Complaint
The Commissioner received a complaint via the Medical Council of New Zealand from a complainant regarding the treatment and care his late wife received from a general practitioner. The complaint is that:
- The GP's management of the consumer's pain was inadequate in the six weeks prior to her admission to Hospital in March 1997.
- In particular the GP failed to refer the consumer to Hospital during this period.
- The consumer received no report on blood tests ordered by the GP despite requests.
Investigation
The complaint was received on 26 June 1997. An investigation was commenced and information was obtained from the following:
- The Consumer
- The Complainant / Consumer's husband
- The Consumer's sister
- The Provider / General Practitioner
- An Anaesthetic Specialist and Acupuncturist
- A Colorectal and General Surgeon Colonscopist
- A second General Practitioner
The consumer's relevant medical records were obtained and viewed. Independent advice was obtained from a general practitioner.
Outcome of Investigation
The consumer had been a patient of the GP since 1983. She had a long-standing history of ischaemic heart disease (IHD) and elevated blood pressure. In 1984 she suffered a myocardial infarction. The consumer also had symptoms of cerebro-vascular insufficiency and had a right carotid endarterectomy in 1981.
In September 1994 the consumer presented with symptoms suggestive of further Transient Ischaemic Attacks (TIAs). Before she could be fully assessed the consumer suffered a stroke in November 1995 resulting in right hemiplegia for which she was hospitalised. In February 1996, after a lengthy period of rehabilitation at Hospital, the consumer returned home and was put on anticoagulant therapy.
A geriatric assessment carried out in July 1996 made reference to pain in the consumer's right shoulder.
In October 1996 the consumer developed low back pain. The complainant described the pain as severe. While making no reference to the severity of the consumer's pain, the GP advised that this was considered first to result from the awkward gait from her paralysis and secondly to constipation which caused the development of an anal fissure. When local anal preparations did not relieve her symptoms, the GP referred the consumer to a colorectal surgical specialist, who examined her in November 1996 and confirmed the presence of two anal fissures. The specialist performed an anal sphincter dilation.
Following the procedure the consumer continued to experience pain "from her lower tailbone". According to the complainant, the consumer was told by the GP that the pain would eventually go away. The complainant described the consumer's pain as "shocking".
In late December 1996 the consumer went to a Medical Centre with her sister. As the GP was away, another general practitioner saw the consumer. That GP arranged an x-ray which the consumer duly had, and prescribed her "some morphine based tablets to ease the pain". The complainant could not remember the name of these tablets.
The consumer continued to experience pain and returned to the GP in early January 1997 for a repeat of the other doctor's prescription. According to the complainant, the GP told the consumer that "she could not have these tablets" and that he had no record of the medication being prescribed or of the x-ray being ordered by the other doctor.
A copy of a prescription was obtained which showed that 20 tablets of Temgesic were prescribed by the doctor and uplifted from a Pharmacy the following day. Also, records obtained from a Radiology Clinic showed that the consumer had an x-ray of her pelvis and sacrum in mid- December 1996. The report from the x-ray was sent to the other doctor.
While acknowledging that the consumer was seen by the other GP, the clinical notes of the GP under investigation make no reference to the x-ray and prescription of a narcotic medication other than that the consumer was being treated with Temgesic. When questioned during the investigation about this, the GP said that Temgesic was documented because that is what the consumer said she was taking. The GP had not prescribed the Temgesic and suggested that a number of providers involved in the consumer's care could have been responsible.
When asked whether he ever discussed with the consumer the option of narcotics the GP said that he had not. He mentioned that the consumer did not give the impression that she was in so much pain that it warranted narcotics. The GP also advised that there was a clinic policy against prescribing narcotics. He has since revised this statement and stated that this was a personal policy and not that of the Medical Centre. The GP advised that he did not consider referring the consumer to another general practitioner as he did not consider that her condition warranted the use of narcotics.
The consumer was reviewed by the Colorectal Surgeon in early January 1997. The GP confirmed to the Commissioner that on eight days after this review, the complainant reported that his wife was experiencing right shoulder pain. According to the GP she rationalised that it might have been associated with her hemiplegia and walking with her tripod stick. At a consultation twelve days later the GP diagnosed a swelling over the consumer's left scapular as a simple sebaceous cyst. He noted that at the time it was causing her no discomfort. At the same consultation the GP noted possible weight loss recording the consumer's weight as 50.5 kg.
In a facsimile to the GP dated late January 1997, the complainant expresses concern at the deterioration in the consumer's health and suggests hospitalisation. In another facsimile the following day, the complainant mentions the difficulties he is having getting the consumer to her appointment. In a letter to the Commissioner the GP confirmed that the complainant had expressed difficulties about bringing his wife to the surgery. The GP states that the complainant did not expect him to make a home visit and his suggestion to transfer to a more accessible clinic was dismissed because of the consumer's long association with the practice.
The GP's notes do not record the complainant's facsimiles sent to him in late January 1997. Also, the GP stated that from this date he received a lot of phone calls from the complainant but did not note down their contents.
In his letter of mid-February 1997 the Colorectal Surgeon noted that he had carried out a dilatation of the consumer's anal canal. He noted that there was a small healing fissure present within the anal canal but suspected a lot of the pain she was experiencing was a neuralgia rather than a problem of the fissure.
The GP had a consultation with the consumer in mid-February 1997. She complained that her right shoulder pain was getting worse and informed him that she had referred herself to an osteopath. The GP referred the consumer to a medical practitioner/anaesthetic specialist and experienced acupuncturist. The consumer visited this specialist twice in late February 1997. He was unable to administer acupuncture due to the fact the consumer was on Warfarin but tried some homeopathic remedies. The acupuncture specialist confirmed that following these sessions there was no communication between himself and the GP. The acupuncturist recommended treatment at a Pain Clinic and suggested the consumer and her husband contact the GP.
In an undated facsimile sent to the GP in March 1997, the complainant states that he phoned the Medical Centre in late February 1997 requesting an urgent referral to the Pain Clinic. The GP responded that the Pain Clinic did not accept acute patients and suggested she continue taking her medication. When interviewed the GP confirmed that he did not contact the Pain Clinic and relied upon a past experience with another patient for this advice. The GP confirms that he has since become aware that the Pain Clinic's policy has changed.
Information obtained from the Auckland Regional Pain Service (TARPS) states that "most people who are referred to the clinic have already been assessed by at least one specialist in respect of their presenting pain problem". Sixty-six percent of the referrals to TARPS came from general practitioners. According to TARPS, "the average duration of pain at referral to the Pain Service is 7 years. In rare cases people are seen who have had pain for less than 6 months".
The GP advised the Commissioner that he had no further direct communications with the consumer after mid-February 1997.
The General Practitioner advising the Commissioner considered that the GP acted appropriately in maintaining the consumer's quality of life. He took into account the fact that the GP referred the consumer to a specialist and an acupuncturist, started the consumer on a strong analgesic, Digesic at the early onset of symptoms, and considered alternatives such as the Pain Clinic. The peer review also notes that withholding narcotics may have been reasonable in the absence of a firm diagnosis.
In early March 1997 the complainant called for an ambulance to take the consumer to Hospital. The complainant felt that this should have taken place six weeks earlier to save pain and despair. On admission to Hospital the consumer's blood results proved irregular. She was discovered to be anaemic, her Warfarin was stopped and she received a blood transfusion. When interviewed the GP expressed the view that in the absence of a diagnosis, referring the consumer to Hospital would have been difficult to achieve. The GP felt that when he saw the consumer there was no indication that he needed to send her to hospital.
Following her admission to Hospital the consumer self-referred to a new GP. In his letter to the Commissioner dated late January 1998 the GP under investigation states that this came as no surprise. Notes were transferred to the new GP in early March 1997.
The complainant reported that in early March 1997 it was discovered that the pain the consumer was experiencing in her back was due to a tumour. Her clinical discharge summary dated mid-March 1997 recorded metastatic adenocarcinoma in the left shoulder, second thoracic vertebra and paraspinal region, erosive gastritis, and anaemia secondary to the latter. The consumer was discharged from Hospital in mid-March 1997. The Commissioner's advisor notes that up to the date of the consumer's death no one was able to determine the primary tumour site. Hospital based investigations of the lower back pain showed no obvious cause and the specific cause is still uncertain.
In a ward discharge summary it was recorded that the consumer had been seen by the pain team and that her pain was "currently being well managed with medications which included Morphine elixir, MST, Amitriptyline and Panadol".
The consumer died in mid-April 1997 at a Hospice.
The Code of Health and Disability Services Consumers' Rights
RIGHT 4
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
3) Every consumer has the right to have services provided in a manner consistent with his or her needs.
5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
RIGHT 6
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option; and
f) The results of tests;
Opinion: No Breach
In my opinion the GP did not breach Right 4(2) and 4(3) of the Code of Health and Disability Services Consumers' Rights.
The GP referred the consumer to a specialist when she first started experiencing pain in her lower back. This was treated by the Colorectal Surgeon. In terms of the prescribing of narcotics I accept that at the time that the consumer presented to the GP it was reasonable to withhold narcotics as a treatment option. The consumer was started on a strong analgesic, Digesic, at the early onset of symptoms.
When he discovered that the consumer was seeking alternative remedies, the GP referred the consumer to the acupuncture specialist. The GP also considered the Pain Clinic but advised that the pain the consumer was experiencing meant that a referral would take a number of weeks to be acted upon. In hindsight he should have contacted the Pain Clinic. However, the Auckland Regional Pain Services "Information sheet for health professionals" states that patients who have had pain for less than six months will only be admitted in rare cases.
In my opinion the GP did not breach Right 4 by not hospitalising the consumer before the beginning of March 1997. After the consumer was referred to the acupuncture specialist, the GP had no further direct communications with the consumer. The specialist confirmed that he did not consider hospitalisation as an option.
Opinion: Breach
In my opinion the GP breached Right 4(5) of the Code as he had no knowledge of an x-ray ordered and Temgesic prescribed by the other GP, nor did he follow up on this. This shows lack of communication with the other doctor as to what was ordered, adequate documentation, and filing of that information. In my opinion the GP also breached Rights 6(1)(b) and 6(1)(f) of the Code. The GP did not advise the consumer that non-prescription of narcotic medications at the Medical Centre was a personal prescribing decision and that she had the option of seeing another General Practitioner. Further, the GP did not give the consumer the results of her blood tests as requested and required by Right 6(1)(f).
Actions:
I recommend that the GP:
- Apologises to the complainant in writing for breaching the Code. The apology is to be sent to the Commissioner who will forward it to the complainant.
- Review his record keeping and advises the changes made to minimise the likelihood of similar omissions in future.
- Discusses this opinion with the other General Practitioners at the Medical Centre.
- Ensures future patients are informed of his personal narcotic non-prescription decisions and give them the option of seeing another General Practitioner.
A copy of this opinion will be sent to the Medical Council of New Zealand.
For further information, contact: HDC Communications Section (09) 373 1060.