A Consultant interview station on MedMock, start to finish

Good morning. I'm the medical director, and I'd like to spend this part of the interview on patient safety and governance. Imagine you've been in post as a consultant for six months. One of your patients, a man in his late sixties, is three days after an elective right hemicolectomy for cancer. At about three in the morning his NEWS2 score rose to 6, but it wasn't escalated to the on-call doctors. On your ward round he's septic, a CT confirms an anastomotic leak, and he goes back to theatre and then to intensive care. He's now recovering there, awake and able to talk. As his consultant, talk me through what you'd do.

Thank you. I'd think about it in three parts: the patient first, then being open with him and his family, then making sure we learn from it properly. For him, I'd be personally involved in his care, see him every day on intensive care and agree the surgical plan with the intensive care team. Alongside that, I'd ask whether anyone else is at risk today. Were other patients on that ward missed overnight? Was the ward short-staffed? Did the electronic observations system alert anyone? If there's an ongoing risk, I'd want a quick huddle with the ward team the same day. I'd report it that day on the trust's incident reporting system, which feeds the national Learn from Patient Safety Events service, and let my clinical director and the patient safety team know. And I'd find out who was on that night and make sure they're supported. I wouldn't assume I know what happened: it's possible somebody was called and it wasn't documented. This isn't a hunt for someone to blame. Then there's the candour conversation, which I'd like to come to.

Go on, then. Is this a Duty of Candour incident, and what does that conversation look like?

I think it is. The leak is a recognised complication and I'd have consented him for it, so the leak itself isn't the incident. The incident is that a NEWS2 of 6 wasn't escalated, and that could reasonably have delayed his return to theatre and made him more unwell than he would otherwise have been. Under Regulation 20, a notifiable safety incident is one that could result in, or appears to have resulted in, moderate harm or worse, and the regulation counts a transfer to intensive care as a moderate increase in treatment. The test is whether it could have caused harm, not whether we've proved it did, so I wouldn't wait for the investigation. As soon as he's well enough, ideally within a day or two, I'd see him in person, with his wife there if he wants her and a senior nurse from the ward. I'd tell him what we know so far without speculating, say sorry, which isn't an admission of liability, explain that there'll be a review and what it will look at, and ask what questions he'd like it to answer. He'd get a named contact, I'd record the conversation in his notes, and it would be followed by a letter setting out the same account, the apology and the enquiries, with the findings shared when they're available. The statutory duty sits with the trust, and failing to meet the notification requirements is an offence the CQC can prosecute. But I also have a personal professional duty of candour under the joint GMC and NMC guidance, whatever the regulation says.

How would the incident then be investigated? Would it be a serious incident?

Not in the old sense. Since the Patient Safety Incident Response Framework replaced the Serious Incident Framework, there's no automatic serious incident with a sixty-working-day root cause analysis. Each trust has a patient safety incident response plan, based on its own incident profile, that sets out which types of incident get which response. A few incident types have a nationally required patient safety incident investigation: deaths thought more likely than not to be due to problems in care, for example. For this one, the patient safety team would review it and decide between a full patient safety incident investigation and a smaller learning response such as an after action review. That depends partly on whether the deteriorating patient is one of the trust's local priorities, as it often is, and what the plan says for those. It isn't my decision alone, and I shouldn't lead a review of my own patient's care. My part is to give a factual account and make sure he, his family and the staff are properly involved, because PSIRF puts a lot of weight on compassionate engagement with everyone affected. The approach is systems-based, using something like the SEIPS framework: staffing that night, workload, whether the system alerted anyone, how escalation actually works at three in the morning. It doesn't decide liability or blame. And the Duty of Candour runs alongside it, whichever response is chosen.

The nurse who was looking after him that night is very upset, and her ward manager feels she should face disciplinary action. What's your view?

I'd be cautious. My first concern is her wellbeing: that someone has spoken to her, that she knows what staff support is available, and that she's kept informed through the review rather than left wondering. On discipline, I don't think that's a decision for me or the ward manager to make at this stage, and I'd say so. The national just culture guide is the right tool. It asks whether there was any intention to cause harm, whether there's a health issue, whether the procedures were workable and actually in use, and then the substitution test: would another nurse with similar experience, on that shift, with that workload, have done the same? If she had eight patients, two of them unwell, and nothing alerted anyone else, that points to the system, and disciplining her would teach every other nurse to keep quiet. If the review found something quite different, say observations that had been falsified, that would go through a separate route, HR and possibly the NMC, not the safety investigation. I'd also talk to the ward manager, because her reaction is understandable and she's under pressure too.

Six weeks later, his daughter writes a formal complaint. She says her father told the night staff he felt unwell and nobody listened, and she wants to know whether this could happen to someone else. How do you handle it?

I'd see it as a fair question, not a threat: it's exactly what I'd want to know. The complaints team will log it and acknowledge it within three working days. Because she's writing on her father's behalf and he has capacity, they'll need his consent before we share his clinical details with her. I'd want the complaint linked to the incident review, so the family doesn't get two different answers from two parts of the trust, and so her specific point, that he said he felt unwell, is put to the review. I'd offer to meet her and her father with the ward matron rather than rely on letters. I'd give an honest statement for the response and make sure it matches what we've already told him under candour. The response should explain what happened, apologise, and say what has changed or will change, and if the review isn't finished, say when we'll come back to her. I'd also reflect on it and take it to my appraisal.

And if she's still not satisfied with the trust's response?

Then she can take it to the Parliamentary and Health Service Ombudsman, and the trust's response letter has to tell her she can. I should have said that at the start. The Ombudsman will normally expect local resolution to have been tried first, so before that point I'd offer a further meeting. In my experience, people escalate a complaint when they feel they haven't been heard, and a second conversation often matters more than a second letter.

Final question. What does clinical governance mean to you as a new consultant, and how would you know whether your own service is safe?

The classic definition is Scally and Donaldson's: a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. For me as a consultant, it means I'm accountable for the quality of my own practice and share responsibility for my team's. To know whether the service is safe, I'd look at several sources rather than one: our emergency laparotomy and bowel cancer audit data against the national picture, and the GIRFT recommendations for general surgery; morbidity and mortality meetings; themes in incidents and complaints, not just single cases; structured judgement reviews and medical examiner feedback on deaths; and what patients and staff tell us. As a registrar I ran our department's M&M meeting for a year and changed it so that every case ended with one agreed action and a named owner, and I'd want to bring that discipline with me. For my own practice, it's appraisal and revalidation: reflecting properly on something like this incident and this complaint, not just collecting certificates.

Thank you, that's very clear. That's the end of this station.