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Emergency contraception - patient's needs and wants (98HDC16189)

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(98HDC16189, 30 June 2000)

Practice nurse ~ General practitioner ~ Professional standards ~ Demanding patient ~ Patient responsibilities ~ Record-keeping ~ Right 4(2)

A 31-year-old woman complained that a practice nurse had supplied her with an incorrect dose of emergency contraception. The contraception failed, and the patient discovered she was pregnant.
The patient had telephoned her regular GP for advice about obtaining emergency contraception following unprotected intercourse in the previous 24 hours. The doctor was aware of the patient's medical history and told her to come in and see a practice nurse. No record was made of this telephone call and advice, nor were the nurses told.

The patient arrived at the surgery near the end of the day and was seen by an experienced practice nurse, who said that the patient refused a full consultation and demanded emergency contraception as soon as possible. The patient claimed that she did not know that a full consultation was necessary, and had simply said that she did not need counselling - she had just had her second unplanned child and definitely did not want a third. She explained that she was rushing to another appointment, and had young children waiting in the car. The nurse reluctantly provided the patient with emergency contraception after a brief discussion of possible side effects and the need to take the tablets 12 hours apart.

At the time, the medical centre did not have written protocols or standing orders covering the provision of emergency contraception, although it did have a "usual practice". The nurse acknowledged that although she understood the surgery's usual practice for providing emergency contraception, she did not adhere to it. She did not conduct a patient assessment, check the medical notes, or contact the doctor to verify the patient's story. Despite the patient's alleged refusal to participate in a full consultation, the nurse still provided her with advice and oral contraception.

The nurse argued that although a full consultation would have been desirable, in the circumstances not to provide contraception as requested would have placed the patient at greater risk. The procedure was not clinically complicated, and it was not unsafe to proceed without the normal consultation. The medical centre submitted that the nurse was acting on a doctor's instructions, albeit delivered indirectly by the patient.

It was held that the doctor's general advice to the patient over the telephone did not amount to a direction or instruction to the nurse to supply a prescription medicine. The nurse was not expressly authorised by a doctor to provide the patient with emergency contraception.

The medical centre stated that patient had clearly expressed her needs to the nurse, who had responded accordingly. The centre pointed to the patient's responsibilities, noting that she was not vulnerable or naïve, but a mature woman who chose not to have a full consultation. Its defence was that requiring the patient to take responsibility for her behaviour and choices was consistent with a "patient-centred" approach to care.

The Commissioner held that providing prescription medication without properly assessing a patient, without the directions or instructions of a doctor as required under the Medicines Act 1981, and without following standard procedures, cannot be in accordance with a patient's needs or best interests. Both the nurse and the centre breached Right 4(2) of the Code by failing to provide services in accordance with professional standards. The nurse did not comply with the standard procedure, and the medical centre had no clear guidelines for her to follow; nor was anything recorded.

This standard may appear high. However, to accept the centre's argument that the nurse was obliged to supply the patient with care "on demand" would be problematic. Provision of service in a manner consistent with a patient's needs cannot be equated with acceding to her "wants". Here, the patient requested emergency contraception, stating that her doctor had said she could have it. No attempt was made to verify her claim that she had spoken to her GP, or that the contraception had in fact been approved.

Patients do have responsibilities as well as rights, and doctors who seek to accommodate a patient's requests are entitled to have extenuating circumstances taken into account. The Code's requirements are not inflexible, and a provider who is shown to have taken "reasonable actions in the circumstances" to give effect to a patient's rights will be excused from a breach (clause 3). However, provision of service in a manner consistent with a patient's needs cannot excuse shortcuts that result in less than adequate care. Even a demanding patient is entitled to receive services of an appropriate standard, delivered in a safe manner.