Station 20 · A colleague's prescribing

Candidates: do not open until you have consulted.

Persona and manner

• Priya Nair, 34, the practice clinical pharmacist, two years in post; careful, conscientious, visibly anxious; you have found something serious and you are frightened of the senior partner and of being blamed for making a fuss.
• You become steadier if the doctor puts the patient first and makes clear that you did the right thing.

Opening line (verbatim)

• “Sorry, I know you're busy. I was doing the high-risk drug audit and I found a methotrexate script Dr Haldane did last week — it says one to be taken daily, fifty-six tablets. It's Mrs Fenwick, she's on fifteen weekly. I haven't rung her. I didn't know whether I should go to him first. What do I do?”

The story

• “The script was issued nine days ago as an acute, by phone. The weekly repeat is still on her record; he must have typed a new one.”
• “Fifty-six tablets of two point five. If she's taken one a day for nine days that's twenty-two and a half milligrams… no, sorry, I mean one tablet a day, two point five a day, so twenty-two and a half milligrams over nine days instead of fifteen in one go. If she took six a day because that's her weekly dose, it'd be far worse.”
• If asked: you have not rung the patient; you have not rung the pharmacy; you have not spoken to Dr Haldane; you have not told anyone else.
• If asked whether the pharmacy dispensed it: you do not know; the script was sent electronically to the High Street pharmacy.
• If asked about Dr Haldane: “He's… not someone you correct. The last pharmacist left.” You have heard he has been tired and distracted since his wife's illness.
• If asked about Mrs Fenwick: lives alone; her daughter rings her; she is sensible; she has been on methotrexate for four years and knows it is weekly.
• If asked what you think should happen: “Ring her now. But I thought you'd want to know first. And someone needs to tell him. Not me.”
• If asked about the practice's process: there is a significant-event form; the last one you raised went nowhere.

Ideas, concerns and expectations

• Idea: That the patient must be rung now, and that someone senior must deal with Dr Haldane.
• Concern: The patient's safety; being blamed; Dr Haldane's reaction; losing the job like the last pharmacist.
• Expectation: That the doctor takes it from here, and that you are not left alone with it.

Impact

• Work: you report to the partners; Dr Haldane signs your appraisal.
• The practice: the last pharmacist left after a disagreement with him; everyone knows.
• You: you have not slept since you found it this morning.

Red flags

• Present: A daily methotrexate instruction for a patient on a weekly regimen, dispensed electronically nine days ago, with no contact yet made; a senior colleague described as tired and distracted; a pharmacist who fears raising it.
• Absent: No evidence yet that the patient has taken the tablets daily; no symptoms reported; recent monitoring bloods normal.

Hidden facts and their triggers

• That Dr Haldane has been tired and distracted since his wife's illness — released only if asked why this might have happened, or about him
• That the last pharmacist left after a disagreement with him — released only if asked why you did not go to him
• That the last significant-event form you raised went nowhere — released only if asked about the practice's process
• Whether the pharmacy dispensed it — released only you do not know; the doctor must find out
• How frightened you are of losing the job — released only if the doctor asks how you are

Behaviour

• Minute 1: “I didn't know whether I should go to him first.”
• Minute 3: “He's… not someone you correct.”
• Minute 6, if the doctor has not yet mentioned the patient: “Shouldn't someone ring her?”
• If the doctor puts the patient first (rings her now, or arranges the call this minute, establishes what she has taken, arranges the bloods and the clinical review or admission the picture needs, rings the pharmacy to stop further supply), tells you plainly that you did the right thing, agrees who speaks to Dr Haldane and how (a senior colleague, today, with the facts, and support for him), explains the duty to tell the patient what went wrong, starts the significant-event process and documents it, and arranges to see you again: steadier. “Thank you. Will you tell me what happens?”
• If the doctor goes to Dr Haldane first and the patient waits: “And Mrs Fenwick?”
• If the doctor says it is not their business because it is Dr Haldane's patient: “So who do I go to?”
• If the doctor blames you for not ringing: go quiet; “I'll ring her now, then.”

Examination findings, if the candidate states what they would examine and why

• None: there is no patient in the room. If the candidate rings Mrs Fenwick during the consultation (the role player can speak her part if the candidate asks): she took one tablet a day for six days before she thought it odd and stopped three days ago; she feels tired and has a sore mouth; no fever, no bleeding, no rash; she still has the box.
• There are no examination findings to give.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Going to Dr Haldane first, or debating how to tell him, while the patient is not contacted (statement D5)
• Treating it as not their business because it is the senior partner's patient, so that the pharmacist is left alone with it (statement R7)
• Omitting the duty to tell the patient what went wrong, or the significant-event process, to spare the colleague (statement C5)

What the examiner is listening for in the last four minutes

By 8:00 the working understanding should have been stated: a methotrexate dosing error with possible toxicity in a woman living alone, and a significant event involving a senior colleague. The examiner is listening for: the patient contacted and what she has taken established; the tablets stopped, the bloods and review arranged today, admission if symptomatic, the pharmacy told; who tells Dr Haldane, today, with facts and support; the patient told what went wrong; the significant-event process started; the safety-net for toxicity; and the pharmacist told what happens next and that she did the right thing.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Methotrexate for rheumatoid arthritis is taken once weekly; daily dosing has caused fatal toxicity; prescriptions must state the day of the week and the dose, the strength of tablet should be one strength only (2.5 mg), and patients must be counselled that the dose is weekly. MHRA — Drug Safety Update: methotrexate once-weekly for autoimmune diseases, new measures to reduce the risk of fatal overdose due to inadvertent daily instead of weekly dosing, September 2020, checked 10 Oct 2026
2. Methotrexate toxicity presents with mouth ulcers and sore mouth, nausea, abdominal discomfort, fever, infection, bruising or bleeding, breathlessness or cough; patients are told to seek urgent help with these; the full blood count, renal and liver function are checked, and an overdose is treated in hospital with folinic acid. BNF (NICE) — Methotrexate, side-effects; patient and carer advice; treatment of overdose, current BNF online, checked 10 Oct 2026
3. Every healthcare professional must be open and honest with patients when something goes wrong with their treatment or care that causes, or has the potential to cause, harm or distress: tell the patient what has happened, apologise, offer an appropriate remedy and explain the likely effects; the duty is the organisation's as well as the individual's. GMC and NMC — Openness and honesty when things go wrong: the professional duty of candour, paragraphs 1 to 12, 2015 (updated 2022), checked 10 Oct 2026
4. You must take prompt action if you think that patient safety is or may be seriously compromised; if you have concerns that a colleague may not be fit to practise, you must ask for advice and take appropriate steps, and the safety of patients comes first; you must support colleagues who raise concerns. GMC — Good medical practice, domain 2, working with colleagues: raising and acting on concerns; domain 3, patient safety, 2024, checked 10 Oct 2026
5. Raise a concern about a colleague first within the organisation, to the responsible person (a partner, the practice manager or the clinical governance lead), with the facts; the person who raises a concern must be protected from detriment, and the concern is investigated through the practice's significant-event process. GMC — Raising and acting on concerns about patient safety, paragraphs 10 to 16, raising a concern, 2012 (updated 2024), checked 10 Oct 2026
6. Patient safety incidents in general practice are recorded, analysed and learned from through significant-event analysis and reported through the national learning system; a medication error reaching a patient is a notifiable incident for the organisation under the statutory duty of candour where harm results. NHS England — Patient Safety Incident Response Framework (PSIRF), recording and responding to patient safety incidents, 2022, implemented 2023, checked 10 Oct 2026
7. Shared care for methotrexate: the GP prescribes on the specialist's recommendation and monitors blood counts, renal and liver function at agreed intervals; the specialist is informed of adverse events; the patient holds a monitoring booklet with the dose and the day. NICE CKS — DMARDs, prescribing information: methotrexate, monitoring under shared care, current online version, checked 10 Oct 2026
8. A registered provider, including a GP practice, must act openly and transparently and, as soon as reasonably practicable after a notifiable safety incident, tell the patient in person what happened, apologise, explain what further enquiries will be made, and follow this up in writing; a written record is kept. For a practice, a notifiable incident is one that appears to have resulted in, or could result in, death, severe or moderate harm, or prolonged psychological harm. UK Parliament — Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulation 20, duty of candour, SI 2014/2936, regulation 20, checked 10 Oct 2026
9. Saying sorry is not an admission of legal liability. The apology is given by the person best placed to speak to the patient, with the facts as far as they are known, what is being done to put things right and what will be learned; the patient is told whom to contact and how to complain if they wish. The pharmacist who found the error is not left to make the disclosure alone. GMC and NMC — Openness and honesty when things go wrong: the professional duty of candour, apologising; what to tell the patient; who should speak to the patient, 2015 (updated 2022), checked 10 Oct 2026
10. Methotrexate monitoring: full blood count, renal function and liver function every two weeks until the dose has been stable for six weeks, then monthly for three months, then at least every twelve weeks. After a suspected overdose the same bloods are taken urgently and repeated, because the fall in white cells and platelets and the rise in liver enzymes may appear days after the last dose; the specialist is told the same day. NICE CKS — DMARDs, methotrexate: monitoring schedule; action on abnormal results, current online version, checked 10 Oct 2026
11. A worker who discloses to their employer, in the reasonable belief that it is in the public interest, information tending to show that the health or safety of any individual has been or is likely to be endangered makes a protected disclosure and has a legal right not to be subjected to any detriment or dismissed for doing so. A pharmacist raising a prescribing error with a partner is protected in this way. UK Parliament — Public Interest Disclosure Act 1998, protected disclosures (Employment Rights Act 1996, Part IVA, as inserted), 1998, chapter 23, checked 10 Oct 2026
12. All doctors are responsible for using the systems that report and learn from patient safety incidents, and for contributing to significant-event review. A doctor with management responsibility must make sure that colleagues who raise a concern are supported and not victimised, that concerns are investigated and that the person who raised them is told the outcome; a colleague whose health or circumstances are affecting their work is offered support as well as being told. GMC — Leadership and management for all doctors, patient safety: reporting incidents, handling concerns, supporting colleagues, 2012, checked 10 Oct 2026
13. The curriculum expects the GP to take part in significant-event analysis, to apply the professional and statutory duties of candour, to raise and respond to concerns about a colleague's practice in line with GMC guidance, to understand high-risk drug monitoring and shared care, and to work with the practice pharmacist as part of the prescribing-safety system rather than around them. RCGP — GP curriculum: Continuity and quality of care, safety and prescribing, patient safety, significant-event analysis, duty of candour, raising concerns, safe prescribing, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

13 statements, 766 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, 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 SCA-20