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Management of bladder cancer (04HDC11624)
Download Management of bladder cancer (04HDC11624) (PDF 147Kb)
(04HDC11624, 4 April 2006)
Urologist ~ Genitourinary surgeon ~ District health board ~
Bladder cancer ~ Cystectomy ~ Consultation with colleagues ~
Decision-making ~ Patient safety ~ Employment issues ~ Standard of
care ~ Professional standards ~ Rights 4(1), 4(2), 4(4),
4(5)
A woman was referred to a urologist by her GP for assessment of
longstanding urinary tract problems. The urologist, a genitourinary
surgeon, performed a cystoscopy and biopsy of bladder tissue. The
biopsy revealed that the woman had squamous cell carcinoma of the
bladder. Nine weeks later he performed a sub-total cystectomy and
hysterectomy, and the woman was referred to a radiation oncologist
for follow-up radiotherapy treatment. Four months later when she
developed abdominal discomfort, the radiation oncologist performed
a CT scan. The scan revealed a collection of fluid in the lower
abdomen. He referred the woman to the urologist for review. The
urologist performed a further cystoscopy and found that she had
developed a fistula between the bladder and the mons pubis, which
was thought to be related to a recurrence of her cancer. She died a
few months later.
It was held that the urologist failed to biopsy the woman's
fistula and to communicate his findings to the other doctors
involved in managing her care, which had an impact on the planning
of subsequent management options. His decision to perform a partial
cystectomy in these circumstances was a severe departure from the
expected standard of care, and he was found to have breached Rights
4(1) and 4(4). It was also held that his failure to consult his
colleagues was not consistent with sound clinical decision-making
and good quality care. In these circumstances the urologist
breached Rights 4(2) and 4(5). Behavioural concerns, no less that
clinical competence concerns, can place patients at risk and must
be addressed by an employing district health board. However, the
board was not held vicariously liable for the deficiencies in the
urologist's clinical decision-making.
The Commissioner recommended that the Medical Council of New
Zealand review the urologist's competence. The urologist was
referred to the Director of Proceedings.
The Health Practitioners Disciplinary Tribunal upheld one charge
of professional misconduct against the urologist. It concluded that
the expert evidence showed that the failure to perform a total
cystectomy constituted conduct that fell far short of that to be
expected of a reasonably competent urologist, and that it amounted
to malpractice (neglect of a professional duty) and negligence (a
breach of duty in a professional setting). The Tribunal considered
that a finding of professional misconduct was needed to protect the
public, maintain professional standards, and punish the
practitioner.
The urologist was censured, fined $5,000, and ordered to pay 30%
of the costs of the investigation and prosecution. He was also
ordered to practise under conditions. Interim name suppression was
lifted.
Link to Health Practitioners Disciplinary Tribunal decision:
http://www.hpdt.org.nz/portals/0/med0639dfindings.pdf