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Inadequate assessment and failure to document consultation (07HDC01315)

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(07HDC01315, 27 July 2007)

Medical officer in general practice ~ Pneumonia ~ Septic shock ~ Documentation ~ Examination ~ Assessment ~ Rights 4(1), 4(2)

A woman complained about the care provided to her 73-year-old mother by a medical officer (MO) in general practice. Her mother had been persuaded by her neighbour to visit the doctor, as she "looked really sick". The following day, the friend accompanied the woman to the consultation. The MO's assessment was cursory. He did not perform a blood pressure check or a full chest examination. He diagnosed flu, and sent her home with a prescription for paracetamol.

The woman's daughter visited her that evening as she was concerned about her mother's condition, and stayed overnight. However, the following day her mother was not improving, so an ambulance was called and she was transferred to hospital. Pneumonia and septic shock were diagnosed, and she was admitted to ICU, where she died a short time later despite aggressive treatment.

Although the MO set out in the clinical record the drugs prescribed, and a blood test request, he made no record of his clinical examination. This he stated was a "human error" - a simple omission. However, he claimed that he reviewed his care of the woman when alerted to the fact that she had died. There is no record of the review.

It was held that the MO's examination of the woman was cursory and incomplete. The deficiencies in his assessment were significant and represented a major failing in the care of an unwell elderly person who was unfamiliar to the treating doctor. He also failed to record his assessment at the time, or retrospectively when he claimed he undertook a subsequent review. The MO failed to provide medical services with reasonable care and skill, and that complied with professional standards and, in these circumstances, breached Rights 4(1) and 4(2).

The MO was referred to the Director of Proceedings, who considered the matter and decided not to issue any proceedings.  Whilst there were some deficiencies in the MO's assessment of the woman, it was considered unlikely that the Health Practitioners Disciplinary Tribunal would find that those failings amounted to professional misconduct. 

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