away because they have been removed and having the practice call the police, or

b) receiving a carefully worded letter notifying them of their removal and the reasons for this removal, and contact details of local practices that participate in the VPS so that the patient can re-register.

Obviously if NHS England or the local CCG is able to step in and proactively contact the patient, advise them where and how to register, or allocate them to a VPS practice, then there is no need for the practice to do so, but they should ask for written confirmation the commissioners have followed up and the patient is safe.”

Last updated : 25 Oct 2017

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