Confidentiality and Teenagers #111 service


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A friend of mine had the need to call 111 at the weekend (the out of hours’ doctors service). Her 13-year-old daughter was very poorly with tonsillitis and she was getting very distressed as she was really feeling unwell and in a lot of pain.

 

My friend answered all the necessary questions asked by the operator i.e. symptoms, how long she had been unwell for and the age of child.

 

The operator then asked my friend if she could speak to her 13-year-old daughter, she handed her the telephone and was asked the same questions by the operator. When they were finished speaking the operator asked the girl to pass the phone back to her mother.

 

The operator then asked my friend if there was any possibility that the girl could be pregnant – to the embarrassment of both the mum and the girl she had to asked the 13 if she could be pregnant, red-faced the girl said no.

 

The operator advised that the girl needed to be seen in the local Treatment Centre and gave the mother an appointment time.

 

What i cannot understand if the operator felt that the girl was old enough to answer her questions – which she was, and if there was any possibility that she “could’ have been pregnant why did she not ask her that very personal question directly to the girl when she was speak to her.

She could have been very confidential and just said “I am about to ask you a question and all you have to answer is yes or no – coud you be pregnant” All the girl would have then had to say was “yes” or “no” simple! So why did she ask the mother?

 

Do you think I’m right – or do you think the operator was right to ask the parent?

© 2011-2017 Reception Training all rights reserved

 

 

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The Sunshine Patient


 

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Working on the front desk as a Receptionist you deal with thousands of patients over the years. But there are those few patients that will always stay in your mind for different reasons. If I think back to the many lovely patients I use to deal with one that automatically springs to mind is Andrew (I have changed his name for this story).

Let me tell you about Andrew and how he used to lighten up my day when he came into the surgery. He was like a ray of sunshine.

Andrew used to come in on a fairly regular basis with his Dad. Andrew was 25 years old and had Downs Syndrome.

It was just Andrew and his Dad – on getting to know them more I found out that sadly Andrew’s mum had died in their house due to Carbon monoxide poisoning. Andrew and his dad were extremely lucky to pull through – but it was so obvious how they missed their wife and mum.

When I first started dealing with Andrew and his Dad on the front desk it was always his dad that made the appointments, did the talking and insisted on going into see the doctor with Andrew.

The doctor that Andrew (and his dad) used to see on a regular basis was concerned that Andrew was not being allowed to be more independent and do more for himself – but the Doctor also identified that this was mainly down to Andrew’s dad not wanting to “let go”. Andrew was all he had in the world. But at the same time it was not fair to Andrew he was being held back.

After some months getting to know Andrew and his Dad Andrew started to really come out of himself and would chat away at the front desk to me he would joke and laugh with me. I always got a great big beam from him when he came into Reception.

Andrew would happily tell me about his day – what they had done that morning and what there were going to do that afternoon. I always looked forward to his visits and the stories he had to tell.

Then Andrew starting to hold the conversation more every time he came in. Andrew even started to book his next appointment by himself and actually started going in to see the doctor on his own. I seen Andrew grow with such confidence. The doctor that Andrew was seeing was extremely supportive and understood Andrews needs so well.

When Andrew was in with the doctor one morning his dad was chatting to me at the desk. He opened up to his fears about Andrew, and confessed that he actually felt that he was holding Andrew back, but Andrew was all he had.  He confessed that he had even put a block on Andrew attending a day centre as he didn’t want to let go. I felt so sorry for his dad and for Andrew too. His main fear was that Andrew would die and he would be left with no one. The love he had for Andrew was amazing but he was holding him back.

Andrew continued to flourish and he even got a bit bold at times – in a nice way. The cheeky chap even tried to chap me up for his dad once and asked if I would go to their house for fish and chips that Friday night – it was all in good fun and he understood that I couldn’t go as I had to get home to my two girls.

Andrew’s confidence continued to grow, with the help of the GP his dad finally agreed that Andrew could go to a day centre – Andrew just loved it there. His eyes would sparkle when he told me about his days there and the friends that he had made.

But his dad’s fears of loosing Andrew never went away.

Life continued in the surgery and Andrew and his Dad’s visit became less frequent. Andrew was becoming much more independent and loved his days at the centre.

Then one Monday morning I was checking through the out of hours reports and to my horror seen that there had been a death at their address – Andrew’s dad had died of a massive heart attack.

I never got to see Andrew again – and never knew what happened to him, but one thing for sure I know that wherever he went he would have brightened up their days just like he had done to mine whenever he came into the surgery.

I would like to think that the independence that Andrew gained over the years would have given him some strength to get through the loss of his Dad.

 

© 2011-2017 Reception Training all rights reserved

Straight from the heart


 

imagesCATMPJJAToday is Fathers Day and what I would give to be able to telephone my dad and wish him a lovely day – something I did every year and took for granted. Sadly my dad died last year and I never got to be with him in time – to have that one last conversation with him. To tell him how much so many people loved him, to tell him what strength he was to me and to tell him simply that I loved him – but I know he knew that anyway.

This blog is a bit different from normal. It is straight from the heart and its one of those stories that left me and my family but more so my lovely dad badly let down by the system that I believe is one of the best in the world – but can show perhaps without the right communication how things can go so badly wrong.

I had a lovely Saturday afternoon, we had been celebrating a friends baby shower and there was lots of laughter and fun, the afternoon had ended and the clearing up underway. My daughter telephoned me to say that she had spoken to my dad (her beloved granddad) and he had commented that he felt unwell – he had been backwards and forwards to the doctors for some weeks with a chest infection and put on various different medications.

My dad asked my daughter to phone a doctor for him – this had alarm bells ringing, my dad would NEVER make a full and in all his life he had never ever phoned a doctor outside of surgery hours, and had never had a home visit. He was of the “old school” he never complained.

My daughter asked if I would phone and speak to him, she knew that I had a good understanding of how the out of hours worked and felt that I would be the best person to speak to someone.

Unfortunately I was not in the UK on this occasion and was phoning from another country. I telephoned my dad and it was pretty obvious he was very poorly he also was very confused – he asked if I could phone the doctor and his wishes were that no one called him as he felt he was not able to have a conversation with someone at this stage. He was confused and he was in pain. He sounded really poorly.

I have a brother and unfortunately we were unable to contact him – but we left a message.

At 17.30 I telephoned the out of hours service. I explained to the operator it was my dad’s wishes that I spoke to them, as my dad was too poorly to speak to anyone. I explained that he was confused in a lot of pain and had not passed urine since the day before. I gave a list of my dad’s medication to the operator. I offered my telephone number to the operator and he said as it was an international telephone number he was unable to take it – this concerned me as I was the point of contact – I offered it again and he again said that he was not able to take the number.

I gave every single bit of information that the operator would have needed to assess the call appropriately. I know if my dad had made that call he would have not given all the facts.

After speaking to the operator and all the details taken into consideration it was confirmed that my dad would need an ambulance. As the operator couldn’t take my telephone number he actually put me through directly in touch with the ambulance service. I explained the circumstances and my concerns that my dad was confused, along and in a lot of pain. They confirmed that an ambulance would be called.

The next hour was a nightmare – worried that I had no news – still no contact from my brother so I telephoned my dad house to find that he was still there and no ambulance had been. The only reassuring thing was my brother had just arrived so at least he had someone there with him.

Concerned that no ambulance had arrived I contacted the out of hours again. I was told that the ambulance had been cancelled – yes cancelled!

Concerned that Dad had been confused perhaps someone had phoned him and he might have told them not to bother – that is something dad might have done if he thought that he was causing a fuss – but speaking to my brother no one at Dad’s had phoned or no one had cancelled the ambulance.

My brother told me that he would take my dad straight away to A&E himself in the car.

Had my dad gone in an ambulance he would have gone straight through – but my brother had to find a car parking space, walk my poorly dad into A&E and wait until the drunks and people with colds were booked in before them – it took over half an hour waiting to be checked in – and as you can imagine a while before he was seen – my dad was finally admitted the doctors told my brother that they would keep him in for a few days.

Sadly my dad died the next evening.

When we got back to my dads house in the early house of the morning the answer machine was flashing – the message was received after 19.00 saying it was the ambulance service calling – and apologised for the delay in the ambulance and if anything has changed please call us back on 999 – thank you. I was confused at this stage to say the least.

I contacted and the ambulance on the Monday to find out what had happened – how my dad was sadly let down by the system. The gentleman dealing with the call was extremely helpful and he assured me he would look into it for me.

I then telephoned the out of hours and asked them why the ambulance had been called – to which I was told because of patient confidentiality I would have to get written permission from the patient before they could release any information. For goodness sake the patient was dead! How on earth was I suppose to do that? I did find that very upsetting. This took me a while to get sorted – there was every chance that they were not going to discuss this with me – but I got there after several stern words.

As you can imagine there was a lot of correspondence backwards and forwards – taking forever to get answers.

The out of hours was blaming the ambulance service for not prioritising the call appropriately and the ambulance was blaming the out of hours – it took a long time to finally find out what had happened. But we finally got to find out what had actually happened.

The out of hours said in their letter that the ambulance service categorisation process resulted in an inappropriate C2 response that on review they acknowledge should have been a C1 priority for a 20 minutes response. The ambulance service also stated this in their letter – but also followed it up with it was one of their busiest nights and went on back that up with figures on calls throughout that day.

As for the cancellation of the ambulance it was confirmed that the reason the call was cancelled was due to the fact that the operator had inaccurately quoted the wrong call number he quoted 3392 instead of 3329. As this point the demographic details should have been confirmed by both parties to ensure the correct call log was being looked at. In this case it did not happen. The call number given to the ambulance service actually related to another call transferred by the out of hours service. The call log that the ambulance service operator was looking at was told that this patient had in fact contacted the out of hours requesting the ambulance to be cancelled. So my dad’s ambulance was cancelled and the gentleman that phoned to cancel the ambulance more than likely still got a visit from the ambulance service.

So, errors all round – would it have saved my dad’s life if the ambulance had arrived – and within the 20 minutes target? We will never know but what was more upsetting is the fact that if my brother had not been able to get to him when he did, and I had not phoned back thinking he was being taken to hospital he would have been waiting for the ambulance and perhaps have collapsed at home when he was on his own, because my dad would not have complained or wanted to have been a nuisance in any way.

When talking to the out of hours service I did share my concerns that they had nor wanted to take my telephone number – the only point of contact they had. The woman who I was dealing with at the out of hours did say that from this incident they would be looking at reviewing their system and every call would have the facility to take a contact telephone number. For me this should have been such an easy process and should have been put in place right from the start.

For me if ever I took a call from a patient, or someone calling on behalf of a patient my first priority would always be to get a contact telephone number. To me this is basic communication.

I sadly still see on the news and read in the papers that this out of hours service that I dealt with are always in the news for all the wrong reasons. Why are they still getting it wrong?

So for my today Fathers Day it’s always a sad reminder that this beautiful man – my dad is no longer here.

 

My Live BBC Radio Interview on Being A Doctors Receptionist


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Last Thursday I was approached from BBC Radio via my blog to do a live radio broadcast in response to a broadcast the previous evening. The previous evening there was a GP speaking about patients and the “stiff upper lip of the British” and that they should go and see their Doctor “sooner rather than later”.

The radio station received several replies from some “unhappy” listeners saying that they have often found it difficult to get appointments at their surgeries. They mentioned lack of appointments, and rude Receptionists.

I was asked along to talk about the role as a Receptionist. Whilst I didn’t have enough time to answer some of the emails sent to the radio station I would like to share a couple with you and what I feel would be a response I would have made.

LETTER FROM A MALE LISTENER

Sender’s message

“Stiff upper lip? Certainly not.

Over crowded surgeries, unapproachable doctors (and receptionists) creaking overloaded health service not working on a Saturday YES YES YES”

My response would be

I agree that surgery clinics can often be extremely busy. Practices do acknowledge this and will try all avenues to spread the various clinics over the day/week. As the healthcare service continues to expand into general practice unfortunately the surgeries get busier. Many Practices offer baby clinics, various Nurse Clinics, minor surgery clinics, Health Visitors Clinics and many more and are often scheduled to run outside normal Doctors appointment clinics. Most Surgeries these days do have extremely pleasant waiting areas. Patients often have TV’s or a radio in the waiting room, magazines to read, an area for children, water drinks dispenser and other items  hopefully making  any waiting time as pleasant as they can. Many also have free wifi. Unlike not so long ago when you just had a waiting room and nothing else.

A busy surgery is often one that is offering several different healthcare services under one roof meaning patients do not have to travel to their local hospital for treatment.

Just because you might “see” a busy or “crowded” surgery does not mean it is not being run efficiently.

It saddens me to read that the gentleman finds the doctors and receptionists unapproachable – to this I cannot comment as I don’t have pacific details , if I was dealing with this gentleman at my surgery I would be asking in what way he found them unapproachable and would deal with it from there. Of course he also has the choice to move to another surgery if he is very unhappy with his present practice.

And as for not working on a Saturday – many surgeries that I know of certainly do work on a Saturday morning. But, is this gentleman aware that there is always the out of hours service and they are there every evening and weekend after the surgeries have closed and therefore he has access to either speak or see a GP or healthcare professional 24/7. Many surgeries are now open to accommodate people who are working and often open from 07.00 through to 20.00 – 5 days a week. A pretty good service I think!

LETTER FROM A FEMALE LISTENER

Sender’s message

I phoned for an emergency appointment when I realised I was suffering from depression. I was so distressed that I blurted out that I had been having suicidal thoughts. The receptionists’ response was to repeat “sorry to hear that, you’ll have to phone back in the morning”.

My response would be

The patient I am sure was pretty distraught by this conversation. Only she knew just how bad she felt – the Receptionist had no way of knowing how bad she actually was – but she was saying she was having suicidal thoughts – bad enough in my opinion.

.My advice to her if she was refused an appointment was to ask if she could speak to a Doctor. In the event that there was no Doctor available to speak to her she should ask to speak to the Practice Manager or someone else in charge. As a patient if you feel that it is urgent enough that you need to see a Doctor that same day and the Receptionist cannot offer you an appointment ask to speak to someone about it or ask for a Doctor to call you back.

 As a manager I would be alarmed if this had been a Receptionist at my Practice but I feel very confident that this would not have happen. All of our Receptionists would have received training in dealing calls similar to this.

This should never have happened. What is to say that there would not have been an appointment the following day? Why ask her to phone back again only to be told there are still no appointments.  The patient requested an urgent appointment. That needed to be taken into consideration straight away. The Receptionist didn’t even have to ask why she needed the appointment, the patient explained why she needed the urgent appointment.

Someone suffering with depression and admitting that she was having suicidal thoughts should have had alarm bells ringing.

If the Receptionist really could not offer the patient an appointment that same day she should have tried her utmost to either speak to a Doctor or nurse and ask their advice. In the event she was going to get a Doctor to call the patient back the Receptionist should not have let the patient end the call without taking a contact number first. (Even if the patient has a number on her records always check – because it has happened many times that patients change their telephone number and do not notify the surgery)

If Surgery had finished and perhaps there was no doctor on the premises (lunchtime) then the Receptionist should have called the duty doctor for advice.

Receptionists are dealing with calls like this on a regular basis, especially for “emergency” and “same day” appointments, it is a difficult task for them as they only have so many appointments that they can offer to patients on a daily basis. A good Receptionist will often be able to give a helpful solution to the patient by either offering an alternative appointment/day or perhaps offering an appointment with another healthcare professional i.e. the nurse or getting someone to call the patient back.

But at the end of the day if the patient insists they need an urgent appointment and the Receptionist is unable to give them one then the Receptionist needs to speak to her Senior Receptionist or perhaps a Doctor for advice.

And then there was a letter from a listener that goes to show that there are many patients out there that are more than happy with the service that we give.

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LETTER FROM A MALE LISTENER

Sender’s message

Can I – as a patient – stand up for those receptionists who are anything but rude, especially those in our local surgery in Hillsborough, Co. Down who are simply exceptional. As a family with two young children we have all had our fair share of visits and always been treated with the utmost courtesy and care.

My response

Whilst we take on board the negative comments , and hopefully deal with them in the appropriate way, it is always nice to get positive feedback. You don’t know how much that means to staff to hear that they are appreciated and the job they are doing are doing it well. Everyone thrives on good feedback.

Thank you.

As a Receptionist and a Manager I am still always overwhelmed at the positive comments and feedback that we get on a regular basis from the patients. This is what makes the job so very special.

 

Christmas Emergency Numbers – informing your patients


We have a week left until Christmas – your surgeries will be busy with people coming in with the usual coughs and colds that this time of year brings – and of course there will be the sudden rush of people wanting their repeat prescriptions before Christmas – and those that will wait until the very last thing and rush in just before you close on Christmas Eve.

But, have you let your patient know what to do if they should need a doctor during the Christmas break?

How have you advertised this?

  • Notices up in the Surgery?( Don’t forget to put one on the front door in case someone comes to the surgery looking for information. )
  • Surgery Website?
  • Answer machine message?
  • Adding a message to repeat prescriptions.
  • Patients newsletter
  • Telling patients if they ask when then come in our phone?
  • Local Village Newsletter for the more rural Practices?
  • Notices in local Chemist / shops

Excellent but do you also have the out of hours number available on all the above too?

The out of hours will be extremely busy over the Christmas period – I know because I worked for them over Christmas for several years  – and what a fantastic service this gives to local people wanting to see a Doctor when there Surgery is closed.

But

Are you aware of how many people who do not know that the out of hours even exists? I was completely surprised when working for the out of hours and the Surgery just how many people were not aware of this service. I lost count of the number of people who would attend the out of hours clinic and said it was the first that they had heard of it. And all agree what a wonderful system it was.

People that do not have cause to go to their Surgery very often will not have the need to know about the out of hours. Some people have not been to their Surgery for years – so how would they know it exists?

Some elderly will still wait days over a holiday period or a weekend until their own Doctors Surgery is open they too might not be aware of the service.

And of course you have the “visitors” that will be coming to your area – to stay in hotels, with family or friends –  ensure that if they need a Doctor that you have enough information / telephone number for them to be guided to the nearest out of hours clinic.

So, please ensure that you have the number available – and perhaps a brief paragraph on what the service is for and where they have to go for it.

If you have all the above in place they you have done as much as you can for your patient – and hopefully not many of them will need to use the service.

 

When a Patient Dies


Does your Surgery have a policy when a patient dies?

You might ask why you might need a policy on this – but it is extremely important in various areas. Let me share these with you.

When one of your patients dies you will probably be notified by one of the following

  • A member of family or a friend
  • A Carer
  • The local hospital (usually comes in the form of a letter or fax)
  • The Out Of Hours Service
  • A Nursing Home (this will normally come via a telephone call)
  • The Health Visitor from your own Surgery (if they were caring for the patient at home)
  • Local Health Authority (the patient might had died in another area/country)
  • You might see it in the local paper under the births deaths column.

COMPUTERS RECORDS

The next step is to record the death on your computer records. If your system does not do all of these automatically you will need to ensure that they are taken off.  Ensure that the patient is taken off any clinics that might generate recall letters such as

  • Flu Clinic
  • Diabetic Clinic
  • Asthma Clinic
  • Blood Pressure Clinics and so on.

If your surgery is mostly computer run it is still very important to make sure that an entry is made in the paper notes.

How does your Surgery record patient deaths?

TRUE STORY

I worked in a surgery before we have our death protocol in place where a very upset wife phoned to say that a letter had been sent out to her husband to have his flu vaccination done – he had died 3 months before. Although someone had entered that he was deceased on his records he had not been taken off the flu recall.

Link up any close member of their family and add to their records that they have been recently bereaved – this will help the Doctor if a member of the family comes in to see them. There is nothing worse than the Doctor asking after the deceased patient. And believe me this has happened on several occasions.

Ensure than any future surgery appointments are cancelled.

Remove patient details for any routine repeat prescriptions.

TRUE STORY

It is important that you put a stop to any further prescriptions – I am happy to say that it didn’t happen at my Surgery but there have been surgeries that have had people coming in to request repeat prescriptions for deceased patients and because they had not got a policy in place the prescriptions were issued – several times

Who you should informed of the deceased patients death will depend on where the patient died.

If The deceased Patient dies at home / or other place please check to see if they have any future hospital appointments booked.

The  most important thing you should check with your local hospital to see if they had any outstanding hospital appointments.

Ask the hospital to check if the deceased patient had any hospital transport booked. Why?

TRUE STORY

Again before our Surgery policy was put in place we had a deceased patient who’s funeral was taking place one Thursday morning – the wife of the deceased heard a knock at the door and thinking it was the undertakers she opened the door to find that hospital transport was there to take the deceased patient for his hospital appointment. Now can you see the importance of ensuring that all future appointments are cancelled?

WHO YOU SHOULD INFORM WITHIN THE SURGERY?

It is important for all staff to be made aware of the death of any patient. How do you record the death of a patient in your surgery?

  • Inform the Doctor
  • Inform the Health Visitor (in the event of a child or pregnant mother)
  • Inform the Health Visitor (in the event that they were due to start visiting the patient)
  • Inform any other healthcare professional that might have a reason to be in contact with the deceased patient.

The best way for this is to send an internal email – and if necessary put it in the message book.

When we reviewed our policy on deceased patients I designed a form that had to be completed. We had a member of staff that had the responsibility of ensuring that everyone was informed of the death. Each section had to be completed or ticked and at the end of the form a surgery supervisor had to sign it too – and this copy was then scanned onto the patient’s records and the paper copy placed in their medical records.

You can design your own form but an idea on what we had on our form:

  • Patients Name and Address
  • DOB (date of birth)
  • Place of Death (ie home/hospital/other)
  • Computer code entered (RIP code)
  • Deduction Requested (deduction from surgery list)
  • Next of Kin (entry made on their notes)
  • Hospital Notified – if applicable (I recommend that this should be done in a fax/email and not verbal.)
  • Hospital Transport Cancelled
  • Surgery Appointments cancelled
  • Doctor informed
  • Health Visitor Informed
  • District Nurse Informed
  • Other staff informed
  • Prescriptions Stopped
  • RIP Message on Notes
  • Records returned to the Health Authority
  • Any other areas that might be applicable to your Surgery

 I hope you have found this helpful. The important thing is to ensure that family / friends are not subjected to any more upset because their loved ones are still on your surgery system as still living.

REMEMBER:  This will be the last thing you will do for the deceased patient – show them the dignity they deserve.

I did go on to have an “alert” board where we also put this information. You can read this on  my blog :

Patients With Special Needs (Special Needs Board) http://t.co/wnWKmxHV

 

A&E – The Morning After Pill


Working in the A&E Department at my local hospital at the weekend for the out of hours was never dull.

I would work part-time one evening a week and part-time Saturday evening and Sunday mornings. For the out of hours service and we were kept fairly busy at a steady pace.

A&E was very different. They never knew how busy they would or would not get until it happened.

I loved the buzz and learned so much in the time I worked there.

Working in a GP Surgery and in an A&E Department was so VERY different in lots of ways.

GP Surgeries, and the out of hours service was mainly for people wanting to see a Doctor for minor ailments, prescriptions and referrals onto the hospital. Along with “well” people visiting to see the Health visitors, Nurses or the doctor to have medicals or forms completed. Of course we had the terminally ill patients that needed the care from the whole team at the Surgery.

Then at the hospital you would get in the more urgent cases – A&E = Accident and Emergency. But it never failed to amazed me just how many people used the A&E Department as an extension of their Doctors Surgery. People would often come in for a prescription, for a simple cough or a sore ear – the A&E Department would be bursting at the seams and people would still come in and want to be seen.

Foreign students cottoned on very quickly that if they went to see a GP they would have to pay – but present themselves at A&E they would not be charged.

One patient that sticks in my mind was a young girl about 19 years of age walked up to the Reception Desk around 7.30 pm one Saturday evening.

The A&E Receptionist took her details and entered them onto the computer – she asked the usually question

“What brings you to A&E this evening”?

The girl replied “I want go get the morning after pill”.   

Now working at the GP Surgery I am fully aware that this is an emergency – a woman has up to 72 hours to take the morning after pill after unprotected sex. The longer she leaves it the more chance she has of being pregnant.

At the Surgery we always would fit someone in with an appointment immediately if they requested this.

What I could not understand was why this girl had come to  A&E Department when she could have phoned her surgery and been put through to us working for the out of hours service (the emergency out of hours for local GP’s) Waiting in A&E she could have been there for hours, seeing us in the out of hours she would have waited about 10 minutes.

The A&E Receptionist realised that although this was an “emergency” it could in fact be dealt with the doctor on call that I was working with. So she asked if the Doctor would see her – I was happy to help.

I went over and took the girls details for our system. She then confirmed that she wanted the morning after pill. I had to ask her when she last had unprotected sex – as this would be important for the Doctor and then this information would be passed onto her own Doctors Surgery when they opened up on Monday morning.

Her reply was “I haven’t had sex yet – I want it for tonight as I am going
out”

She seen the Doctor and after a long chat in how to be more responsible she was sent away with a flea in her ear.