We have listened to people who use ‘Good Medical Practice’ in their work - doctors in practice, NHS managers, patient representative groups and others. The new edition, refined in the light of their views, includes:  emphasis on maintaining good medical practice through personal, professional development, audit and appraisal  the duties of medical teachers  the importance of effective team working  the doctor’s duty to tell patients if things go wrong, apologize where necessary, and put things right if possible  more emphasis on reporting dysfunctional practice.

CASE 1 Mrs H.G. 54 years old Developed sudden onset of severe headache, vomiting, neck stiffness in September ’07 Following day drooping of left eyelid was noted

CASE 1 Attended Moka Eye Hospital Ct scan brain done 2 days later at JNH Discharged and prescribed eye drops and parentrovite injection Headache persisted together with drooping eyelid Attended VH in October ’07 Findings: left 3 rd cranial nerve palsy Referred to medical unit

CASE 1 Further CT brain requested at JNH reported as having small lacunar infarcts Patient seen by 2 specialists (physicians) and was about to be discharged home INTERVENTIONS FROM HIGHER QUARTERS

CASE 2 Mr B.C. 44 years old H/o headache, irritability, confusion and personality change since 3 months Recently developed urinary incontinence Attended hospital Given symptomatic treatment Condition worsening and patient taken to psychiatrist

CASE 2 CT scan brain: huge bifrontal tumour Operation in May ’07 Right-sided tumour removed and divided into two halves Report 19/05/07 from private lab: Appearance consistent with meningioma Report 18/06/07 from VH: Metastatic undifferentiated carcinoma

CASE 2 Four blocks submitted for counter examination Durban, South Africa Report July ’07: Meningoma; no abnormal mitosis, no cytological evidence of malignancy Subsequent report from VH lab August ’07: Cellular malignant neoplasm of meningeal origin Frequent mitoses and foci of necrosis Nuclear polymorphism conspicuous

CASE 2 Is it a meningioma with no mitotic activity requiring no further treatment? Is it a metastatic undifferentiated carcinoma (to look for primary)? Radiotherapy? Chemotherapy? Is it a meningioma? Aggressive, anaplastic type, requiring radiotherapy?

CASE 3 Mr R.Y. 43 years old Airline pilot, referred from Seychelles Medical report stating that he had a brain tumour on CT scan No CT scan films sent with patient Presenting symptoms: Sudden onset of headache, vomiting, collapse and urinary incontinence one week earlier

CASE 3 On examination:  Patient conscious  Headache ++  Neck stiffness  Provisional diagnosis of sub- arachnoid hemorrhage  MRI and MRA brain requested- Report: Normal study What next?

CASE 4 Mr I.C. 67 years old Collapsed in bathroom Unconscious; brought by SAMU to hospital Admitted to Cardiac Unit with diagnosis of CVA CT scan brain showed extensive sub- arachnoid hemorrhage Transferred to ICU and put on ventilator

CASE 4 Gradual improvement in clinical condition, from grade IV to grade I Extubated and transferred to private clinic for CT Angio Result: No evidence of aneurysm or AVM What next?