GP Cases 2005-2010
Management of anticoagulation therapy.
In June 2011 the HDC released a decision following the death of a 25 year old man. The young man had an aortic valve replacement at the age of 22, and needed to be on an ongoing anticoagulant regime.
The young man did not always attend the clinic for his blood tests and would miss taking his warfarin from time to time. His INR results fluctuated and it was found that the clinic took steps to try to ensure that he did attend and advise him to take his medication. The HDC found that the management of the INR levels and beta blocker use were not in breach of the Code.
However, the young man’s GP was found to be in breach. The Commissioner considered that the young man should have had 6 monthly health checks. The GP could not establish that these had occurred, and that when the young man did attend the surgery, the notes did not record any physical examination, in particular the heart rate and blood pressure checks, check for oedema, and auscultation of heart sounds and lung fields.
The GP asserted that the records did not accurately reflect the reviews that he had actually undertaken, given that the young man would often attend the clinic opportunistically, which would then mean that he would see the patient in the nurse’s rooms. He also thought that the Patient Management System (MedTech) was not always reliable, especially if other users were using the system at the same time. He also asserted that he made handwritten notes on occasion, which may have been lost. However the GP was not helped by the fact that he provided conflicting explanations as to what had occurred, which would have affected the Commissioner’s view as to the GP’s credibility. The Commissioner found that many of the documentation shortcomings were within the GP’s control, and should have been avoided
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Decision of the Health Practitioners Disciplinary Tribunal 50/Med06/28D
Dr S, a GP, was charged with failing to undertake and/or record an adequate assessment of a patient on 4 occasions. The patient attended with a bloated stomach and abdominal discomfort. The patient failed to improve over the 4 consultations (over 5 months) and ultimately she underwent surgery and a 14.7kg mucinous cystadenocarcinoma of the ovary was removed. The Tribunal was clear that the charges did not relate to a failure to diagnose the cyst; the focus was on the inadequate examinations and steps taken by the doctor when consulted.
The doctor was successful in his application for name suppression, but was censured, had a condition imposed on his practice, and was required to pay $22,500 towards the cost of the proceeding.
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Decision of the Health Practitioners Disciplinary Tribunal Med05/08P
Dr Brock-Smith, a GP, appear to have come under the control of a drug addict, Mr A, and consequently provided Mr A with controlled drugs. Mr A was subject to a Restriction Notice due to his addiction, which prohibited every medical practitioners from prescribing or supplying him with controlled drugs, except for prescriptions/ supplies associated with an Alcohol and Drug clinic.
Dr Brock- Smith was interested in ADHD in adults, and believed he could help Mr A. He began dispensing Ritalin to Mr A in the belief that if he did so, Mr A would not need methadone.
Dr Brock-Smith subsequently moved to a new town, but Mr A found him and asked the doctor to be his GP. Dr Brock-Smith refused, but said he would be his medical support person. Mr A attended the surgery and demanded drugs. Dr Brock-Smith succumbed to the pressure and providing him with morphine sulphate tablets. Dr Brock-Smith subsequently obtained a trespass order against Mr A, but provided more medication. He went on to write a script for diazepam and temazepam in another’s name to get around the Restriction Notice on two occasions. He also gave diazepam directly to Mr A without prescription.
Dr Brock-Smith was censured, fined $7,000, was required to pay 30% of the cost of the proceedings, and significant conditions were imposed on his practice, including a course which focussed on dealing with difficult and assertive patients.
Decision of the Health Practitioners Disciplinary Tribunal 8/Med04/03P
Dr Nuttal (Dr N) offered a couple marital counselling, although he had no training or experience in this field. A sexual relationship developed between Dr N and the wife. Dr N also continued to treat her children during the years of the relationship. Dr N claimed that he had ended the doctor-patient relationship with the wife prior to the sexual relationship’s commencement, but the records did not bear him out. The sexual relationship continued for 5 years, at which point Dr N left his wife and family, and the relationship ceased to be a secret.
As to the sexual relationship the Tribunal considered this to be gross negligence, malpractice and that it brought the profession into disrepute. The same applied to Dr N’ continuing to treat the woman and her children. The doctors records of consultations with the woman were considered very poor, so that this too constituted negligence.
Dr N’s registration as a medical practitioner was cancelled, and he was required to undergo an assessment for applying to re-register. A comparatively modest order of costs was made due to the doctor’s financial circumstances.
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Decision of the Health Practitioners Disciplinary Tribunal Med06/29P
Dr Keshvara had a long standing history of opioids and alcohol dependence. Dr Keshvara forged the signature of another practitioner on a prescription form to enable him to obtain DHC (Dihydrocodeine Tartrate) for his own use from a pharmacy.
Dr Keshvara had a history of charges being brought against him in relation to offences related to his dependency. On this occasion he was suspended for 12 months. The Tribunal further imposed 11 conditions for a period of three years. The Tribunal also ordered that Dr Keshvara pay 1/3 of the costs of the proceeding and that a summary of the decision be published in the New Zealand Medical Journal.
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Decision of the Health Practitioners Disciplinary Tribunal Med06/33D
The Tribunal considered Dr Johri, a GP, i should have been alert to the possibility that his patient was suffering an aggressive form of breast cancer and that it was essential that she be carefully monitored.
The parties accepted breast cancer in pregnancy is particularly aggressive and needs urgent management. The Tribunal considered it was incumbent on Dr Johri to arrange for a referral to a specialist once he appreciated that the lump had not completely disappeared in response to antibiotic treatment. Dr Johri should have alerted the patient’s midwife and made sure her progress was monitored. If there had been a subsenquent appointment made which the patient did not attend then Dr Johri should have left no stone unturned and made sure that the patient was again seen and examined.
The Tribunal was satisfied Dr Johri’s acts and omissions were a serious departure from the standards ordinarily expected of a general practitioner in his circumstances and that they constituted negligence. The Tribunal ordered that Dr Johri be censured, that he should pay 30% of the costs of the Proceeding and that a summary of the hearing be published in the New Zealand Medical Journal.
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Decision of the Health Practitioners Disciplinary Tribunal Med06/36D
Dr Patel was a GP. For 7 months he had a sexual relationship with Mrs X, his patient. For the same period he failed to provide health services with reasonable care and skill to your patient; in particular:
- He failed to take appropriate steps to immediately terminate the relationship; and failed to take appropriate steps to immediately refer the patient to another medical practitioner; and/or
- Continued to treat the patient whilst having a sexual relationship with her; that treatment including ongoing care/management of a psychiatric illness.
The Tribunal ordered that:
- Dr Patel be suspended from practice for a period of 2 years;
- During the currency of Dr Patel’s suspension he was to undertake the Medical Council’s Sexual Misconduct Assessment (SMAT) and to undertake such treatments and conditions as the Medical Council may impose upon him as a result of this programme;
- Once Dr Patel’s suspension was lifted Dr Patel was to comply with such conditions as the Medical Council may impose upon him relating to the treatments and conditions ordered by SMAT;
- During the currency of the suspension, Dr Patel is to maintain and to continue to participate in an approved recertification programme relevant to the scope of general practice;
- Dr Patel be fined $10,000;
- Dr Patel be censured;
- Dr Patel pay 50% of the costs of the hearing and prosecution; and
- The Executive Officer arrange for publication of a summary of the decision in the New Zealand Medical Journal.
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Decision of the Health Practitioners Disciplinary Tribunal 58/Med05/15D
Dr Martin (Dr M) was the GP for a patient with longstanding constipation issues. Dr M failed to address the possibility that the patient’s symptoms could indicate a problem more serious than Irritable Bowel Syndrome. This was despite the fact that another practitioner discussed with Dr M the possibility that cancer should be excluded. The patient developed bowel cancer which was only discovered at an advanced stage and she died less than 2 months after being diagnosed at the age of 43.
Dr M was accused of having altered her notes relating to the patient, and that they were deficient in their original form. She was also accused of having misled the HDC in respect of her changes to the notes.
Dr M was found guilty of negligence and professional misconduct in respect of her care of the patient, and her note keeping. The charge that she had misled the HDC was considered the most culpable misconduct. She was censured, fined $10,000 in respect of misleading the HDC, and $5,000 in respect of the other charges. She was also required to pay $20,000 for the costs of the proceeding. On appeal to the High Court the fines were reduced to $7,000 and $3,000 respectively.
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Decision of the Health Practitioners Disciplinary Tribunal 56/Med05/27Med06/32D
Dr Wilson (Dr W) was approached by a patient wanting a vasectomy. During their discussion Dr W failed to explain that a vasectomy is not regarded as successful until there has been a nil sperm count. No consent form was completed. Dr W performed a “pinhole” vasectomy during which he failed to cauterise or ligate the severed ends of the vas or to send a vas specimen to a laboratory for histological analysis. The patient completed two sperm specimens, both of which indicated that the vasectomy had been unsuccessful, but the doctor failed to inform the patient. The patient’s wife became pregnant. The doctor offered to perform another vasectomy free of charge. The child was born placing a huge financial strain on the couple. The doctor performed an open vasectomy but again failed to cauterise or ligate the severed ends of the vas. In addition he used suture needles as a modified clip to both inferior stumps. He failed to resect the vas and to send a specimen to the lab. He failed to remove the sutures post-operation and 7 months later they came out of the skin and caused an infection. Again the sperm counts indicated that the vasectomy had failed, and the doctor failed to advise the patient after 4 sperm tests indicated that this was the case. The patients’ wife became pregnant again and despite deeply held beliefs opposing termination the couple decided they would have the termination. The doctor apologised profusely for what had occurred and offered to pay the cost of termination. The patient underwent a third vasectomy with another doctor, which was successful.
Another patient had a similar experience with Dr W where Dr W failed to explain that a vasectomy is not regarded as successful until there has been a nil sperm count, and performed the vasectomy where he failed to resect the vas or to send a specimen to the lab. This patient’s wife also became pregnant after the operation.
Dr W was found guilty of professional misconduct , and was censured, the decision was published by the New Zealand Medical Journal, he was fined $1,000 (the offers of payment to the first family were taken into account), 25% of the costs of the proceeding, and a condition on Dr W’s practice was imposed: that he not undertake any more vasectomy procedures for 3 years.
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Failure to diagnose and inaccurate record keeping
This case was about a general practitioner, Dr A, who failed to diagnose colorectal cancer in his patient. The patient was seen by Dr A and was diagnosed with iron deficiency in November 2007, for which iron supplements were prescribed. There was no evidence of Dr A having carried out an abdominal or rectal examination on the patient, nor were tests ordered to investigate the cause of the patient’s anaemia. Further, on two occasions throughout 2008 Dr A diagnosed the patient with gastritis without carrying out an abdominal examination.
The patient sought a second opinion from another GP, who immediately arranged a CT scan and further blood tests upon identifying a swollen liver. The CT scan revealed a primary tumour in the patient’s caecum and secondary cancer in her liver. She was immediately referred to the oncology team at a public hospital where chemotherapy commenced. The patient was diagnosed with stage IV colorectal carcinoma for which she received palliative care. She has since passed away.
HDC decision
Dr A, while he treated the symptoms for anaemia, did not undertake appropriate investigations to determine the cause of the anaemia. The Commissioner found that Dr A should have carried out an abdominal and rectal examination on the patient, and should have requested a number of lab tests. Further, he should have referred the patient for a gastroscopy when she presented with upper gastrointestinal tract symptoms and anaemia. Given this, the Commissioner found that Dr A breached a number of the patient’s rights:
- Rights 4(1) and 4(4) for failing to appropriately investigate and manage the patient’s iron deficiency anaemia;
- Rights 4(1) and 4(4) for failing to examine the patient’s abdomen prior to diagnosing gastritis; and
- Rights 4(2) for failing to meet professional standards in terms of documentation.
A patient has the right to receive services of an appropriate standard by his or her doctor. This includes not only receiving treatment for symptoms, but also having symptoms investigated appropriately so as to find the underlying cause. In this particular case, iron deficiency anaemia is not a disease but a symptom of an underlying condition, the cause of which needs to be identified and, if possible, treated. Further, patients presenting with upper gastrointestinal tract symptoms and anaemia should be referred for a gastroscopy. Appropriate investigation and management of iron deficiency anaemia is within the scope of a competent GP and the HDC held that the patient’s safety was compromised by her GP’s failure to get the basics right.
Use of “hot keys” in general practice
The “hot key” function is commonly used in general practice – it enables a word, phrase, or list to be inserted into patient notes quickly by activation of one or more keys. The HDC commented on the use of “hot keys” in general practice, noting Dr A’s frequent use of the function when recording the patient’s notes. In Dr A’s case, there were three phrases that appeared on nine, eight and two separate occasions, identical in both spelling and format. The patient disputed some of the notes’ contents, leading to the view that Dr A failed to accurately record the activity that took place during some of the patient’s consultations. Consequently, he was found in breach of the professional standards expected of him for documentation.
HDC recommendations
In light of the breaches, the HDC made the recommendation that Dr A undergo additional training on clinical documentation and familiarise himself with the contents of “Guidelines for the management of iron deficiency anaemia”
The Commissioner also reiterated the importance of ensuring that patient records accurately reflect the care provided at each consultation and that examination findings are recorded as well as clearly identifying who the service provider is.
Dr A was also referred to the Director of Proceedings for the purpose of deciding whether any proceedings should be taken. The Director has since decided to issue proceedings.
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Communication of significance of PSA test, and loss of referral
Mr C (70) had an elevated PSA test in 2006. His GP, Dr B, asked for a repeat 3 months later but did not explain the significance of the test or the importance of the follow up, and it did not get repeated. One year later he saw Dr B abour blood in his urine and had another PSA test which was further elevated. Dr B referred him to the DHB which “lost” the referral for 6 weeks. Mr C was then told there would be a 4 – 6 week waiting time, which was actually 4 – 6 months. In October 2007 Mr C was diagnosed with prostate cancer which had spread.
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Diagnosis of cardiac problem
Mr B arrived at an accident and medical clinic complaining of bad indigestion. The triage nurse gave him an ECG and passed him on to the duty doctor. Two ECG traces were taken but Dr A only looked at one, which showed mild cardiac involvement. He sent Mr B to the hospital in his own car for a non urgent appointment. At the hospital it was discovered that he had suffered an MI.
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GP management of elderly patient over eight-year period
Dr C was Mrs A’s GP for approximately eight years until her death in 2003. She had multiple conditions and consulted Dr C frequently. From late 2002 Mrs A’s family noticed her weight loss, tiredness and lack of appetite. Some blood test results that year, and subsequent ones in 2003 were abnormal. In June 2003 a liver ultrasound showed a mass, which was diagnosed in a liver biopsy a month later as advanced cancer in the liver. She as referred fro palliative care and given a letter about Iscador, an alternative treatment using mistletoe extracts, and died later that year.
Mrs C’s son complained about Dr C’s care, querying whether his mother’s cancer could have been diagnosed and treated earlier.
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Inappropriate prescription of medication to partner
Mrs A began a de facto relationship with Dr B. He was not her GP at first, but after they began living together he diagnosed her with depression and began prescribing Aropax, Paradex and other medication. During the de facto relationship, which lasted about three and a half years, she consulted no other GP and consulted a psychologist once. Dr B kept no written records of his treatment of her. Mrs A claimed that Dr B added the Paradex and other medications to her scripts for his own use.
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A Retirement Facility
Mrs A suffered a severe left-sided CVA which left her with little overall movement and limited control of her upper body. Following admissions to two hospitals she was transferred to a retirement facility for six weeks, where she experienced weight loss of approximately 10 kilograms and developed a bed sore that required surgical removal of the dead tissue.
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Care and treatment of ongoing sore throat with unusual clinical presentation
A man presented seven times to six doctors over a period of a month with an ongoing sore throat of unusual clinical presentation. He was diagnosed and treated for tonsillitis but continued to feel unwell. Following his seventh visit he was admitted to hospital where a rare form of T-cell lymphoma was diagnosed. The man died a short time later.
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Monitoring of deteriorating chest infection in an elderly resident of an aged care facility
An 86 year old woman developed a cough after transfer to an aged care facility. After three weeks she developed a cough and was prescribed cough elixir by the visiting GP. Nine days later it had worsened and the doctor ordered blood tests and instructed the staff to provide her with analgesics and adequate fluid. The following week the woman’s condition had deteriorated further. The GP ordered a chest X-ray and commenced her on antibiotics. The X-ray confirmed she had bronchopneumonia. Her condition continued to deteriorate on the same medication, and four days later the GP admitted her to hospital. On discharge she did not go back to the same aged care facility.
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Prescription of an anti-emetic to a six-month-old baby
A locum GP prescribed three different antibiotics and a 3mg dosage of Maxalon to a six-month-old baby with diarrhoea, eczema, irritability and an itchy rash. The pharmacist dispensed the medication in tablet form but provided 5mg instead of 3mg, then did not include dosage frequency on the retyped label. The baby vomited after the first dose of Maxalon, was given more two hours later, then experienced an overdose reaction and required hospital treatment.
The locum GP should have known that it was inappropriate to prescribe Maxalon and should not have over-prescribed antibiotics, and breached Right 4(1).
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Summary of recent HDC GP Cases
Three quarters of breaches involved a failure to provide services of an appropriate standard (Right 4). Inadequate record keeping was the most commonly cited failure by GPs. This involved lack of detail in clinical notes, inadequate reference to previous patient records, as well as unsatisfactory transfer of records between carers. Doctors never work in a vacuum; the responsibility to communicate clearly with other health professionals and with one’s patients was highlighted. Inadequate explanations to patients and their families of medications and their side effects, abnormal test results and their significance, and of the need for follow up tests, made up almost one quarter of breaches (Right 6 – the right to be fully informed.)
• 4(1) – Every consumer has the right to have services provided with reasonable care and skill.
• 4(2) – Every consumer has the right to have services provided that comply with legal, professional, ethical and other relevant standards.
• 4(5) – Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
• 6(1) – Every consumer has the right to the information that a reasonable consumer, in that consumer’s circumstances, would expect to receive, including:
• (a) – An explanation of his or her condition; and
• (b) – An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option; and
• (c) – Advice of the estimated time within which the services will be provided; and
• (d) – Notification of any proposed participation in teaching or research, including whether the research requires and has received ethical approval; and
• (e) – Any other information required by legal, professional, ethical, and other relevant standards; and
• (f) – The results of tests; and
• (g) – The results of procedures.
Whilst they constitute the elements of good medical practice, we have listed below the lessons to be taken from these cases as a reminder of where problems can arise.
Record Keeping
• Make sure all clinical records are clear, accurate and full.
• Record patient’s symptoms, signs and examination findings
• Document your reasons for ordering tests.
• Document your discussions with the patient and with the family
• Make sure clinical records of casual patients are transferred to their own doctor to ensure continuity of care.
• Keep accurate and consistent records regarding allergies/sensitivities. Make sure they are readily accessible to all practitioners treating the patient.
• Always put allergy/sensitivity information on admission form, never just “refer to …(another document)”
• Always refer to previous clinical records.
• Make sure you are familiar with all your clinic’s policies and procedures.
Concerning the Patients
• Explain abnormal results to patients. Make sure they understand their significance and that of follow-up instructions.
• Provide adequate information about various treatment options
• Respond promptly and sensitively to requests for information from patient and family.
• Always provide sufficient information about risks of medications to parents/patients.
• Always investigate further in an unusual clinical presentation.
• Devise a specific follow-up plan for ongoing symptoms.
• Always respond to complaints in a timely manner.
Concerning Rest Homes
• As a key part of a multidisciplinary rest home team you have a responsibility to ensure the team works cohesively and that proper standards are maintained, to ensure appropriate care can be delivered.
• Be proactive about reviewing rest home patients whose conditions deteriorate.
• Instruct nurses to update you on any failure of the patient to improve after prescribing medication.
Concerning Yourself
• Do not self-prescribe, or treat family members or those close to you without the overall management of an independent practitioner.
• Work within your competence. If working as a locum under supervision, insist that your supervision is satisfactory.
