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Decision 05HDC05429
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Names have been removed (except the expert who advised
on this case) to protect privacy. Identifying letters are assigned
in alphabetical order and bear no relationship to the person's
actual name.
Dr C, General Practitioner
A Report by the Health and Disability Commissioner
(Case 05HDC05429)
Parties involved
Ms
A
Consumer/Complainant
(deceased)
Mr
B
Complainant/Ms A's
partner
Dr
C
Provider General
Practitioner
Ms
D
Midwife
Complaint
On 15 April 2005, the Commissioner received a complaint from Ms
A and Mr B about the services provided to Ms A by Dr C. The
following issue was identified for investigation:
- The appropriateness of the care, treatment and follow-up
provided by Dr C to Ms A in November 2004 to March 2005.
An investigation was commenced on 5 July 2005.
Information reviewed
- Information from Ms A
- Information from Mr B
- Information from Dr C, including case studies and
testimonials
- Information from Ms D, midwife
- Ms A's medical records from the District Health Board.
Independent expert advice was obtained from Dr Tony Birch,
general practitioner.
Information gathered during investigation
Ms A, aged 40, saw her midwife, Ms D,[1]
for a routine check-up on 22 November 2004. Ms A was 21 weeks
pregnant at the time. Ms D's notes document Ms A having a
lump in her left breast and that she advised Ms A to see her
general practitioner.
First consultation
Ms A and her partner, Mr B, attended a consultation with Dr C,
general practitioner, on 24 November 2004.
Dr C recalled that he took a full history regarding the breast
lump, family history of breast cancer and whether there had been
any discharge from Ms A's nipple. He also asked whether Ms
A's midwife had noticed any abnormality of her breasts at the first
antenatal examination. According to Dr C, Ms A did not know
of any abnormality.
Dr C said that he did not know who Ms A was seeing for her
midwifery care. He recalled that he asked Ms A and that she
responded that she did not know the name of her midwife or where
she had seen her. Dr C did not receive any information from
Ms D.
Dr C examined Ms A's breasts:
"*Flat of the right hand while
steadying the breast with left hand was used to examine the right
breast in 4 quadrants, axillary tail, areola and nipple were
examined in that order - bra was checked for any blood stain on the
inside of the cups.
*Right supraclavicular region and
detailed examination of right axilla - medial, lateral anterior and
posterior walls and apex was carried out."
The examination revealed that there was an inflamed area of
hardening, the skin was red and warm, and there was marked
tenderness. The areola of the breast was also inflamed.
Dr C also examined Ms A's abdomen.
Dr C diagnosed an "acute infection involving the breast tissue
and overlying skin - cellulitis" which could be related to the milk
gland being blocked. A ten-day course of antibiotics was
prescribed. Dr C said that he explained to Ms A that her
symptoms could possibly be due to a neoplasia (cancer).
Dr C's notes state:
"*3d [day] h/o [history of] a
painful lump in the Lt [left] breast o/e [on examination] 3 cm
diameter lump in the Lt[left] breast most likely a blocked duct and
infection or a neoplasia ABs [antibiotics] and c [see] next week
and if not gone ref [refer] to [a general surgeon]
Dx: Lump in breast
(K3171.00) - Lt
Rx: 40 - Floxapen
Cap 500 Mg (P) - 1 cap, Four Times Daily
Rx: 120 - Panadol
500MG TAB - 2, Twice Daily."
Dr C recalled that he discussed his treatment plan with Ms
A. This included the prescription of the antibiotics, a
review in seven days' time and a further review after Ms A had
finished the course of antibiotics. If the lump/symptoms had
not resolved by the time of the final review, he would organise
blood tests, a fine needle aspiration (FNA), ultrasound scan and
referral to a general surgeon, for a mammogram. Dr C told Ms A:
"… due to the age of the foetus
being 22 weeks and 5 days it may not be possible to do it [the
mammogram] because radiation could harm the foetus. It is not
advisable to perform a mammogram if the foetus is less than 28
weeks due to fear of radiation damage to the foetus so it will have
to be done after the foetus is more than 28 weeks (after
8th January 2005)." [Dr C's emphasis]
Dr C said that he gave Ms A "clear
instructions" to come back earlier if the condition worsened.
He said that Mr B contributed
frequently in response to the questions Dr C asked Ms A and that he
was "controlling".
Ms A said that no tests (including mammogram and ultrasound)
were mentioned, and that Dr C said that it would be difficult doing
any tests because she was pregnant. She also stated that
there was no discussion about returning to see Dr C if she was
concerned about the lump, and that Dr C did not explain that her
symptoms could be related to cancer.
Second consultation
Ms A and Mr B saw Dr C again on 1 December 2004. Ms A told
Dr C that while the lump remained, it was not as sore as it had
been at the previous consultation, the swelling had gone down, and
she had been taking the antibiotics prescribed by Dr C.
Dr C stated that on re-examination of Ms A's breast, he found
that the infection was settling and the area of induration
(hardening) had decreased in size. He was satisfied that
there was no abscess and advised her to continue with the
antibiotics.
Dr C returned to the consultation room, opened the computer
file, and commenced writing up notes on the consultation with Ms
A. He advised that he was interrupted by Ms A returning,
having finished getting dressed.
He made an appointment for 6 December 2004 at 11.45am on the
computer booking sheet, and gave Ms A an appointment card. He
advised Ms A to attend this appointment in order for him to
reassess the breast and so that further investigations, including
referral to the general surgeon, could be arranged.
In response to my provisional opinion, Dr C stated that Ms A and
Mr B did not appear pleased by this suggestion:
"While I was sitting … both of them
got up and stood over me and began talking loudly. Since I
had deliberately left the door open by a few inches, for my own
safety, I was really frightened. I was stunned that a patient
and her spouse [would] talk to me like that, including waving her
finger at me."
Dr C stated that Ms A said she wanted to enjoy her pregnancy;
that she was being looked after by a midwife; and that she would
come back if the lump did not improve. Dr C said that he
reiterated to Ms A that he needed to see her following the
completion of the antibiotics the following week and for further
investigations and referral.
Dr C advised that he was suspicious that she might not return to
see him (as she had missed appointments in the past). Ms A
had said to him that she would "wait and see in March when the baby
is due" and Mr B was concerned that it was costing them
money. As a result, Dr C "put a recall on our computer for
1st March 2005 for her to come back and get it
checked".
Dr C's notes state:
"*the lump has gone down in size not
as sore also no discharge wait and see in March when baby is
due
Dx: Lump in breast (K3171.00)
- Lt."
Ms A did not recall having had an examination of her breast or
abdomen at this consultation, and advised that "to her knowledge"
no further appointments had been made to see Dr C. Mr B
advised that there was no examination of Ms A's breast and that
they were not asked to return to see Dr C. According to Mr B,
Dr C told Ms A that she needed to be seen by a midwife as he did
not do obstetrics.
Ms A did not attend any further appointments with Dr
C.
Subsequent events
Ms A saw her midwife, Ms D, again on 20 December 2004 and 17
January 2005. Ms D advised that she was told by Ms A and Mr B
that Dr C was not concerned about the lump; he had reassured them
and said that he would monitor the lump.
Dr C's receptionist attempted to contact Ms A in February 2005
regarding the recall appointment for March 2005, but did not speak
to Ms A.
Ms A moved to another city on 8 February 2005. Ms A said
that she spoke with Dr C's receptionist about the move to the city,
as they had a credit with the surgery. She also gave the
receptionist her forwarding address.
Once Ms A's new midwife became aware of the presence of a lump
in Ms A's left breast, she was immediately referred to the Breast
Clinic at the public hospital. Further investigations
revealed that Ms A had breast cancer. She was induced on 25
March 2005, and her baby was born the same day.
Ms A underwent a mastectomy on 14 April 2005, and an 8 x 8.5cm
cancerous mass was removed. Ms A was subsequently also
diagnosed with cancer of the liver. Ms A died a few months
later.
Telephone calls
Ms A also complained that Dr C telephoned her approximately
seven to eight times on the same night. This was after he had
received a letter from a consultant surgeon, at the District Health
Board, informing him that Ms A had been diagnosed with breast
cancer. She was unsure the exact night that Dr C telephoned,
but recalled that it was approximately one month after she had
moved to the city.
She asked Dr C to cease telephoning her.
Dr C explained that he contacted Ms A once on 4 April 2005 to
discuss the "reminder call" for a March appointment, the reason for
her not attending the appointment on 6 December 2004, and why they
had not requested their medical notes since moving to another
city. Dr C recalled that Ms A said to him during this
conversation that she remembered him mentioning, "the cancer
doctor".
Dr C recalled that "after I had talked to [Ms A], [Mr B] came on
the phone and became very abusive and started shouting".
Appointment system
Dr C provided computer printouts of the booking sheet for 6
December 2004. The first booking sheet does not have Ms A's
appointment recorded. Dr C explained that Ms A's name was removed
as she did not attend her appointment. The practice at that time (6
December 2004) was to remove names from the booking sheet if
patients did not attend their appointments, so that the empty time
could be made available to other patients.
On the second sheet Ms A is recorded as having an appointment
booked for 11.45am. An "N" is beside her name. Dr C explained that
this sheet was included in the documentation to illustrate where Ms
A's name would have been if her name had not been removed at the
time, and that the use of an "N" is now the system for recording
when patients do not attend booked appointments.
Independent advice to Commissioner
The following expert advice was obtained from Dr Tony Birch,
general practitioner:
"Medical/Professional Expert Advice - File 05/05429: Dr C
Thank you for your letter of 26th September 2005
requesting I provide an opinion to the Commissioner about the
services provided by [Dr C] to [Ms A], as detailed in the documents
you supplied. I can confirm that I have no personal or professional
conflict in this case. I have read and agree to follow the
Commissioner's Guidelines for Independent Advisors. I understand
also that my report is subject to the Official Information Act and
that my advice may be requested and disclosed under that Act and
that the Commissioner's policy is to name his advisors where any
advice is relied upon in making a decision.
I qualified MB, ChB in 1968 from Victoria University of
Manchester, UK. I also hold a Diploma in Obstetrics from the Royal
College of Obstetricians (1970) and a Diploma in Health
Administration from Massey University (1985). I have been a Member
- now Distinguished Fellow - of the Royal New Zealand College of
General Practitioners since 1980. Prior to working in New Zealand I
worked in an isolated area of Fiji for three years. For the past 31
years I have worked as a rural general practitioner […]. This
practice involves on call work and the care of patients in a small
rural hospital.
I have read the supporting information supplied
by the Commissioner, viz:
Supporting Information
Complaint letter dated 13 April 2005 (pages 1-2)
Notification letters to [Ms A] and [Dr C] dated 5 July 2005
(pages 3-7)
Correspondence from [Dr C] dated 25 May 2005 and further
correspondence received on 11 August 2005 (including Appendix 2
only). Letter to [Dr C] dated 22 August 2005 and response
from [Dr C] received 6 September 2005 (including appendices 3-5 and
7 only) (pages 8-34)
Patient Medical History for [Ms A] dated 23 May 2005 and 10
August 2005, including correspondence dated 24 March 2005 and
Patient Appointments dated 11 August 2005 (pages 35-44)
Notes of telephone call between [Ms A] and [HDC] investigator on
21 June 2005 (pages 45-46)
Correspondence from [Ms D], Registered Midwife, dated 8 July
2005 (including maternity booking form and clinical notes) and
notes of telephone call between [Ms D] and [HDC] investigator, on 1
August 2005 (pages 47-50)
Clinical Notes for [Ms A] from [the District Health Board]
(pages 51-83)
Report
1) Was [Dr C's] care and treatment of [Ms A] on 24
November 2004 adequate and appropriate?
[Ms A] presented to her GP [Dr C] at 26 weeks pregnant with
a painful lump in her left breast. All the evidence points to the
conclusion that [Dr C] made a thoughtful differential diagnosis and
instituted appropriate management. There is some dispute about
whether [Dr C's] concern about the possibility of breast cancer was
shared with [Ms A]. [Dr C] makes the point that [Ms A's] partner
was present during the consultation and was controlling and, he
felt, aggressive. This brings an element into this that makes
things even more difficult. [Dr C] may have omitted to mention the
possibility because of the partner's presence, or his presence may
have had the effect of confusing [Ms A's] perception. Whatever the
case, [Dr C's] management plan was reasonable: treat the infection
and review; if the lump is still there, reconsider the diagnosis
and proceed from there.
2) Was the treatment according to the RNZCGP Early
Detection of Breast Cancer Guidelines published in 1999?
I do not have this publication to hand. From memory,
however, this is not relevant to this situation when there is
already a lump and the woman is pregnant. The guideline is more
about early detection and screening.
3) Was [Dr C's] care and treatment of [Ms A] on 1 December 2004
adequate and appropriate?
This is a difficult question to answer. It is dependent on
two things which are in dispute: did [Dr C] examine [Ms A's]
breast? Did [Dr C] arrange to see [Ms A] at the end of the
antibiotic course? [Dr C's] record for the consultation is of
little assistance. It is not clear whether the statement, '*the
lump has gone down', is a record of [Ms A's] history or of [Dr C's]
examination. A perusal of previous records seems to indicate that
it was his practice to write 'o/e' (on examination) prior to
recording his findings; there is no such note here. He also makes
no mention in the notes of wishing to see [Ms A] again and that
being refused - a compromise being agreed on. All that is written
is, 'wait and see in March when baby is due'.
If [Dr C] did not examine [Ms A] again and only arranged to
see her four months later, I would view this with severe
disapproval.
4) Was the treatment according to the RNZCGP Early
Detection of Breast Cancer Guidelines published in 1999?
I do not believe these to be relevant. Breast cancer in a
pregnant woman is a particularly aggressive form of the disease and
needs urgent management. Even then the outcome is not good. This
was already a large lump - at 3cm diameter - and had shown evidence
of inflammation.
5) Are [Dr C's] clinical records of an appropriate
standard?
I have no problem with [Dr C's] clinical records. As I
mentioned in a previous report, I find the use of the SOAP
(Subjective, Objective, Assessment, Plan) system of recording
findings a good discipline. The patient management system that [Dr
C] uses does not encourage this.
If not included in the above, can you please respond to the
following:
6) At the appointment on 24 November 2004, what further
investigations or tests, if any, should [Dr C] have conducted or
requested?
As mentioned above, I believe that [Dr C's] management was
fine at this appointment. It was reasonable to have a trial of
antibiotic treatment and review. Nothing further would have been
indicated.
7) Should [Dr C] have referred [Ms A] to a specialist
following the consultation on 24 November 2004?
[Dr C's] statement regarding this issue is quite correct. A
specialist would have expected the GP to have at least treated any
infection. If [Dr C's] initial diagnosis had proved to be correct,
referral to a specialist would have been a waste of resources and
reduced the confidence of the specialist in [Dr C's]
management.
8) At the appointment on 1 December 2004 what further
investigations or tests, if any, should [Dr C] have conducted or
requested?
If he didn't do, [Dr C] should have examined [Ms A's] breast
again. With the reduction of the inflammation, he may well have
been able to assess whether the lump was solid or fluctuant. This
is the most important 'investigation' at this time.
9) Should [Dr C] have referred [Ms A] to a specialist following
the consultation on 1 December 2004?
With hindsight, it is obvious that [Dr C] should have
urgently referred [Ms A] to a specialist at this consultation. If,
as he contends, he arranged to see her the following Monday
(6th December), it would be reasonable to expect that he
might defer the decision until that time.
10) It is unclear whether a third appointment was
made for [Ms A] on 6 December 2004.
i. Were follow-up
arrangements subsequent to the consultation on 1 December 2004
adequate and appropriate? If not, why not?
It appears from the clinical
records of 1 December 2004 that [Dr C] was happy to 'wait and see
in March'. This is totally unacceptable. As I stated above, breast
cancer in pregnancy is particularly aggressive. It grows quickly
and metastasises early; it is almost an obstetric
emergency.
ii. Did [Dr
C] adequately monitor the condition of [Ms A's] breast after the
appointment on 1 December 2004? If not, what should he have
done?
The assumption that it is
reasonable to defer review of the progress of a breast mass in
pregnancy for three months seems incredible to me. I would be
wanting to be totally reassured that the lump had disappeared - or
at least just left a small area of induration. Knowing all that he
did about [Ms A's] past history and her social situation, I cannot
understand why [Dr C] did not flag the notes and insist on some
review in the next week. At the very least he could have discovered
who [Ms A's] midwife was and made sure that she monitored
progress.
I agree with [Dr C] that
patients should be expected to take some responsibility for their
own problems. It is unlikely, however, that, even if she was aware
of the possibility of cancer, [Ms A] would be aware of the
aggressive nature of the problem in pregnancy and the absolute
importance of making sure that the lump disappeared. Even if, as he
says, [Dr C] made an appointment for [Ms A] on 6th
December, when she did not turn up he should have left no stone
unturned to be sure that she was seen again and re-examined. I view
the failure to do so with severe disapproval.
Further comments
From the statements of [Dr C], it appears that he had problems
with [Ms A's] partner. He felt threatened and uncomfortable. This
is unfortunate but should not have been allowed to interfere with
the care that his patient, Ms A, was entitled to expect.
I wonder whether there is a question here regarding the
knowledge base of [Dr C] with regards to obstetric care. There are
the statements that 'nothing can be done' because of the pregnancy
and that cancer 'could not be diagnosed' until she had her baby,
both of which are wrong.
There are many discrepancies between [Ms A's] recall and
statements, and those of [Dr C]. I am unable to sort these out.
[…][2]
In summary, [Ms A] has been poorly served by the health service
and the outcome for her and her new baby is likely to be poor.
I trust that this report is of assistance to the Commissioner in
reaching his judgment. Please do not hesitate to contact me
if any further clarification is required.
[…]."
Response to Provisional Opinion
Dr C responded to the provisional opinion and made a number of
comments in relation to the second consultation on 1 December
2004.
Dr C said that he "vividly" remembers this consultation and that
an appropriate examination was completed. It was "unpleasant" and
left him with an "unhappy feeling". Dr C said that he did not
show his unease to Ms A or her partner and maintained his
"cool".
Dr C regrets that his notes for this consultation do not reflect
"the difficulty and stress of the appointment which was
lengthy". Dr C also noted that as the appointment on 1
December 2004 was a follow-up appointment and he knew the history
of the complaint, he did not to enter it again. He said:
"As other notes can show, I do write
o/e [on examination] often for the initial consultation, but at
follow up I often do not write it and simply write the examination
findings. If I do not examine a patient I write this in the
notes."
Dr C advised that "wait and see in March when baby is due" (in
his notes for the consultation on 1 December 2004) was a statement
made by Ms A, which he then entered into her notes. He said
that as he was not her midwife or her obstetrician he would not
have known that she was due to deliver in March, unless Ms A had
told him her due date. "Only she would have known her due
date and made the statement, which I wrote down."
Dr C also regrets that his practice had not "kept on chasing up
her non attendance on the 6th December 2004".
Dr C explained that his practice has made a number of changes to
its system:
"My receptionist and I have taken Dr Tony's Birch's criticism
very seriously and have made the following changes:
- We have changed our system so that instead of removing unkept
appointment, we record them as such. We write a note 'dna - did not
attend' or 'patient cancelled'. This still enables the time to be
made available to another patient while ensuring there is a record
of the appointment and the fact that it was not kept.
- I have made changes in the way consultation notes are recorded.
History is clearly recorded, followed by examination and treatment
provided. This also applies to follow-up appointments.
- Under the new system either myself or my receptionist chase up
all patients who have not attended their appointments and have not
contacted us. Our practice is now to ring up 4 times on the same
day and when phoning doesn't meet with success to always
send a letter so that it is on the
file. We have a number of standard letters for different situations
which can be shown to you.
- We have also set out the limits and boundaries for enrolling
new patients, even though there are insufficient General
Practitioners for the area and we come under considerable pressure.
This tragedy has reinforced to me that patient care can slip
through the cracks when the workload is high."
Dr C noted:
"In this case there was some
reassurance in that I believed [Ms A] was aware of the concern of
possible cancer, she had in the past not kept an appointment then
turned up casually later, she was under midwife care and [the]
midwife was aware of the breast lump."
Dr C expressed his condolences to the family of Ms A. He
commented as follows:
"I deeply regret this tragedy. Not a
day goes by when I don't think of [Ms A]. Every time I examine a
breast I think of her. This case is an omission of follow up in
respect of one patient. It was not a deliberate act. I cannot go
back in time to make the outcome different - if I could I would.
What happened does not reflect my usual practice or how every other
patient I have examined with a breast lump has been treated, namely
by referral to a general surgeon, as was planned in this case
…."
Dr C submitted that there was no need to refer him for a
competence review or to the Director of Proceedings.
Code of Health and Disability Services Consumers' Rights
The following Right in the Code of Health and Disability
Services Consumers' Rights is applicable to this complaint:
RIGHT 4
Right to Services of an
Appropriate Standard
1) Every consumer has
the right to have services provided with reasonable care and
skill.
Opinion: Breach - Dr C
Right 4(1) of the Code of Health and Disability Services
Consumers' Rights (the Code) states that patients have the right to
have services provided with reasonable care and skill. In my
opinion, Dr C did not provide Ms A with appropriate care and
breached the Code. My reasons are set out below.
Ms A attended two consultations with Dr C following the
discovery of a lump in her left breast - on 24 November and 1
December 2004.
On 24 November 2004, Dr C took a history of the lump and
examined Ms A's breasts and abdomen. He diagnosed an
infection of the milk gland in the breast and prescribed a ten-day
course of antibiotics. He advised Ms A to return to see him
on 1 December 2004.
My expert in general practice, Dr Birch, commented on the care
and treatment provided by Dr C at this consultation and stated that
Dr C's differential diagnosis was appropriate. Dr C's
management plan - to treat the infection and then review, and if
the lump remained to re-evaluate the diagnosis - was a reasonable
plan. Moreover, referral to a specialist was not indicated
following this consultation.
Dr Birch noted that Dr C appears to have been intimidated by Ms
A's partner, and that this may have had an impact on the
consultation in relation to the information given to Ms A regarding
possible differential diagnoses.
Ms A returned to see Dr C on 1 December 2004. Whether a
breast examination was conducted by Dr C, or a further appointment
(for 6 December 2004 at 11.45am) was made at this consultation, is
in dispute.
Ms A did not recall an examination of her breast at this
consultation; "to her knowledge", no further appointment had been
made. Her partner confirmed that there was no breast
examination conducted at this consultation and that they were not
advised to return to see Dr C. In contrast, Dr C said that
following an examination of Ms A's left breast, he recommended that
she attend an appointment the forthcoming Monday (6 December 2004),
to assess the lump (following the completion of the antibiotics)
and to review the management plan as necessary.
According to my expert, the appropriateness of Dr C's care at
this consultation relies heavily on whether a breast examination
was undertaken and a further appointment made for Ms A to follow up
the lump and review the management plan.
It was unclear to my expert whether the statement in Dr C's
notes "*the lump has gone down …" referred to the history provided
by Ms A or Dr C's examination findings. Dr Birch noted that
it appears to have been Dr C's usual practice to write "o/e"
referring to "on examination", prior to recording his examination
findings.
In response to the provisional opinion, Dr C advised that he
usually writes "o/e" for the initial consultation, but at follow-up
appointments he simply writes his examination findings. Dr C
stated that if he does not examine the patient he writes
this in the notes.
I have reviewed Dr C's notes for Ms A. Dr C did indeed have a
practice of recording his examinations. He recorded "o/e" for the
breast examination on 24 November; for his examination of Ms A's
abdomen on 3 September; for his examination of Ms A's epigastrium
on 17 August; and on 24 June Dr C recorded his examination of Ms
A's abdomen.
In light of Ms A and Mr B's comments that she was not examined,
and in the absence of any recorded examination, I conclude that Dr
C did not re-examine Ms A's left breast at the consultation on 1
December. I am satisfied that had such an examination taken place,
Dr C would have continued his usual good practice of recording his
findings. I am not convinced that Dr C would have a different
practice of recording examination findings for follow-up
appointments (ie, that he would not preface any examination
findings with "o/e"). I also find it inexplicable that he would
have performed an examination and not recorded it. Dr C
suggested in his response to the provisional opinion that he would
write in his notes if he had not examined a patient. I do not
believe that the absence of any reference in his notes to having
not examined Ms A implies that he therefore examined her
at this consultation.
In addition, it appears from the clinical records that Dr C was
happy to wait until after the baby was born in March. Dr Birch
described this as:
"… totally unacceptable. As I
stated above, breast cancer in pregnancy is particularly
aggressive. It grows quickly and metastasises [spreads]
early; it is almost an obstetric emergency."
Dr C said that the reference to reviewing in March was a
statement made by Ms A and that he would not have known when her
baby was due, unless he had been told by Ms A and he had not been
told.
Dr C explained that he not only booked an appointment for Ms A
to return to see him the following week, he also gave her an
appointment card. Ms A did not recall receiving an appointment
card.
In response to the provisional opinion, Dr C advised that Ms A
and Mr B were threatening towards him at the consultation on 1
December 2004, when he suggested a third appointment.
I have difficulty in accepting Dr C's account of what was
discussed during the consultation on 1 December. His notes do not
reflect that a follow-up appointment for the following week had
been made, and, in fact, show that he was content to wait until
March to re-assess the situation. The previous recorded
consultation (for 24 November) shows that Dr C wrote when he next
expected to see Ms A, while notes of the preceding consultation
record Dr C's plan to perform an ultrasound scan if Ms A's gastric
symptoms continued. If Dr C has given an accurate account of what
happened on 1 December, then he did not record this in the clinical
record. I do not believe that this is the case.
Even if a further appointment was made for the following week,
Dr C did not see Ms A. Dr Birch contends that, as the doctor
in this situation, he would have wanted to have been reassured that
the lump had disappeared, or had left only a small area of
induration. Faced with the situation of Dr C's having not
seen Ms A since she completed her antibiotics, it was
incomprehensible to my expert that Dr C did not insist on some
review of Ms A the following week or, at the very least, find out
who Ms A's midwife was, and ask her to monitor the progress of the
lump.
I do not accept Dr C's account that Ms A was unable to provide
the name of her midwife and where she saw her, when he asked her at
the consultation on 24 November 2004. Ms A had seen her
midwife a total of three times before she attended Dr C on 24
November, and the most recent visit to the midwife had been two
days prior to her consultation with Dr C. I do not believe
that Ms A could not have given Dr C sufficient information about
her midwife to enable him to contact Ms D, had he wanted to.
Ms D advised that she was told by Ms A and Mr B on 20 December
2004 that Dr C was not concerned about the lump and that he would
follow her up. I am not convinced that any proposed follow-up
was planned within the timeframe that my expert suggested was
appropriate.
Dr C contends that Mr B was concerned about the cost of Ms A
attending a third appointment. I note that Ms A and Mr B were
in credit with the GP surgery after paying a prior bill. In
any event, if Dr C had realised the potential seriousness of Ms A's
circumstances, an arrangement could surely have been made to see Ms
A, irrespective of any payment difficulties.
Dr Birch referred to Dr C's knowledge base regarding obstetric
care, questioning Dr C's comment to Ms A that nothing could be done
because of the pregnancy. It appears that Dr C did not have a good
understanding of obstetric care and did not treat Ms A's breast
symptoms with the urgency that was clearly required.
In conclusion, Dr C's explanation for his care of Ms A during
the consultation on 1 December is unconvincing. It is also
inconsistent with Ms A's and Mr B's recollection. Dr C's
explanation is at odds with what he recorded in the consultation
notes, and the opposite of his usual good practice. In any event,
Dr Birch is strongly critical of Dr C's lack of follow-up when Ms A
did not attend the third appointment. The evidence is that Dr C
provided Ms A with care that was significantly substandard.
In these circumstances, Dr C breached Right 4(1) of the
Code.
Other matters
Telephone calls
Ms A complained that Dr C repeatedly telephoned her on the same
night, after he became aware of her diagnosis of breast
cancer. She asked Dr C to cease telephoning her.
Dr C advised that he telephoned on 4 April 2005, first leaving a
message on Ms A's answer phone, and then calling again ten minutes
later and speaking to her about the treatment he provided.
I have not been able to establish how many telephone calls Dr C
made to Ms A.
In response to the provisional opinion, Dr C stated that he did
not ring Ms A repeatedly on the same evening and indicated that
telephone records prove that this is the case. I have not
seen the telephone records and therefore am unable to form a view
on this aspect of the complaint. However, if he did telephone
Ms A repeatedly, his behaviour was unwise and
inappropriate.
Follow-up actions
- Dr C will be referred to the Director of Proceedings in
accordance with section 45(2)(f) of the Health and Disability
Commissioner Act 1994, for the purpose of deciding whether any
proceedings should be taken.
- Dr C will be referred to the Medical Council for a competence
review. In conducting a competence review, the Council considers
whether the "health practitioner's practice of the profession meets
the standard of competence" (s 36(5), Health Practitioners
Competence Assurance Act 2003). A doctor may be required to
undertake an educational programme to address any weakness in his
practice. The results of a competence review are not public
information, unless they lead to restrictions, conditions or
suspension of a doctor's practice.
- A copy of this report will be sent to the Medical Council of
New Zealand and the Royal New Zealand College of General
Practitioners.
- A copy of this report, with details identifying the parties
removed, will be sent to Women's Health Action, the Federation of
Women's Health Councils Aotearoa, and the Maternity Services
Consumer Council, and placed on the Health and Disability
Commissioner website, www.hdc.org.nz, for educational
purposes on completion of the Director of Proceedings'
processes.
Addendum
The Director of Proceedings issued proceedings before the Health
Practitioners Disciplinary Tribunal and, at a hearing on 21 July
2006, a charge of professional misconduct was upheld. The Tribunal
considered that Dr C failed to adhere to the standards ordinarily
expected of a general practitioner in the circumstances in this
case. Dr C was censured and ordered to pay 30% of the costs of the
Director of Proceedings and the Tribunal. Dr C has instituted a
number of changes to his practice to ensure that at-risk patients
are carefully monitored and followed up.
[1] An investigation has been commenced
into the care provided by Ms D, and will be reported
separately.
[2] Please note that Dr Birch's advice
also discusses the care of another provider. As this does not
relate to the care provided by Dr C, it has been removed from this
document.