Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Complaint
The Commissioner received a complaint from the consumer concerning the services provided by his general practitioner. The complaint is that:
- The GP continued to administer kenacort A40 injections to the consumer after the initial course prescribed by a dermatologist. The initial course instructed five injections were to be given on a monthly basis.
- In January 1997 the GP prescribed dermovate scalp lotion but did not record that the consumer had suffered hair loss and his entire body was hairless.
- While receiving kenacort A40 injections, the consumer's asthma worsened. This deterioration was not recorded in the medical notes. The GP did not perform peak flow tests, examine the consumer's chest or offer any treatment other than previously prescribed ventolin.
- The consumer had one set of blood tests performed in early June 1997 at his own request as he was feeling tired, stressed and his eczema appeared infected. There is no record of the test results or the antibiotics prescribed.
Investigation
On receipt of the complaint dated 16 February 1998 from the consumer the Commissioner decided to conduct an investigation in accordance with the Health and Disability Commissioner Act 1994. Information was received from:
- The Consumer
- The Provider / General Practitioner
- The Dermatologist
The consumer's medical records were obtained from the GP and reviewed by the Commissioner. The Commissioner also sought independent medical advice from a general practitioner.
Information Gathered During Investigation:
The consumer has suffered from asthma and severe atopic eczema since he was a baby. In 1993 he enrolled with the GP. At this time the GP advised that the consumer had explained that he (the consumer) was actively involved in the management of his asthma and that he had access to equipment to take peak flow readings. The GP advised that the consumer principally consulted him concerning his eczema.
In 1995 the consumer felt that he would like a second opinion about the treatment of his eczema and asked the GP to refer him to a specialist. The GP referred him to the dermatologist. The dermatologist saw the consumer in August 1995, and following an examination administered a kenacort A40 injection (a steroid). He prescribed a course of kenacort A40 injections to be administered monthly for five months and informed the GP of this in writing. The GP administered a kenacort A40 injection each month until January 1996, in accordance with the dermatologist's recommendation.
In May 1996 the consumer's condition worsened and the GP restarted the kenacort A40 injections. The GP continued to administer one injection a month until January 1997. The GP did not consult the dermatologist before recommencing the kenacortA40 treatment, and there had been no instruction from the dermatologist to repeat the course of injections. The consumer initially noted some improvement in his condition, but by January 1997 his eczema was worse. In addition to this, the consumer's hair had started to fall out; he was stressed, tired and generally run down. The consumer refused further injections and subsequently made another appointment with the dermatologist. The dermatologist was surprised at the number of kenacort A40 injections administered by the GP to the consumer.
The GP confirmed that the dermatologist had asked him to administer monthly kenacort A40 injections to the consumer. At this time the GP was of the opinion that kenacort A40 injections administered once a month was too much. He advised the consumer to revisit the dermatologist three months after the start of the treatment. The consumer did not revisit the dermatologist until January 1997. The GP administered the first injection in early September 1995 and continued to administer them at monthly intervals until mid-January 1996.
The GP advised that:
"?[T]here was then a break of a 5 month period before the kenacort injections were recommenced [in early] May 1996. A further course of kenacort was then given monthly until [early] January 1997. As you will see from the notes, kenacort A40 was given in accordance with [the dermatologist's] referral letter, in that 5 monthly injections were given. [The consumer] then reported an improvement in his condition, as noted in the notes at [early] April 1996 where I have noted no complaints, "Keeping very well". At the time the kenacort injections had been concluded, in accordance with [the dermatologist's] instructions. The kenacort were only recommenced when there had been deterioration in [the consumer's] eczema as noted by him."
With regard to the consumer's claim that the GP had failed to record that he had suffered hair loss and his entire body was hairless, the GP advised that:
"On [a date in early] January 1997 I saw [the consumer]. As my notes typed on the [date in early] January 1997 show, [the consumer] did not advise me that his body was entirely hairless. My notes state "got patchy hair loss and more like to be a disorder of autoimmune type and asked to go to see [the dermatologist] again". I had diagnosed [the consumer's] hair loss as alopecia areata, which is an autoimmune condition, not a complication of the kenacort injections. The blood tests completed on [a date in early] June 1997 were essentially normal, and do not show any further deterioration of the immune system. Accordingly there was no medical indication to alter [the consumer's] medication."
The consumer believed that his asthma was getting worse during the administration of the second course of kenacort A40 injections, but the GP did not take any peak flow readings, examine his chest or offer any further treatment. The consumer also reported that he had a blood test done as he was feeling very tired and stressed and his eczema appeared infected. There is no reference in the GP's notes to the antibiotics that the consumer claims were prescribed by the GP following the blood tests.
With regard to the consumer's asthma, the GP reported that:
"[The consumer] did not report to me that he had severe asthma. He himself is actively involved in the management of his asthma. He had equipment to take his peak flow readings, and he did not report that these were in anyway abnormal. [The consumer] reported to me that he was a keen surfer, which, with severe asthma would not have been possible. This is because surfing requires a great deal of energy and strength. [The consumer] did not report to me the symptoms that he had mentioned in his letter in relation to his asthma. For example he did not state that he could not sleep during the night as a result of his asthma. He further did not advise me that he was stressed."
In response to the claim that the GP did not proceed with the necessary care in administering further injections without a directive from a specialist dermatologist, the GP expressed his view that:
"[The dermatologist] prescribed the initial 5 injections. In sending the patient back to me to administer the injections, he was relying on me to assess the condition at the time and treat as required. Normally a specialist will ask if they wish the patient to be sent back to him or if a review is required by the specialist.[The consumer] was comfortable and he was improving with the injections. This is an injection that can be prescribed by a general practitioner, and not a specialist only recommended injection. This is a common injection given in various situations. The side effects of the injections are well known and I was looking for the side effects. After a break in the injections it was apparent to me that they should be resumed, having resulted in an improvement in [the consumer's] condition. Later when there was deterioration I asked [the consumer] again to attend [the dermatologist]."
The GP advised the Commissioner that there are three parts to his medical records. One is the consultation, where the day to day clinical records are entered. The second part of the notes are completed within twenty-four hours of seeing the patient and therefore are not a contemporaneous record. Some of the longer consultations the GP had with the consumer were typed up the following day. The third part of the notes is laboratory reports.
Advice to Commissioner
The Commissioner obtained advice from an independent general practitioner who commented:
"[W]hile it is obviously true that [the dermatologist] only prescribed 5 further injections of kenacort A forte and that [the GP] went on to administer more of these in 1996 (in fact he administered a further 9 over and above what [the dermatologist]recommended), nevertheless kenacort A forte is not a specialist drug and is allowed to be used appropriately by registered general practitioners. Thus [the GP], if he felt it was reasonable to administer the therapy, was not necessarily doing this unreasonably. However, he was certainly using a high dose of steroids reasonably aggressively and I would have thought that it would have been reasonable to seek further dermatological opinions about whether this was a reasonable thing to do before he went on and did it. He could have obtained such advice either over the phone or by writing to [the dermatologist]. This was clearly not done. Thus [the consumer] need not necessarily have seen [the dermatologist] but it would have been appropriate for [the GP] to at least talk to or written to [the dermatologist] about this issue."
In relation to the claim that the continued use of kenacort A40caused the consumer's hair loss, my advisor noted that:
"Chemical injections in this quantity should not cause severe hair loss and I feel that the diagnosis of alopacia areata was not an unreasonable one in the circumstances."
In relation to The GP's note taking:
"Regarding the quality of notes that [the GP] has kept, whilst they are somewhat confusing in there [sic] outline because of the way[the GP] has kept them on the computer nevertheless it would appear that they are more a record of medication prescribed rather than a record of the examinations and conditions that a patient has presented with. For example although he has continued to treat [the consumer's] asthma with becotide and ventolin there is no record of [the consumer's] peak flow or chest signs at the time of the consultation. Thus I feel that the quality of the record is probably inadequate. There is no evidence in the notes of any description of the severity of [the consumer's] asthma or eczema. I feel that medical notes need to contain more than just a description of what is described."
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.
Opinion: Breach
In my opinion the GP breached Right 4(2) of the Code of Health and Disability Services Consumers' Rights.
Kenacort A40 Injections
The GP administered the initial course of kenacort A40 injections in accordance with the treatment instructions prescribed by the dermatologist. As a result of this course of treatment the consumer's condition improved. After completion of the course of treatment the consumer's condition deteriorated and the GP recommenced the kenacort A40 injections. The GP believes this was in the best interests of the consumer.
While the treatment may have been justified initially the GP continued to administer the injections for a period of nine months. There was no direction from the dermatologist or any other dermatologist specialist to do so. Although I have been advised that kenacort A40 is not a specialist only prescription drug, in my opinion the GP should have contacted the dermatologist for his advice before recommencing the medication. Such action would have been evidence of meeting the required standard, particularly as the GP had earlier expressed reservations about continuing high frequency use of kenacort A40.
I accept the advice that the kenacort A40 injections did not contribute to the consumer's hair loss and that the GP's diagnosis of alopecia areata in respect of the consumer's hair loss was reasonable in the circumstances. In relation to his asthma, the consumer had a long history of asthma suffering, and had been keeping his own peak flow recordings and actively taking part in decisions surrounding its treatment. This was appropriate given the consumer's familiarity with his condition.
Record Keeping
The GP's system of note recording is somewhat fragmented which may be a result of his software package. While the notes recorded by the GP contain a record of medications prescribed, the record of examinations and conditions that the consumer presented with is insufficient, with the GP's recording notes in supplementary records where he considered further comment was necessary.
In my opinion the GP breached professional standards with regard to his note taking, which should reflect the examinations, diagnosis and discussions of his consultations.
Actions
I recommend the GP takes the following actions:
- Provides a written apology to the consumer for breaching Right 4(2) of the Code of Health and Disability Services Consumers' Rights. The apology should be sent to the Commissioner who will forward it to the consumer.
- Rationalises his system of record keeping to ensure examinations, discussions and clinical findings are documented at the time of consultation as well as prescription records.
- Contacts the specialist who has prescribed a particular treatment if he intends to treat his consumer beyond that contemplated by the specialist.
Other Actions
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 or by email: your.rights@xtra.co.nz