What do dogs have to do with medical indemnity? More than you might at first realise.
A review of MDU files opened over a recent five year period shows that medico-legal problems for doctors can arise in unexpected circumstances. Here are some anonymised examples of the types of doggy dilemmas in which the MDU has supported doctors.
Assistance dogs on practice premises
A practice manager contacted the MDU for advice after a patient brought their dog into reception. The patient refused to leave the dog outside when asked to do so by the receptionist, explaining that he suffered from anxiety and needed his dog with him at all times.
He said he would make a formal complaint if the dog was not allowed into the surgery, on the basis that this discriminated against him as a disabled person.
Under the Equality Act 2010 reasonable adjustments must be made in order to avoid discriminating against people with disabilities. This could include allowing a disabled person to be accompanied by their assistance dog.
The MDU adviser suggested the practice manager write to the patient to explain that unfortunately they didn't allow dogs into the surgery except in special circumstances, such as guide dogs and assistance dogs. If the patient could provide evidence that the dog was acting as an assistance dog, the practice would allow the dog on the premises.
Assistance dogs are highly trained and recognisable by the harness or identifying coat they wear. The assistance dog user also carries an ID book giving information about the assistance dog and training organisation. The practice didn't receive a reply from the patient, but he didn't bring the dog to the surgery again.
The Equality Act 2010 applies to England, Wales and Scotland, but similar provision is made by the Disability Discrimination Act 1995 in Northern Ireland.
Visiting patients with aggressive dogs
During a home visit, a GP was bitten on the leg by a patient's dog. The patient was a frail elderly man in poor health. His carer was very apologetic and explained that the dog, a large German shepherd, had bitten before, resulting in the Royal Mail refusing to deliver the patient's post.
The patient would require more home visits in the future, and the GP was concerned that he was too frail to restrain the dog, if necessary. The GP asked the MDU whether he could refuse to visit because of the dog.
Could he insist that the patient attend the surgery instead?
The MDU adviser explained that doctors have a duty of care to their patients and, as the GMC states in Good medical practice, to make the care of their patient their first concern. The guidance also states that if a patient poses a threat to a doctor's health or safety, they 'should take all available steps to minimise the risk before providing treatment or making suitable alternative arrangements for providing treatment'.
The adviser suggested that if the patient could not come to the practice, the GP could ask that the dog be shut in another room when he visited. If the patient didn't agree to restrain the dog, then the GP might need to ask the RSPCA or police to attend with him.
If this did not resolve the situation, the doctor could refer to guidance from NHS Protect on unacceptable behaviour, which includes uncontrolled animals in a list of antisocial and nuisance behaviour, and suggests that a warning letter might be considered appropriate. If this too was ignored, and the GP felt it was impossible to continue to treat the patient then, as a last resort, the GP could consider asking the patient to register elsewhere and remove him from the practice list.
Reporting animal harm to the RSPCA
The wife of a patient told the GP that her husband, who suffered from alcohol dependency, had viciously kicked their dog and cat when in a drunken rage. This was not the first time he had been cruel to their animals and, while her husband had never been violent to her, she was worried for their pets' safety.
The GP contacted the MDU to ask whether she should disclose this information to the RSPCA so the patient's animals could be removed. She was aware of her duty of confidentiality to the patient, but wondered whether she should disclose the information in the public interest.
The MDU adviser explained that the circumstances which can justify disclosing confidential information in the public interest are explained in the GMC's confidentiality guidance. It states 'disclosure without [patient] consent may be justified if failure to disclose may expose others to a risk of death or serious harm'.
In this case, the adviser suggested the GP consider asking the patient's wife to report the matter to the RSPCA, and if she was unwilling to do so, to consider seeking consent from the patient to involve the RSPCA, if this did not put the wife at risk of harm. If after careful reflection, the GP felt a disclosure without consent was justified in the public interest, then she was advised to disclose the minimum information necessary for the purpose, and to document her reasoning carefully.
Prescribing for animals
A consultant geriatrician contacted the MDU asking whether she could prescribe prednisolone for her sick dog. The vet had initiated the treatment, and the doctor had spoken to a local chemist to see if she could issue a private prescription to save time.
The MDU adviser sympathised with the geriatrician's situation, but explained that what she proposed was unlawful, and potentially a criminal offence. The practice of veterinary surgery is restricted to registered vets by section 19 of the Veterinary Surgeons Act 1966. This law allows animals to be treated by registered medical practitioners 'at the request of' a registered vet, but this exemption would usually apply if the vet needs a doctor's specialist expertise or skills, such as in the recent case of a baby gorilla born by caesarean section at Bristol Zoo.
The adviser also explained that if a doctor were prosecuted for this offence, then they would also be required to inform the GMC, which could put their registration at risk.