“I just wanted it all to stop” — a young woman in the emergency department

Candidates: do not open until you have consulted.

Persona and manner

• Jade Fenwick, 22, a trainee veterinary nurse in her second year at the vet practice. You share a flat with Sophie, your best friend from school. You have been with your partner Kieran for three years; he moved in six months ago.
• You sit on the edge of the trolley with your coat on and your bag on your lap. Tearful, flat, ashamed; you answer in short sentences and look at the floor. You warm up only if the doctor is calm, unhurried and does not judge.

Opening line — say this verbatim

• “I’m fine now. I just want to go home — Sophie shouldn’t have brought me. Can I go?”

Volunteer freely if given the space

• You and Kieran had a huge row last night — he said he was leaving. He walked out at about ten.
• You took “a load of paracetamol” from the bathroom cabinet. You did not count them.
• You feel sick and your stomach hurts a bit. You have not vomited.

Only if asked

• What and how much: two boxes of 16 paracetamol 500 mg tablets, bought from the supermarket at different times — “most of them, I think; maybe 28 or 30”. The boxes are at home.
• When — the important detail: not all at once. “Some about half ten, more at about one, and the last ones about three when I still couldn’t sleep.” So over about four and a half hours. If the doctor asks only “what time did you take them?” say “last night” and wait for a more specific question.
• Anything else — only if asked about other tablets, alcohol or drugs: half a bottle of wine during the row, before the tablets — nothing since. No other medicines. No illegal drugs. Sophie’s sleeping tablets: keep this for the ‘anything to add’ moment unless the doctor asks specifically whether you took anything belonging to anyone else, or anything from Sophie’s room.
• Intent: “I wasn’t thinking about dying. I wanted it all to stop — the row, the noise in my head.” You did not write a note, did not tell anyone, and did not plan it beforehand — you took what was there. You thought you would just sleep. This morning you feel stupid and frightened about what the tablets might have done.
• Now: if asked directly whether you still want to die or hurt yourself: “No. I don’t think so. I don’t know.” You cannot promise it will not happen again if Kieran leaves. You have no plan.
• Before: you have never done anything like this. You cut your arms a few times at fifteen, when your parents split up. Never seen anyone about it. No diagnosis, no medication, no counselling.
• Mood over the last few weeks: low since the summer, sleeping badly, not enjoying work, crying easily. Eating less. Still going to work.
• Kieran — only if asked about the relationship, feeling safe at home, or whether anyone frightens or hurts you: he shouts and has thrown things, never at you; he checks your phone and does not like you going out with Sophie. He has never hit you. “It’s not like that.” You do not want him contacted.
• Family: your mum, Tracey, lives an hour away. You do not want her told — “she’ll panic, and she’ll tell everyone”. Your dad is not in touch.
• Physical: no vomiting, no jaundice, no previous liver problems, not pregnant (period ten days ago; you use the pill). No allergies.
• Capacity — how to play it: you understand when things are explained plainly, you can repeat them back, and you can give reasons for your choices. You are not confused. Your refusal at the start is about wanting the night to be over and fear of being “sectioned”, not about failing to understand.

Impact on daily life — home and work (only if asked)

• You have a clinic list at eleven and your practice manager, who has given you a chance, will be furious; you are frightened of losing the place at the practice.
• Money is tight — Kieran pays most of the rent, which is part of why you cannot imagine him leaving.
• You have stopped seeing friends apart from Sophie because Kieran does not like it.

Ideas, concerns and expectations

• Idea: you thought paracetamol was “harmless, it’s just paracetamol” — you feel all right now, so it must be fine.
• Concerns: that you will be sectioned or locked up; that your mum will find out; that your practice manager will find out and you will lose your job; and, once the doctor explains, what the tablets have done to your liver.
• Expectation: to be allowed to go home; a doctor who will not lecture you.

Cues to deliver, timed

• Minute 2: “Am I going to be sectioned? Sophie said they section you for this.”
• Minute 4, if the doctor has not yet asked exactly when you took the tablets: “Does it matter that I didn’t take them all together?”
• Minute 6, if nothing has been said about the drip or the antidote: “So can I go, then? I feel fine.”

If the doctor summarises and asks whether you want to add anything

• If it has not come out: “There is something. I took a few of Sophie’s sleeping tablets as well — about four, from her drawer. I don’t know what they’re called. Is that bad?”
• If it has: “You won’t tell my mum, will you?”

How to respond to the doctor

• If the doctor is calm, sits down, and asks what happened before asking what you took: you tell the story. If the doctor fires closed questions from a checklist (“any suicidal ideation?”): short answers and “I don’t know”.
• If the doctor explains honestly that paracetamol can damage the liver even when you feel well, that the damage shows up later, that there is an antidote drip which works best early, and that because the tablets were spread out they will not wait for a blood level: frightened — “I didn’t know that” — then: “OK. I’ll have the drip.” You agree to stay.
• If the doctor says a blood test will tell them whether you need treatment and you can go if it is normal: you accept it gladly. (The examiner marks this.)
• If the doctor says “you could die”, “you will be sectioned” or “we can detain you”: you shut down — “Then I’m going.” You stand up. If the doctor then recovers — sits down, apologises, explains properly — you sit back down.
• If the doctor says you need treatment before you can go, or asks you to stay: “No — I’ve decided. I’m going home.” Keep to that until the doctor has explained the liver risk and the antidote in plain words, then: “OK. I’ll have the drip.” If the doctor explains that you can only be treated with your agreement, that you have the right to refuse if you understand what that means, and asks what you understand: you engage and ask sensible questions — “What would happen to my liver?” — and then agree.
• If the doctor asks directly whether anyone at home frightens, controls or hurts you: you cry and tell the doctor about the phone and the shouting. If the doctor then says the word “abuse” before you do: “It’s not like that — he’s never hit me.” If the doctor offers information and a choice, without pushing: you take the leaflet.
• If the doctor says someone from the mental health team will come to talk to you here, today, before any decision about going home, and explains what that is for: “Will they section me?” If answered honestly — it is an assessment and a conversation, not a sectioning: “OK.”
• If the doctor says your mum must be told: “No. I’m 22. You can’t.” If the doctor accepts that and gently asks who you would like to know: “Sophie. Just Sophie.”
• If jargon is used (“NAC”, “SNAP”, “staggered”, “psychosocial assessment”): “What does that mean?”

Do not

• Volunteer the sleeping tablets, the times of ingestion, the wine, Kieran’s behaviour or your mood unless asked as scripted, or invited to add anything (apart from the timed cues).
• Say “overdose”, “staggered” or “liver” before the doctor does.
• Agree to the drip until the doctor has explained what it is for.

Findings to give the candidate — only if asked for

Give these only if the candidate asks for examination findings, results or an ECG. Do not interpret them — if asked “is that high?” say “that’s the number, doctor”. (Where a separate examiner is present, the examiner reads them.)

Domain marks — with the key facts that earn a 4 at this station

Domain score (educational construct):

This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. Paracetamol toxicity and the single treatment line (MHRA / Commission on Human Medicines, September 2012; BNF, poisoning): acetylcysteine is given to anyone whose timed plasma paracetamol concentration is on or above the line joining 100 mg/L at 4 hours and 15 mg/L at 15 hours after a single acute ingestion, whatever their risk factors — the second ‘high-risk’ line was removed in 2012. A level taken before 4 hours cannot be interpreted. Staggered or uncertain-time ingestion (tablets taken over one hour or more, or a time that cannot be established): the nomogram does not apply and acetylcysteine is started without waiting for a level; the level, LFT, INR, U&E and bicarbonate are still sent. TOXBASE gives a weight-based threshold below which treatment is unlikely to be needed for staggered ingestion (around 75 mg/kg in 24 hours — check the live TOXBASE entry); at 250 mg/kg she is well above it.
2. Dose taken: 30 tablets × 500 mg = 15 g; at 60 kg that is 250 mg/kg. TOXBASE gives thresholds for serious toxicity (around 150 mg/kg in 24 hours, rarely between 75 and 150 mg/kg — check the live TOXBASE entry). Toxic doses are calculated on actual body weight up to a ceiling of 110 kg (BNF). Alcohol taken acutely with the paracetamol does not change the treatment line.
3. Acetylcysteine regimens (BNF; TOXBASE): the licensed 21-hour regimen — 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours (the first infusion was lengthened from 15 minutes to 1 hour in 2012 to reduce reactions); the 12-hour SNAP regimen — 100 mg/kg over 2 hours, then 200 mg/kg over 10 hours — which the BNF now lists, which TOXBASE and the National Poisons Information Service recommend and the Royal College of Emergency Medicine (May 2023) asks to be the default in emergency departments, with fewer reactions (antihistamine needed for a reaction in 2.0% vs 11.0% in a 2019 three-centre UK evaluation of 3,340 patients, with no difference in liver injury) and the same protection; it remains unlicensed (MHRA position 2017, that evidence was then insufficient to recommend it; the BNF says SNAP is not endorsed by the MHRA but is recommended by the Royal College of Emergency Medicine and the National Poisons Information Service, and TOXBASE advises it; the 2019 evaluation is Pettie et al., EClinicalMedicine). Bloods (paracetamol, ALT, INR, creatinine, bicarbonate) are taken at or just before the end of the second bag, and a further 200 mg/kg over 10 hours is given if ALT or INR are abnormal or paracetamol is still detectable — the department’s TOXBASE-based protocol gives the exact criteria. Glucose 5% is the usual diluent.
4. Anaphylactoid reactions (BNF; MHRA 2012): flushing, itching, urticaria, wheeze or hypotension, usually during the first bag — pause the infusion, treat (antihistamine, bronchodilator as needed) and restart at a slower rate; a previous reaction is not a contraindication, because the reaction is dose-related and not immune-mediated. Acetylcysteine may slightly raise the INR.
5. Co-ingestants: every other drug taken is checked on TOXBASE — here an unidentified ‘sleeping tablet’ (a benzodiazepine or Z-drug is most likely: supportive care, observation of conscious level and respiratory rate; flumazenil is not used routinely in mixed overdose). The flatmate is asked to bring the packet. An ECG is taken in any overdose where a cardiotoxic drug is possible.
6. NICE NG225 Self-harm: assessment, management and preventing recurrence (September 2022): physical and psychosocial care run concurrently (1.7.3); in the emergency department, establish at triage the severity, emotional state, immediate safety, safeguarding concerns, willingness to accept treatment, the observation level and any care plan (1.7.12); offer referral to liaison psychiatry as soon as possible after arrival (1.7.13) and a mental health professional sees the person at every attendance (1.7.14); do not delay the psychosocial assessment until medical treatment is complete (1.5.2) and do not use breath or blood alcohol to delay it (1.5.4); do not use risk assessment tools or low/medium/high stratification to predict repetition or to decide treatment or discharge (1.6.1–1.6.4) — a mental health professional makes a risk formulation (1.6.6); if the person wants to leave before assessment, assess their safety and mental health before they go (1.5.14); do not use mechanical restraint to stop someone leaving (1.7.18). First aid for self-poisoning follows the BNF, TOXBASE and the NPIS (1.7.4).
7. Capacity (Mental Capacity Act 2005, ss 1–3; NG225 1.2.1, 1.7.1): presume capacity; a person is not treated as lacking capacity merely because the decision is unwise; capacity is decision-specific and time-specific — assessed for this treatment, now. The functional test: can she understand the information relevant to the decision, retain it long enough, use or weigh it, and communicate the decision; the diagnostic limb is an impairment of, or disturbance in, the functioning of the mind or brain (intoxication, severe distress or depression can qualify, but do not automatically). Where an adult has capacity and refuses, treatment cannot be given against her will; the right response is time, honest information, senior and liaison involvement, and documentation. Where capacity is lacking, treatment in her best interests may be given under s5 of the Act using the least restrictive option. The Mental Health Act 1983 (amended by the Mental Health Act 2025, most of whose reforms are not yet in force) is not a route to treat the overdose in an adult who has capacity; detention needs a mental disorder of a nature or degree that warrants it, assessed by a psychiatrist and an approved mental health professional, not by the FY2. An FY2 assesses and records capacity and involves the registrar and liaison when there is doubt or a refusal.
8. Confidentiality (GMC, Confidentiality: good practice in handling patient information, 2017): an adult with capacity decides who is told — her mother is not informed without consent unless disclosure is needed to protect her or others from a risk of death or serious harm, and even then she is told what will be shared and why. NG225 1.2.2 and 1.4.1: seek consent to involve family and carers early, and remember that they can still give information even when the person has not consented to involvement.
9. Safeguarding and domestic abuse (NG225 1.3.1; Care Act 2014; Serious Crime Act 2015 s76, controlling or coercive behaviour; Domestic Abuse Act 2021 definition of domestic abuse): ask about domestic abuse, violence or exploitation at the earliest opportunity and when the person is alone; monitoring her phone, isolating her from friends, shouting and throwing things are features of coercive control even without physical violence. Offer information, an independent domestic violence adviser or the National Domestic Abuse Helpline, and a referral with her consent; record it; do not confront or contact the partner. Ask about children in the household — a child would change the duty to act.
10. Before discharge (NG225 1.5.15–1.5.16; 1.9 discharge; 1.10 aftercare; 1.12 supporting people to be safe): a care plan and a written safety plan agreed with her; the GP informed; means reduced (the paracetamol pack size rule exists because of this harm — 16 tablets over the counter, 32 in pharmacies); a crisis contact number; the mental health team decides the follow-up, not the FY2.

Where candidates lose marks at this station

• “We’ll check a level at four hours and see” — in a staggered overdose.
• Asking “what time did you take them?” once and writing down “last night”.
• Never asking about other tablets, alcohol — or anyone else’s medicines.
• “If you leave we’ll have to section you.”
• Saying “she has capacity” (or “she doesn’t”) without assessing it for this decision.
• Liaison psychiatry “once the drip has finished”.

Guidelines for this station

• TOXBASE — National Poisons Information Service (login; paracetamol and acetylcysteine entries)
• MHRA Drug Safety Update (September 2012) — Treating paracetamol overdose with intravenous acetylcysteine: new guidance
• BNF — Acetylcysteine (21-hour and 12-hour SNAP regimens; safety information)
• BNF — Poisoning, emergency treatment (paracetamol)
• Royal College of Emergency Medicine — Use of the SNAP regimen for the treatment of paracetamol toxicity (May 2023)
• NICE NG225 — Self-harm: assessment, management and preventing recurrence (2022)
• Mental Capacity Act 2005
• GMC — Confidentiality: good practice in handling patient information
• GOV.UK — Domestic abuse: how to get help (National Domestic Abuse Helpline)

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-34