Communication OSCE stations

Preparation prior to discussion

I would ensure:

• Any immediate patient safety concerns are addressed.
• The department is safe (handed over to a colleague).
• Information gathering had occurred (eg, review of notes, ideally see patient yourself).
• Quiet, private location.
• Senior member of nursing staff present.

Introduction and acknowledgment of problem

“Hello, my name is Dr Smith, I am one of the Senior Doctors working in the Emergency Department today.”

“Can I just confirm your name and whose relative you are?”

“I have been told you have concerns you would like to discuss, shall we move to somewhere more private to do this?”

“Before we start, shall we sit down, and is there anything I can get you? Do you need any pain relief or a drink (situation dependent)?”

Problem

“Please can you tell me what you are concerned and unhappy about?”

Acknowledge concerns

“Thank you for informing me of this.”

“Let me just summarise what you have said so I can ensure I understand your concerns.”

Apologise

“I am sorry this has been so upsetting. I want to understand what has happened and help put things right.”

If an error is known, acknowledge it and apologise directly. Explain what you know and what still needs to be clarified; avoid speculation or blaming others.

Plan

First, address care now.

“I would like to assess you, make sure you are comfortable and review your results. We can then agree the next steps together.”

For a relative’s concern, assess the patient and check what information they have agreed can be shared.

Then explain what happens next.

“I will share these concerns with the appropriate senior team and explain how they will be followed up. We will agree who will keep you updated.”

Record a patient safety incident where appropriate and follow the local response plan. Explain the learning process without promising a particular investigation, outcome or that an event can never recur.

Closure

“Have we addressed your main concerns? Is there anything else you would like to discuss?”

“If you want advice or help raising this further, I can give you the contact details for the Patient Advice and Liaison Service (PALS) and the complaints team.”

“Thank you for raising this with me.”

Confirm the agreed plan, contact person and next update.

Complaints procedure

For NHS services in England, immediate concerns can often be discussed with the care team or PALS. Patients can also use the formal complaints process; reporting a safety incident does not replace responding to their complaint.

• Acknowledge a formal complaint and offer a discussion about handling it within 3 working days.
• Agree the likely response timescale. There is no universal 30-day deadline; explain delays and keep the person informed.
• Follow the organisation’s complaints process. If dissatisfied after the local process, explain the route to the Parliamentary and Health Service Ombudsman.

Reference: NHS England — feedback and complaints.

Patient safety incident response: PSIRF

In England, the Patient Safety Incident Response Framework (PSIRF) has replaced the Serious Incident Framework and its “serious incident” threshold.

• Address immediate risks and report the event through the local system.
• Involve and support the patient, family and staff.
• Use the organisation’s response policy and plan to select a proportionate learning response.
• Agree communication and timescales; do not apply the old fixed SIRI/RCA timetable.

Reference: NHS England — PSIRF.

Duty of Candour

The professional duty is to be open and honest when care goes wrong and causes, or could cause, harm or distress: explain what happened, apologise, offer support or a remedy where possible, and explain the consequences.

The provider’s statutory duty is separate. In England, Regulation 20 includes specific requirements for notifiable safety incidents, including notification, support, records and written follow-up. Follow your organisation’s policy; legal arrangements differ across the UK.

GMC professional duty of candour · CQC Regulation 20

Example scenarios

• Long wait to be seen
• Missed fracture/diagnosis management
• Parents/caregivers or patient requesting CT head post minor head injury

Preparation prior to discussion

I would ensure:

• Any immediate patient safety concerns were addressed.
• The department is safe (handed over to a colleague).
• Information gathering had occurred (eg, review of notes, ideally see patient yourself if a previous attempt to refer has not been successful).
• Quiet, private location.
• Senior member of nursing staff present.

Introduction and acknowledgment of problem

“Hello, my name is Dr Smith, I am one of the Senior Doctors working in the Emergency Department today.”

“Can I just confirm your name and whose relative you are?”

“I have been told you have concerns you would like to discuss, shall we move to somewhere more private to do this?”

“Before we start, shall we sit down, and is there anything I can get you? Do you need any pain relief or a drink (situation dependent)?”

Problem

“Please can you tell me what you are concerned and unhappy about?”

Acknowledge concerns

“Thank you for informing me of this.”

“Let me just summarise what you have said so I can ensure I understand your concerns.”

Apologise

“I am sorry this has been so upsetting. I want to understand what has happened and help put things right.”

If an error is known, acknowledge it and apologise directly. Explain what you know and what still needs to be clarified; avoid speculation or blaming others.

Plan

Consider the following where appropriate:

• Acknowledge concerns/frustrations
• Explain reasons of doing/not doing something
• Explore particular concerns
• Offer a second opinion
• If a condition: time frame, how to manage
• Safety net
• Try and agree plan

Closure

Just to summarise,

“Your concerns were…”

“We have discussed that…”

“Our plan is… including safety net and online resources”

“Do you feel I have addressed your concerns, or do you have any further questions?”

Example scenarios

• Request for antimicrobials
• Tick bite, requesting antibiotics
• Refusing tetanus
• Giving DVLA advice

Preparation prior to discussion

I would ensure:

• Any immediate patient safety concerns were addressed.
• The department is safe (handed over to a colleague).
• Information gathering had occurred (eg, review of notes, ideally see patient yourself if a previous attempt to refer has not been successful).
• Quiet, private location.
• Senior member of nursing staff present.

Introduction and reason for the call

“Hello, I’m Dr Smith, one of the ED registrars. Can I confirm your name and role? I need to discuss a patient who requires your team’s input. Is now a safe time to talk?”

State the urgency immediately if the patient is unstable; do not allow politeness to obscure the need for urgent help.

Outline Case

Use SBAR (Situation; Background; Assessment; Recommendations):

S: I have Mr Jones with…

B: The background is this…

A: Having just seen the patient I am concerned that…

R: Which is why I feel referral under your team is appropriate

Listen

• Listen to their concerns

Acknowledge their concerns

Acknowledge the other team’s workload or concerns. Apologise for a specific communication problem if appropriate, while keeping the current patient’s needs central.

Restate the concern and offer help

“I am concerned about… I do not think this patient is safe to discharge or remain in this setting, and I would appreciate your assessment.”

“Is there anything clinically indicated that we can arrange while you come to see the patient?”

Agree investigations on clinical grounds, rather than ordering a CT or MRI simply to secure acceptance of a referral.

Plan of action

Successful:

“Ok many thanks…”

“Do you have a rough time frame for when you may be able to make it down?”

Unsuccessful:

“I don’t think we are making progress here, what I’ll do is I will chat to my Consultant and ask them to ring either you or your Consultant directly, does that sound reasonable?”

Close

“Thank you for your time.“

Document the time, names, agreed responsibilities, review timeframe and escalation plan. Escalate immediately if the patient deteriorates.

Example scenarios

• 'Social admission'
• Confusion about admission pathways (cardiology or medicine; orthopaedics or spinal; etc)

The approach will vary depending on the information given in the vignette. If the person has come to you directly or is clearly upset then your approach may be more direct than the one given below.

Preparation prior to discussion

I would ensure:

• Any immediate patient safety concerns were addressed
• Department is safe (handed over to a colleague)
• Information gathering (including review of clinical work done to date and any other patients seen during the time frame of concern)
• Another member of staff is present take notes (situation dependent)

Introduction and opening question

“Hi, I’m Dr Smith, one of the Senior Emergency Doctors on today.”

“I don’t think we’ve met properly before, what’s your name?”

“I was wondering if we could have a chat, shall we go to the office and have a cup of tea?”

“I just wanted to check if you are ok?”

Explore

Says NO – explore further

Says YES – “I just wanted to ask you because…”

• LISTEN

Probe for examples

INTOXICATION: one off? Do they think its a problem? Plans to address?

LIFE: money; unwell relatives; marriage upset

DIFFICULT COLLEAGUE/CASE

Acknowledge and support

“I’m sorry you feel like this/that this has happened”

“Is there anything I can do to help?“

Plan of action

Safety first. If impairment may put patients at risk, arrange prompt senior help, remove the colleague from clinical duties while assessed, and review potentially affected patients. Do not wait for their permission to address an immediate safety concern.

“My priority is to keep you and our patients safe. Let us arrange the right support and work out what needs to happen next.”

• Consider urgent clinical assessment if they are acutely unwell or intoxicated. Arrange safe transport if leaving; an impaired person should not drive.
• Explain who needs to know and why. Share only necessary information, and protect privacy as far as possible without promising absolute confidentiality.
• Agree practical support through the responsible senior, occupational health and, where relevant, educational supervisor. Discuss rota arrangements without promising cover you cannot guarantee.
• Agree follow-up and offer time to reflect and discuss the situation once the immediate concerns are addressed.

Reference: GMC professional standards and raising patient safety concerns.

Close

“Does all that sound reasonable?”

“Do you have any other questions or is there anything else I can do to help?”

Example scenarios

• Intoxicated colleague.
• Bullying (either being bullied or accused of).
• Failing/distressed trainee.

Preparation prior to discussion

I would ensure I had:

• ensure the department is safe and handed over control of the department to a senior.
• arranged cover for urgent calls so the conversation can proceed with minimal interruption.
• read the patient's notes.
• understood diagnosis, immediate and longer term management.
• member of nursing staff present to support patient privacy.

Introduction

"Hello my name is Dr Smith, I am one of the senior ED doctors working today."

"Can you confirm for me your name and date of birth please?"

"Are you comfortable? Do you need any pain killers?"

Reason for conversation

“I have come to talk to you about what’s brought you into hospital and what we think is going on. Would that be ok with you?”

“Do you want someone else with you?”

Clarify history

“Can you briefly tell me what’s brought you to hospital?”

Current understanding

“Do you have any ideas about what is going on?”

Explain Diagnosis

“The tests suggest X. What have you heard about that before?”

Explain the diagnosis, or remaining uncertainty, in short chunks and plain language. Give a warning phrase if the news is unexpected, then allow time and silence.

“The immediate plan is Y. I will explain what we know, what we still need to find out and who will support you next.”

Explore questions and the effect on the person’s life. Discuss relevant treatment, resources and lifestyle changes without giving blanket reassurance about the prognosis.

Close

“To check I have explained this clearly, could you tell me what you understand about the diagnosis and the next steps?”

• Invite questions and correct misunderstandings.
• Give suitable written information and reliable resources.
• Confirm the responsible team, follow-up and specific safety-net advice.
• For a child or young person, involve parents or carers appropriately, taking account of capacity/competence, confidentiality and safeguarding.

Example scenarios

• Anaphylaxis
• Type 1 Diabetes
• Atrial fibrillation
• Malignancy

Preparation prior to discussion

I would ensure I had:

• ensure department is safe – handed over control of department to a senior.
• arranged cover for urgent calls so the conversation can proceed with minimal interruption.
• fully aware of the details of the patient's case.
• member of nursing staff present to support them.

Introduction

"Hello my name is Dr Smith, I am one of the senior Emergency Doctors working today."

"Can I just confirm your name; whose relative you are and your relationship to them? May I call you…”

"Is there any one else coming or anyone else you want with you?“

"Before we start can I offer you a drink or anything else?“

Confirm relative's knowledge of events

“I’m really sorry you are here today. What is your understanding of the events that brought your loved one to hospital today?“

Break the news

Briefly explain the sequence of events, then give a clear warning phrase and use the person’s name.

“I am very sorry. I have some very sad news. [Name] has died.”

Pause. Allow silence and respond to the family’s reaction; counting slowly to ten can help you avoid rushing in. Check gently what they have understood and invite questions.

Use this wording only after death has been confirmed. A discussion about a patient who is still alive but may die is a separate prognosis conversation: explain the specialist assessment, uncertainty and care plan without presenting a prediction as a confirmed death.

Support/after care

“Is there anyone you would like us to contact? Would support from a faith representative or someone else be helpful?”

Offer the opportunity to see their relative when appropriate and explain gently what to expect. Provide bereavement support and practical information at a pace they can manage.

If donation may be possible, involve the consultant and specialist nurse for organ donation early. Plan any approach together, with sensitivity to the family’s understanding and circumstances; it should not be a routine, unplanned question inserted into the initial death notification.

Reference: NICE CG135 — planning the approach to families.

Plan

“We can give you some time now. [Name and role] will stay with you and explain the next steps when you feel ready.”

“I am very sorry for your loss. Please let us know any questions, however small.”

Give a clear contact route and arrange continuity when you leave, rather than promising personal availability you cannot provide.

Example scenarios

• Adult or paediatric death
• Sudden unexpected death in infancy and childhood: follow the local joint-agency response pathway
• Organ donation

RCPath/RCPCH multi-agency SUDI/C guidance (2016) remains a reference alongside child death review guidance for England and local procedures.

A colleague may hand over several patients, with questions about management, discharge advice or learning needs. Establish the most urgent concern first and make safe decisions in a supportive way. Time passes quickly: keep each patient’s plan explicit.

Introduction

“Hi I’m Dr Smith the ED Doctor running CDU today.”

“I believe you have some patients to hand over to me?”

“What is your name and grade/previous experience?”

“Before we start I just want to make sure the rest of the department is safe and that there are no patient safety concerns.”

“Is there anything from an educational perspective you would like to discuss or do as an assessment?”

Cases

“So shall we start?”

“Is there anyone you are worried about or want to discuss first?”

Technique pointers:

• Allow an uninterrupted account unless an urgent safety concern requires you to intervene.
• Ask further questions as you feel indicated (eg. how the patient is now with results of any investigations).
• If you feel:
  • further investigation or management is needed try and explore this with the junior to ascertain their understanding.
  • a learning need has been highlighted explore this with the junior and offer resources to support learning.

“So, in summary we have:”

Summarise the ongoing plan for each patient, particularly the safety net instructions/resources for any patients going home.

Close

Thank your colleague for their work

“We can discuss more formally as a workplace-based assessment if you would like?”

Example scenarios

Presenting complaint	A point to explore
Head injury	Does the patient meet current CT criteria?
Older person with abdominal pain	Has aortic aneurysm been considered where clinically relevant?
Young person with abdominal pain	Could pregnancy be relevant, and has it been assessed?
First seizure	Driving advice, safety-netting and follow-up.

Major incidents are uncommon but suit structured communication and leadership stations. Know your local emergency preparedness, resilience and response (EPRR) plan and current NHS England major-incident guidance.

Definition

A major incident has serious consequences that require special arrangements by one or more emergency responder agencies. It is not defined by casualty numbers alone. Declare and communicate the incident according to your organisation’s plan and authority.

Reference: JESIP joint doctrine.

Examples

• Sudden onset (“big bang”): an explosion or transport incident.
• Developing (“rising tide”): an infectious disease outbreak or sustained service pressure.
• Anticipated threat (“cloud on the horizon”): a foreseeable hazard requiring preparation.
• Planned event: a large public gathering requiring advance contingency arrangements. A planned event is not automatically a declared major incident.

Categorisation

Be clear whether the local plan is on standby, a major incident has been declared, or arrangements are being stood down. Follow local terminology for cancelling an alert and keep staff informed of changes.

Command Structure

• Strategic (Gold): sets the overall objectives and strategy.
• Tactical (Silver): coordinates how that strategy is delivered.
• Operational (Bronze): carries out and manages actions within allocated areas.

Roles, reporting lines and locations depend on the local plan. Confirm your assigned role and contact arrangements; do not assume that being the senior ED doctor automatically makes you Bronze commander.

METHANE report

Prompt	Information to communicate
M	Major incident declared?
E	Exact location
T	Type of incident
H	Hazards: present and potential
A	Access and egress routes
N	Number of casualties and severity of injuries
E	Emergency services present and required

Reference: JESIP M/ETHANE.

Triage

Update for England: the NHS Major Incident Triage Tool (MITT) replaces triage sieve, triage sort and the paediatric triage tape. It is a single tool for adult and paediatric casualties, used by NHS responders.

Ten Second Triage (TST) provides a rapid initial approach for responders, prioritising immediate lifesaving actions. Use the current official tools, training and local plan rather than memorising the old sieve/sort sequence.

Reference: NHS England — MITT and Ten Second Triage.

Triage priorities

Priority	Meaning
P1	Immediate
P2	Urgent
P3	Delayed

Use the official tool for the full algorithm and other labels. Reassess as circumstances change. These categories are not Revised Trauma Score cut-offs and do not automatically determine a hospital destination.

This station may begin with a pre-alert. Set out a structured response, adapted to the information given and your local plan. Think about the existing department as well as incoming casualties.

Introduction (to who has given you the initial alert)

"Hello, thank you for giving me that information. I’m Dr Smith, one of the senior doctors, can I just confirm your name and your role as I haven’t met you before.”

Information

“Have you received a METHANE report or any further information?”

Confirm the alert through the recognised route and establish reliable contact through the command structure. Verification should not delay necessary immediate protective action.

Instigate Major Incident Plan

Confirm and inform

• Activate the appropriate local plan and alert the ED consultant, nurse in charge, hospital/site command and switchboard using the designated route.
• Confirm whether the organisation is on standby or has declared a major incident, and record key decisions and times.

Brief the team

• Obtain the major-incident plan, action cards, equipment and designated communications.
• Maintain essential clinical cover while briefing staff. Share the METHANE report, priorities, assigned roles, command location and contact details.
• Allocate tabards and action cards, and confirm appropriate PPE. Arrange regular operational updates; plan a supportive debrief when operationally safe.

Staff

• Appoint appropriate senior clinical and nursing leads for triage and treatment areas. Match teams to casualty needs and available skills.
• Use the call-out cascade; retain capacity for relief and a prolonged response.
• Coordinate with porters, security and police as required. Manage access and crowds while maintaining safe emergency exits.
• Route media enquiries through the designated communications team.

Environment

• Establish triage and treatment areas using the current major-incident triage arrangements. Direct casualties to agreed pathways after assessment; do not automatically send all P3 patients away.
• If contamination is possible, protect staff and other patients and activate the appropriate decontamination plan.
• Review the waiting room, minors, majors, resuscitation and CDU. Arrange safe discharges or transfers with receiving teams.
• Reconfigure areas according to the plan, including family/survivor support and mortuary capacity as required.

Documentation

• Use designated major-incident identifiers and records, and maintain patient tracking and destination information.
• Document decisions, communications and outstanding actions; confirm that instructions have been understood.

The person may be a healthcare worker or a member of the public. Acknowledge the anxiety and promptly assess the exposure: prevention can be time critical.

Introduction

"Hello, I’m Dr Smith one of the senior Emergency Department Doctors working in the ED today."

"Can I confirm your name and date of birth please?

Problem

"Why have you come to the Emergency Department today? How can I help?"

History

• Injury: exact time, depth, hollow or solid needle, visible blood, procedure and first aid; consider mucosal or non-intact skin exposure.
• Recipient: hepatitis B vaccination and documented response, relevant conditions, medicines and pregnancy possibility where relevant.
• Source: known bloodborne infection, treatment and viral load if available. Base risk on the actual exposure and clinical information, not assumptions about identity.

Arrange appropriate source testing with consent through the responsible team; the injured worker should not seek that consent themselves.

Management

Immediate care

For a sharps wound, encourage gentle bleeding, wash with soap and running water, and cover with a waterproof dressing. Do not scrub or suck it. Seek urgent assessment and report the incident. HSE first-aid guidance.

Assess and explain the risk

Transmission risk varies with the exposure, the source’s infection status and the recipient’s immunity. Explain the individual assessment and arrange baseline tests under the local exposure pathway.

Prevention and follow-up

• HIV: use the BASHH risk assessment and obtain expert advice when needed. If PEP is indicated, start urgently—ideally within 24 hours and no later than 72 hours—and prescribe a 28-day course. Do not delay indicated PEP while awaiting source results.
• Following a sharps injury from a source with sustained viral suppression, PEP is generally not indicated. Check the guideline’s treatment, viral-load and adherence criteria, and seek specialist advice about the individual injury.
• Hepatitis B: vaccination and, where indicated, hepatitis B immunoglobulin depend on exposure, source status and documented immunity. Follow the current Green Book chapter 18.
• Hepatitis C: there is no PEP; arrange appropriate testing and follow-up.
• Arrange prompt occupational-health or appropriate clinical follow-up, a written testing plan, advice on preventing onward transmission and blood donation, and support for distress. Do not use a blanket six-month “all clear” date.

BASHH specifies a final HIV test at least 45 days after completing PEP; hepatitis follow-up depends on the exposure and immunity. Discuss side effects, adherence and how to seek help.

Reference: BASHH/BHIVA HIV PEP guideline (2021, amended 2023).

Close

“Do you have any other questions you want to ask?”

“Are you clear with the plan?”

Crowding is a whole-system patient-safety problem. Use RCEM’s current crowding guidance and the local escalation plan. PEWS BLIPS is a prompt for organising your response.

Patient Safety

Ascertain whether any immediate patient safety concerns. The nurse in charge (NIC) is often best person to ask.

If yes: allocate a senior to see immediately.

Escalate to Site Team

Escalate through the hospital/site team and local command structure, agree a whole-hospital response and request an update. Report harm or near misses through the local patient-safety system.

Walk around with Nurse in Charge

Identify pressure points and whether staffed, equipped and clinically appropriate space is available. Expansion must include safe monitoring, supervision and access to care.

Skill Mix

Are people currently working in their areas of strengths?

Change roles to help achieve priorities identified on the board round.

Consider whether staff can be pulled from other areas in the hospital to support.

Board Round with Nurse in Charge and Site Team

PRIORITIES, use team to:

1. Clear CDU as able.
2. Clarify plans for patients being seen.
3. Direct admit to specialities – if patient has a clear destination and is clinically stable.
4. Identify those likely to go home – ideally cohort in one place and assign senior.

Long stay patients (awaiting a bed)

Assign clear medical and nursing responsibility. Set review and observation frequency according to acuity, deterioration risk and the local monitoring pathway; do not rely on a fixed 2–4-hour interval for every patient.

• Review and administer time-critical medicines, including antibiotics, insulin and anti-seizure medicines where prescribed.
• Review investigations and act on results.
• Address pain, hydration, nutrition, toileting, pressure care and dignity.

Investigations that will help flow

Arrange clinically indicated investigations promptly—for example, head imaging according to NICE NG232 and hip imaging for suspected fracture. Do not order tests solely to accelerate flow or apply blanket imaging rules.

Patients

• Make sure all patients who need it have pain relief.
• Apologise for waits.
• Provide clear updates about waits and how to seek help if symptoms worsen, while protecting confidentiality.
• Offer food and fluids when clinically appropriate.

Staff

• Confirm they are aware of their roles.
• Ensure they all take their breaks fully.
• Support ambulance personnel who may be in the department.

These stations assess a meaningful conversation about treatment, guided by the GMC’s seven principles of decision making and consent. Procedural sedation for shoulder reduction is one example; tailor the discussion to this patient and the proposed procedure.

Introduction

“Hello, my name is Dr Smith, I am one of the Senior Emergency Doctors working in the Emergency Department today

“Can you confirm your name and date of birth please?”

“How is your pain currently? Do you need more pain relief?”

Check understanding

“Whats your understanding of what has happened to your shoulder?”

“Have you seen your x-ray and been told the results?”

“This is your x-ray, this is the shoulder joint and it shows it is out of joint currently.”

Management

“We need to discuss the options for getting your shoulder back into joint, how each might help and the risks that matter to you.”

Explain suitable analgesia and reduction options, which may include local or regional anaesthesia, inhaled analgesia, procedural sedation or theatre management depending on the circumstances. Discuss reasonable alternatives, including the consequences of declining or delaying treatment.

“What matters most to you about these options?”

Appropriate indication

Assess the patient, airway, relevant comorbidities, medicines, allergies, previous sedation problems, fasting and aspiration risk. Consider urgency, trained staff, monitoring, equipment, recovery arrangements and the safety of the rest of the department.

For an urgent ED procedure, fasting status informs an individual risk assessment; failure to meet elective fasting intervals does not automatically mean delay.

Reference: RCEM procedural sedation guideline (2022).

Informed consent sedation

“Sedation may make the procedure easier to tolerate. I will explain the medicines we propose, the benefits, the risks and how we monitor and support you.”

Discuss material risks for the patient, chosen drugs and procedure. These may include pain on injection, vomiting, low blood pressure, breathing problems, aspiration, or the need for airway or breathing support. Explain the safeguards and alternatives, using reliable risk estimates relevant to the proposed treatment and patient.

For reduction, explain the possibility of an unsuccessful attempt, injury such as fracture, and the need for further treatment or theatre.

Understanding

“Could you tell me in your own words what you understand about the options and the main risks? What questions do you have?”

Support a voluntary decision and allow time proportionate to the urgency. Presume adult capacity and assess it for this decision if there is reason for concern. Document the discussion and decision, including a refusal. A completed form records consent; it does not replace the conversation. Consent is ongoing and the patient can change their mind.