Medico-legal scrutiny grows over health professionals’ duty to chase results and patients.
When a patient walks out of a GP consultation with a test request, who carries the legal burden of making sure the test is carried out and the results followed up?
The question is increasingly confronting general practitioners as medico-legal commentary sharpens around the GP’s duty to ensure clinically significant results do not fall through the cracks.
Anthony Mennillo, Head of Claims and Legal Services at Australian medical indemnity insurer Miga, says it’s a hot medicolegal topic.
“It is still one of the leading causes of claims for medical indemnity insurers, and particularly for general practitioners nowadays, where there is more disjointed care, where multiple practitioners might be seeing the same patient,” he explains.
“Referrals and results can slip through the cracks which can have an adverse impact on patient care, which can lead to a claim.”
Lack of follow-up of investigations, whether they are blood tests, imaging, or other test referrals, are some of the main causes for complaint, he says.
It could be that a patient either doesn’t have the test at all or takes a long time to get it done, and the results then become lost in the process.
“When these issues eventually come to light, it is often because a patient develops new or worsening symptoms that prompt further investigation. This naturally leads to questions about why the initial test was not completed or why the results were not communicated back to the patient,” says Mr Mennillo.
“For instance, in cancer-related cases, delays in undertaking investigations and a lack of timely follow-up can have serious and potentially harmful consequences.”
Practitioners often ask where the patient’s own responsibility begins. If a patient fails to return for results or ignores advice to book a follow-up appointment, is the GP legally required to pursue them?
The answer is yes, Mr Mennillo explains. By referring a patient for tests, a GP takes on a responsibility to follow-up both the completion of the test and the results.
“The law requires practitioners to take reasonable and proactive steps to ensure that test results are obtained, clearly communicated to the patient, and appropriately followed up,” he says.
“So when a practitioner refers a patient for any form of investigation—whether blood tests or imaging—they have a responsibility to ensure the patient completes the test, or that there is a clear and documented reason if it is not done. This includes having a conversation with the patient to understand any barriers and to explain the importance of proceeding with the investigation.”
It’s important to recognise that the law does not hold GPs responsible for every adverse outcome that follows when a patient chooses not to act on medical advice. Courts have long recognised the principle that patients ultimately retain autonomy over their own healthcare decisions.
Yet clinical reality rarely fits neatly into legal principles. Patients may fail to obtain their results for a variety of reasons unrelated to deliberate non-compliance. Advice may be misunderstood or forgotten. Patients may assume that no news is good news, believing their GP would contact them if a problem had been detected. Others may not realise that some results have been received while others remain outstanding.
Mr Mennillo says it’s vital that the patient understands the reason for the referral in the beginning. Explaining the clinical reasons for the blood test or imaging for example, will help a patient appreciate the importance of ensuring it is done in a timely manner. Being explicit about the urgency of tests is also important.
And as with everything medicolegal, everything must be documented. Notes about why the tests have been ordered, when the referral was given to the patient and the plans for follow-up to receive results should always be taken and placed in the patient’s medical record. Similarly, if the patient expresses a desire not to undertake tests, the clinician must ensure the patient understands the potential consequences – and this must also be documented.
“Where this is clearly documented, it significantly strengthens the practitioner’s position, otherwise it will be a contest between the patient’s word and the doctor’s, and that is never a good position to be in a legal environment,” Mr Mennillo explains.
Professional standards emphasise systems as well as communication. The Royal Australian College of General Practitioners requires practices to maintain clear procedures for managing pathology results, imaging reports and other clinical correspondence. Results must be reviewed by a GP, appropriately recorded and acted upon in a timely manner. Practices are also expected to have written policies describing how results are handled and how patients are advised about the process.
Equally important are systems for recalling patients when clinically significant findings require further action.
Mr Mennillo suggests practices have a system of triaging results. This could include practice nurses calling patients with uncomplicated results or recalling patients that need a face-to-face consultation with the GP.
“I have seen this work extremely well in practices that have clear systems in place—where the doctor is not necessarily the one making every phone call, but is instead determining whether results can be appropriately communicated by phone (by a nurse) or whether the patient needs to return for a dedicated appointment to discuss them,” he says.
“Practices that lack these systems are often the ones where results are more likely to slip through the cracks.
“Effective systems include multiple layers of checking: administrative staff reviewing outstanding results daily, and doctors and nursing staff routinely monitoring and confirming that results have been received, reviewed, and acted upon.
“Practices with strong, reliable processes in place significantly reduce the risk of an adverse outcome due to a missed result or an investigation that was never completed or followed up. Having these systems is absolutely essential.”
Finally, Mr Mennillo says it’s important for practices to have systems in place to capture results when a practitioner has left the practice. The practice needs to assume responsibility for ensuring follow-up in these cases.
“If the doctor leaves the practice, they still have the obligation for any investigation they have ordered but not completed. Before they leave the practice, they should be checking any outstanding results and ensuring that there is a proper handover from the time they leave the practice,” he says.
