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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),
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
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.