GP gets warning over discharge summary errors that led to patient’s death

BMJ 2013; 347 doi: (Published 04 July 2013) Cite this as: BMJ 2013;347:f4330
  1. Clare Dyer
  1. 1BMJ

A doctor whose record keeping errors led to the death of an older patient with cancer has received a warning but no further sanction, after a Medical Practitioners Tribunal Service panel concluded that he was unlikely to repeat his mistake.

GP Hassan Twins was contracted to work two hours a day at New Haven Rehabilitation Centre, used by mostly older patients discharged from Brighton and Sussex University Hospitals NHS Trust. He was tasked with “clerking in” patients, as well as preparing treatment charts for their stay and discharge summaries when they left.

In the case of patient A, a 90 year old man with myeloma, Twins made errors on both documents. In the first, he prescribed prednisolone daily instead of on alternate days as indicated by the hospital discharge. In the rehabilitation centre’s discharge summary, he failed to record that hydroxocobalamin had just been stopped. He also recorded the dose of the cytotoxic drug cyclophosphamide as daily rather than weekly and failed to note that this was being administered by the hospital and was not the responsibility of the patient’s GP. Patient A received a cumulatively lethal dose and died five weeks later.

Twins told the panel that the atmosphere in the rehabilitation centre was “chaotic” and that he was expected to fit five hours’ work into a two hour shift. His role was that of a “jobbing doctor,” he said, and it was unclear who had overall clinical responsibility. He also claimed that he had been called away while writing up the discharge summary and had forgotten to complete it correctly on his return.

The panel found Twins guilty of serious professional misconduct. But in considering a doctor’s current fitness to practise, panels are bound to take into account evidence of overall practice, insight into past failings, and efforts at remediation.

Twins had taken the initiative to telephone patient A’s family to apologise and accept responsibility for the errors he made and did so again at the inquest. He also took a voluntary three month leave to reflect on his mistakes and took several courses aimed at tackling weaknesses in his practice.

He ­­admitted most of the factual charges early on in the GMC’s investigation and contributed to a “learning from incidents report” on the case. He submitted a large number of positive testimonials from patients, professional appraisals, and references from colleagues to support his counsel’s contention that he was “a fundamentally good doctor.”

These factors convinced the panel that he had shown insight, had worked towards remediation, and was unlikely to commit similar errors again. The warning will remain on his record for five years.


Cite this as: BMJ 2013;347:f4330

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