Personal Details:

Name: James Brown

Age: 55 years

Occupation: Construction manager

Medical Record

Recent hospital admission: 4 weeks ago with MI

Discharge letter

Patient Name: [James Brown ] Date: Four weeks ago

Reason for Admission: Chest pain

Principal Diagnoses:

MI

Family History of Ischemic Heart Disease

History:

Admitted with Chest pain radiating to the left arm, diaphoretic.

Hospital Course: Admitted for MI. Had PCI to LAD with stent placement.

Blood pressure discharge day (120/80)

Medications on Discharge:

·       Aspirin 75 mg daily

·       Clopidogrel 75 mg daily

·       Atorvastatin 80 mg daily

·       Propranolol 5mg daily

·       Lisinopril 2.5mg

Discharge Instructions:

·       Take all medications as prescribed.

·       Repeat blood test (U+E) in 1-2 weeks after discharge.

·       Continue blood pressure monitoring in the community.

·       Low-fat diet advised.

·       Stay active and gradually increase physical activity but avoid strenuous activity initially.

·       Cardiac rehabilitation in the community

·       Seek immediate medical attention for chest pain and shortness of breath.

·       Can resume driving after 4 weeks of discharge.

Opening Sentence: "I want to know why nobody followed up on my hospital discharge letter. This is completely unacceptable!"

Open History (to give freely): I was in the hospital four weeks ago. They told me my GP would follow up, but I haven't heard anything. I just received the discharge summary today, and the instructions say I should have had blood in 1-2 weeks after discharge, but no one called me.

I am about to run out of my medication, When I called to ask about it, I was told the letter was filed with no action needed. Someone's not doing their job properly here.

ICE:

Ideas: You believe there has been negligence in your care

Concerns: Worried about potential health implications of the missed follow-up

Expectation: Wants immediate action and an explanation

How to Act: Appear visibly angry and frustrated. Speak loudly and assertively. Show impatience with any explanation that doesn't immediately address your concerns.

More History (only if asked):

• Admitted to hospital with chest pain
• Diagnosed with angina, started on medication
• The discharge letter mentioned that follow-up tests are to be arranged by the GP, and blood pressure must be monitored. No one explained that to me when I was discharged, and it is now four weeks and nothing happened.
• Has been taking medication as prescribed and is about to run out next week.
• No worsening of symptoms since discharge, no chest pain, feels generally physically well. Felt a bit low after having this unexpected event, but now catching up and feel mentally better, doesn’t feel low or depressed.
• Tried to book follow-up appointment but was told it wasn't necessary, and discharge summary filed with no action needed.
• Feels his health concerns are being ignored.
• Worried about the deterioration in his health and more heart problems, also cardiac rehabilitation nurse hasn’t contacted him yet.

Social History: Married, two adult children. High-stress job in construction management.

Questions to ask:

Who was the GP who filed this letter?

The blood was supposed to be more than two weeks ago. What if something is going on now and has been missed because this was not done appropriately?

You don’t want to complain, but you are keen for this not to happen to anyone, as people can come to harm.

Example consultation 

Acknowledgement

Hi James, I can see you’re upset, and I can hear your frustration. I am sorry that the instructions for your discharge summary were not met, and you didn’t have any blood tests or blood pressure monitoring.

You have clearly had a very stressful time in the past month, but I am glad to hear that you have been doing well since then. I am sorry that you were waiting to have an ideal and appropriate follow-up and I understand that this can be disappointing. I promise that I will do my best today to find out what is best we can do.

Let’s start by reviewing the details of your hospital stay and the discharge instructions. It sounds like there has been a gap in our system; you were told the GP would initiate the follow-up, and unfortunately, that didn’t happen.

Immediate Steps to Address the Issue

Here’s what we’re going to do next:

1. Blood Test: I’ll arrange for your blood test (U+E) as soon as possible to ensure everything is as it should be.
2. Blood Pressure Monitoring:  Do you have a blood pressure machine at home? Can you monitor it at home and update us with any changes? If you don’t have one, I can book you in the next few days to have your blood pressure checked with one of the nurses to make sure it is well controlled with your medication, if it is high we can change your medication further.

Investigating the Process Breakdown

I will personally look into what happened with your discharge letter's filing and discuss this with the GP involved. Additionally, I’ll bring this incident to our next GP meeting to ensure we learn from and prevent such occurrences in the future.

I will write to the cardiac team to make sure you will have your cardiac rehabilitation and you will be followed up by them appropriately.

Conclusion

Thank you for bringing this to our attention and I appreciate your feeling that you don’t want anyone else to come to harm, which I share with you. We will do our best to learn from that and if you want we can update you with the outcome.

 Management objective

What is scenario testing?

This scenario tests the candidate's ability to handle an angry patient, address a medical error professionally, remain professional and acknowledge the situation, show flexibility to investigate and find out more and learn from any errors to improve the service.

Important areas in data gathering

• Details of the hospital admission and discharge instructions
• Current health status and any ongoing symptoms
• Patient's understanding of their condition and required follow-up

Highlight the management objectives.

• Acknowledge the error and apologize
• Not to blame anyone until finding out more and get back to the patient
• Explain the process for addressing the mistake, discuss it with the GP who filed the letter, and take it forward for the next GP meeting to be discussed and learned from.
• Review the discharge letter and arrange necessary follow-up. Arrange a blood test as soon as possible, and ask the patient to monitor BP at home or to come into the surgery to have it checked. Explain further changes in blood pressure will be decided based on the blood pressure.
• Reassure the patient about ongoing care and rebuilding trust.

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