Cases/Urgent & Unscheduled care

Haemoglobin of 70 Refusing Hospital Admission — Free SCA Practice Case

Veteran with a haemoglobin of 70 refusing hospital admission

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Frank Doherty

Age

58 years

Consultation Type

Telephone

Age

Situation

Urgent Telephone Consultation, to discuss blood results taken two days ago.

Reason for Encounter

"You've rung about my blood test. I'll save you some time — I'm not going into hospital."

Medical Records

●PMH: Upper gastrointestinal bleed 2 years ago (managed in hospital; OGD performed — patient reports the experience as traumatic). Alcohol dependence. Military veteran (British Army).
●Medications: None currently (omeprazole issued after the previous admission, not requested since).
●Allergies: NKDA.
●Blood results (2 days ago): Haemoglobin 70 g/L (was 120 g/L eight months ago). MCV raised. Platelets normal. Gamma-GT markedly elevated; other liver function tests mildly deranged. U&Es: urea mildly raised, creatinine normal. INR normal.

Patient Script

For the friend playing the patient role

Character Overview: You are Frank, a 58-year-old former soldier, living alone. You had a bleed from your stomach two years ago; you were admitted and had a camera test (OGD) which you found deeply traumatic — it triggered flashbacks and you have never forgotten it. You drink heavily most days and have done since leaving the army; you would say you drink to blot out things you saw during service. Over the last few weeks you have felt increasingly tired and breathless going upstairs, and you have been dizzy on standing; you have noticed your stools have been very dark, almost black, for about a week. You had blood tests two days ago. You are absolutely clear that you are not going into hospital, whatever is said — you understand it might be serious and you accept that risk. You are not depressed or suicidal; you simply cannot face the hospital and the camera test again. You are calm, articulate, and entirely lucid. You will, however, agree to come into the surgery today to be checked over if that is offered.

Opening Sentence: "I know why you're ringing — it'll be about my blood test. Let me save you some time, Doctor. I'm not going into hospital. I'll listen to what you've got to say, but I'm telling you now, that's not happening."

History if Asked (Data Gathering Phase)

●Symptoms: "I've been shattered for weeks. Out of breath going up the stairs, which isn't like me. And I go dizzy when I stand up."
●Stools — if asked: "Now you mention it, my stools have been very dark. Almost black. For about a week."
●Vomiting blood: "No, I've not vomited any blood."
●His previous experience: "Two years ago I had a bleed and they admitted me and put a camera down. It was horrific. It brought everything back. I've never got over it. I'm not going through that again."
●His drinking: "I drink most days, and a fair bit. I'm not going to pretend otherwise. It's how I cope with what I saw."
●His position: "I understand you're worried. I'm not stupid. But I'm not going in, and that's my decision."
●Coming to the surgery: "If you want me to come down to the surgery so you can check me over, I'd do that. It's the hospital I won't do."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Frank understands he is anaemic and may be bleeding again, and knows this is serious. "I know I'm probably bleeding again. I'm not daft."
●Concerns: His dominant concern is not the bleed but the hospital — specifically the endoscopy and the memories it triggered. He is also worried about being detained or overruled. "It's not dying that frightens me, it's that place and that camera. And I'm worried you'll try to force me."
●Expectations: He expects to decline admission and be left to it — but he is willing to be checked at the surgery. "I expect you to try and talk me into it. I'll come to the surgery, but that's as far as it goes."

If Asked — Bleeding, Haemodynamic, and Capacity Screen

The patient answers these only when directly asked.

●If asked about melaena (black, tarry, offensive stools): "Very dark, almost black, and they smell foul. About a week now."
●If asked about haematemesis or coffee-ground vomit: "No, nothing like that."
●If asked about dizziness, syncope, palpitations, or breathlessness at rest: "Dizzy standing up, breathless on the stairs. Not dizzy sitting still, and I haven't blacked out. No palpitations."
●If asked about chest pain: "No chest pain."
●If asked about abdominal pain, indigestion, or reflux: "A bit of burning indigestion, on and off."
●If asked about NSAIDs, aspirin, anticoagulants, or steroids: "I take ibuprofen for my knees fairly often, from the shop." (Relevant contributory factor.)
●If asked about alcohol quantity: "Most days. Spirits mainly. More than I should — probably the best part of a bottle some days."
●If asked about weight loss, appetite, dysphagia: "I've lost a bit of weight. Appetite's poor. No trouble swallowing."
●If asked about previous variceal bleeding or known liver disease: "They said something about my liver last time. I didn't take it all in."
●If asked about how he is managing at home and who is around: "I live alone. I've got a neighbour who looks in. No family nearby."
●If asked, sensitively, about mood, hopelessness, or thoughts of self-harm: "I'm not depressed and I'm not trying to do away with myself, if that's what you're asking. I just can't face that hospital."
●If asked about his military service and any support: "Twelve years in the army. I've never had any help with any of it. Nobody's ever offered."
●If asked whether he understands the risks of not going in: "I understand I could bleed badly and it could kill me. I've thought about it. I'm still not going."

Responses to Management (The Negotiation Phase)

●If the Doctor explains the result and the risk clearly: "So my blood count's halved. And that black stool means I'm bleeding from my stomach. Right. I hear you." (The tested point is explaining the severity honestly.)
●If the Doctor explores why he is refusing — key: "You're the first person who's actually asked me why. It's the camera test. It brought back things from the army I've never dealt with." (The tested point is exploring the reason behind the refusal rather than simply arguing against it.)
●If the Doctor assesses capacity: "Of course I understand. I've told you what could happen." (The tested point is a proper capacity assessment — he clearly retains capacity.)
●If the Doctor attempts to coerce or repeatedly pressures him: "I've told you. Are you going to keep pushing? Because if so I'm going to put the phone down." (Coercion is a failing behaviour — it loses the patient entirely.)
●If the Doctor offers the middle path — a same-day surgery review: "Yes. I'll come down this afternoon and you can check me over. That I will do." (The tested point is negotiating what he will accept, rather than accepting nothing.)
●If the Doctor addresses the endoscopy trauma practically: "You mean it could be done differently — with proper sedation, or someone who'd understand why I'm like this about it? Nobody's ever suggested that. I'd think about it."
●If the Doctor offers veteran-specific support: "There's help specifically for veterans? After all this time? I might take that."
●If the Doctor safety-nets and leaves the door open: "And if I change my mind, or if I get worse, I just ring 999. Understood."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

Recognising Significant Upper Gastrointestinal Bleeding

●A haemoglobin of 70 g/L with an acute fall from 120 g/L, together with melaena, postural symptoms, and a raised urea, indicates significant, active upper gastrointestinal bleeding. Contributory factors here include NSAID use and heavy alcohol intake with possible liver disease (raising the possibility of peptic ulceration or varices). The standard management is emergency admission for resuscitation, transfusion, and endoscopy.

Capacity — the Central Principle

●Under the Mental Capacity Act 2005, capacity is presumed and is decision-specific: can the person understand, retain, weigh, and communicate the decision? Crucially, an unwise decision is not evidence of incapacity. A capacitous adult has the right to refuse even life-saving treatment, and that refusal must be respected.

Explore Why — Refusal Usually Has a Reason

●A flat refusal almost always has a reason behind it. Here it is a previous endoscopy experienced as traumatic in a veteran with unprocessed military trauma. Asking why — rather than arguing — is what makes negotiation possible and is the pivotal skill in the consultation.

Negotiate the Middle Path

●The choice is not between full admission and nothing. Negotiate what the patient will accept: same-day face-to-face review, observations including postural blood pressure, examination, repeat bloods and group and save, a proton pump inhibitor, stopping NSAIDs, and consideration of iron replacement. Address the specific barrier — for example, discussing sedation or anaesthetic options and a trauma-informed approach with the endoscopy service.

Exclude Mental Illness as the Driver

●Sensitively distinguish an informed, capacitous refusal from a decision driven by depression, hopelessness, or a wish to come to harm — the management differs entirely.

Document Meticulously

●Record the results, the risks explained (including death), the recommendation made, the capacity assessment and its basis, the patient's informed refusal, the alternative plan agreed, the safety-netting given, and that the patient may change their mind at any time. This is both good clinical practice and essential medicolegal protection.

Safety-Net, Support, and Keep the Door Open

●Provide explicit safety-netting (haematemesis, worsening melaena, collapse, breathlessness at rest → 999), involve a neighbour or other contact, offer veteran-specific mental-health support (Op COURAGE, Combat Stress, SSAFA) and alcohol services, arrange proactive follow-up, and make clear the door remains open.

Common Candidate Mistakes in This Case

●Attempting to coerce or override him: including wrongly invoking capacity or mental-health legislation to force admission.
●Never asking why he is refusing: arguing against the refusal instead of exploring it, so nothing changes.
●Accepting a flat refusal with no alternative: leaving an actively bleeding patient with no assessment, treatment, or plan.
●Failing to document the capacity assessment and informed refusal: a serious medicolegal omission.
●Ignoring the trauma, alcohol, and veteran dimensions: missing both the reason for the refusal and the support that might change it.

Free MRCGP SCA practice case for GP registrars covering Haemoglobin of 70 Refusing Hospital Admission — Urgent & Unscheduled care. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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