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Good documentation: The key to protecting yourself and patients


Dr X is a Specialty Doctor in Psychiatry who contacted MDS for advice after being invited to attend a witness statement meeting to detail their involvement with a psychotic patient after concerns were raised that they had been the subject to physical abuse whilst an inpatient. 

Dr X had attended the patient to carry out a seclusion review late one evening, but was unable to assess them because they were uncooperative. Dr X left the patient with a carer in the knowledge that they would be re-assessed the following day by the day team. 

The patient was later examined and found to have bruising consistent with physical abuse. An investigation was subsequently opened with a suspicion that the attendant carer was responsible for harming the patient. In retrospect Dr X did think that the carer had exhibited a slightly inappropriate affect.

During this process, informal concerns were raised with Dr X about the standard of his record keeping and they were removed from the on-call rota in order to facilitate further training.


MDS reviewed Dr X’s witness statement providing advice on amendments that could be made to further clarify their involvement with the patient. 

Dr X was also assured by the MDS Medico-legal advisor that measures such as being removed from the on-call rota were not unusual when potentially significant harm to a patient is being investigated. This represented a precautionary step taken to manage risks and allow any learning and remediation required within the organisation. 

MDS further advised Dr X to ensure that all the arrangements with regards to their removal from the on-call rota and future training were documented in writing alongside the progress required to facilitate the lifting of the restrictions. 

Dr X was encouraged to consider the opportunity for personal development that this incident represented. The Dr subsequently went on to develop a departmental proforma for seclusion reviews and used this to undertake a QIP to better inform the service’s seclusion reviews.

After completing the required additional training and working under supervision for a short period, Dr X was allowed to return to the on-call rota. The Clinical Director and Appraisal and Revalidation Lead confirmed that they had no further concerns about Dr X’s practice and that the concerns raised about his documentation had had no harmful impact on the patient. 

Dr X was able to use this event as an important learning exercise for both themselves and the department. The take home points are that all should be aware of the risks for abuse in vulnerable patients such as this and make all reasonable attempts to complete a full physical examination. However if unable to do this, as in this case, all should document the examination as incomplete and hand the situation over to ones colleagues.


This case study is highly topical given several high profile cases involving the abuse of vulnerable patients in recent years. It illustrates the difficulties encountered by clinicians when assessing vulnerable patients who will not or can not cooperate with an examination. Those not able to be clinically examined are at risk of hidden clinical issues including signs of abuse.

Clear and detailed documentation is of paramount importance as a clinician and this case serves as a useful reminder. If you cannot examine a patient, or carry out a full examination to the standard you would normally expect this should be clearly documented. This not only protects patients to ensure that this is later investigated but also helps clinicians avoid a variety of medico-legal issues.

When an investigation is initiated against yourself or another it is always best to take a co-operative approach. Dr X was not the subject of the investigation but he was asked to provide useful information to further the investigation. As part of this process, concerns were raised about Dr X however, he responded well to the criticisms and took the opportunity to develop and enhance his practice. Dr X’s involvement in creating a proforma for seclusion reviews and undertaking a QIP is exemplary behaviour and demonstrates his commitment to improving as a doctor.