96HDC1787
ComplaintThe Health and Disability Commissioner received a complaint on 2 October 1996 regarding the care the complainant's late father received from the provider, a general practitioner. The complainant was dissatisfied with the general care given to her father from mid-July 1996 until he was admitted to hospital in mid-August 1996. The complainant considers that the provider should have admitted her father to hospital at an earlier date. It was only at her father's insistence that he was admitted to hospital.
An investigation was undertaken and information obtained from:
- The complainant/consumer's daughter
- The Consumer's widow
- The Consumer's other daughter
- The Provider/General practitioner
The consumer's hospital records and the original medical notes taken by the provider were viewed. Advice was also obtained from an independent expert.
The consumer was visited at his home by the provider in mid-July 1996. The consumer had been experiencing a flu-like illness. The provider prescribed Augmentin 500mg. There is no indication in the medical notes of the quantity or length of the course of medication prescribed. There was no arrangement made for a follow-up consultation.
The consumer's family report that his condition did not improve over the following two weeks and this resulted in him consulting the provider again in early August 1996. The consultation occurred at the provider's rooms. The provider's notes of the consultation state that the consumer was improving slowly. The consumer's blood pressure was measured but there is no record of any other physical examination. Blood tests were arranged and a throat swab was taken. A chest x-ray was suggested but declined. The provider prescribed Ceclor 250mg three times a day. There is no indication of the length of the course of antibiotic.
The consumer's family report that his condition continued to deteriorate and he was very weak and breathless. The consumer rang the provider during the weekend three days after the consultation. The provider was not on duty that weekend and an answerphone message advised callers of alternative medical cover. The consumer left a message on the answerphone requesting the provider contact him. The provider did so and the consumer informed the provider that he continued to feel unwell and it was agreed that there would be a further consultation.
The consumer attended the provider's rooms the next day. The medical notes state that the consumer was feeling very weak, there were no problems with his cardiovascular system but there were problems with his respiratory system. These are not detailed. The provider gave a Lincocin (600mg) injection and prescribed a course of Doxycycline. There is no mention of the strength or length of the course of medication. The notes state that hospitalisation was discussed and declined. A chest x-ray was recommended.
The following day the consumer went for his chest x-ray which showed that he was suffering from a right upper lobe pneumonia. The consumer was advised by the radiologist to see the provider on his way home. The consumer contacted the provider, discussed the x-ray with the provider and the notes again record that hospitalisation was refused.
The next day the consumer contacted the provider by telephone again and advised that he continued to be most unwell. The provider states that he again advised the consumer that he required hospitalisation but the consumer did not want this arranged until the next morning. The medical notes show no record of this conversation. The consumer's wife reports that that evening following the telephone call her husband advised her that the provider had suggested that if he did not feel any better in the morning then the consumer could come to the surgery and receive another injection. She recalls no mention by her husband that the provider suggested hospital admission during this conversation. She did however recall her husband indicating that he wanted to go to hospital.
The following morning the consumer called the provider and indicated that he did not wish to receive the injection as discussed the previous evening but wanted to be admitted to hospital. The provider visited the consumer at his home and wrote a letter of referral to hospital. Originally the consumer was to be driven to the hospital by car, however he was too weak to leave his bed unassisted. The consumer's wife contacted the surgery and requested an ambulance to transport her husband to hospital.
The provider's letter of referral to the hospital admitting medical registrar lists the consumer's clinical problems as severe right upper lobe pneumonitis, developed pneumonia in mid-July 1996, essentially recovered, collapsed again in mid-August 1996, still very weak and short of breath. It notes that the consumer received Augmentin 500mg prescribed in mid-July 1996, Lincocin 600mg IM stat then Doxycycline. It does not record the Ceclor prescribed in early August 1996.
On admission to hospital it was noted that the consumer first developed shortness of breath in late July 1996 which had been a problem since, he also had pain between his shoulder blades and had cool peripheries. He had been seen by his GP and managed with oral antibiotics with little response. A diagnosis of pneumonia with possible pulmonary embolus was made. This was confirmed following a ventilation/profusion scan.
The consumer died in the early hours of the morning two days after his admission to hospital.
1) Every consumer has the right to have services provided with reasonable care and skill.
In my opinion the provider breached Right 4(1) of the Code of Rights.
The overall management of the consumer's illness by the provider was not carried out with reasonable care and skill.
There is little evidence of physical examinations being performed during consultations. A diagnosis of severe flu is noted without any additional information. The provider also did not keep an accurate record of the antibiotics he prescribed. On all occasions there is no indication of the length of the course of the medication. There is also no record of the strength of the dose of Doxycycline or the frequency of the dose of Augmentin.
In a statement to the Commissioner the provider advised the consumer "essentially recovered" following the consultation in mid-July 1996, yet his medical notes comment "improving slowly" without any other observation. There is no data to support either his medical notes or his statement. The provider has not provided any information on how he reached these conclusions.
In early August 1996 there is no record of any physical examination other than a blood pressure measurement.
The provider's statement advised that the consumer was feverish and showed signs of consolidation in his right upper lobe at the consultation five days before he died. The latter is a significant clinical finding yet it is not recorded in the medical notes. Additionally, the medical notes do not record the fever or the consumer's temperature.
Five days before the consumer died, the provider decided that the consumer was sufficiently unwell to warrant an injection of Lincocin and another change in antibiotic therapy. His ill health also prompted a recommendation that hospitalisation was required. The provider stated that this was declined and he then insisted on a chest x-ray. However there were no arrangements made for follow-up or review and the consumer's family were not aware of any having being made. Indeed, it was only on the advice of the radiologist that the consumer contacted the provider following the x-ray. When the result of the x-ray was notified to the provider he did not make arrangements to review the consumer even in light of his note that hospitalisation had been refused. A person who is sufficiently unwell that his doctor should recommend hospitalisation would require close monitoring to ensure that further deterioration did not occur necessitating additional discussion on the merits of hospital care.
The medical history taken from the consumer on admission to hospital two days before he died recorded "First developed SOB [shortness of breath] in late July 1996 ?and been a problem since", pain between shoulder blades and cool peripheries. They noted that the consumer had been on oral antibiotics with little response, and this supports his family's view that the consumer's health did not recover as has been stated by the provider.
The referral letter to hospital written by the provider two days before the consumer died advises that the consumer collapsed three days previously. This deterioration is not reflected in the provider's records. In this referral the provider did not give a full account of the antibiotics he had prescribed to the consumer, omitting that Ceclor was prescribed in early August 1996.
I am unable to establish whether or not there was any discussion between the provider and the consumer regarding admission to hospital before the consumer's death. The provider has noted on two occasions that the consumer refused hospitalisation in the three days before the eventual admission. There is evidence to show that they spoke to each other on those dates. However, I am unable to conclude that because the consumer did not discuss this option with his wife, that the matter was not discussed with the provider. Although the consumer's wife accompanied her husband to the surgery five days before his death she was not present during the consultation. However, it was the consumer who arranged for the provider to come to his home in the morning two days before he died.
The consumer's wife confirmed that the consumer rang the provider in the night before his admission to hospital and that the consumer had said the provider would be up in the morning to give him an injection. The next day when the provider arrived, the consumer's wife advised that the consumer said "I don't want your injection, I want to go to hospital." The following day the consumer advised his wife that another doctor told him he should have been in hospital three weeks earlier and "he was going to have a go at the provider when he got out of hospital." These statements do not give credibility to the provider's advice that he recommended hospitalisation.
The provider is to apologise in writing to the consumer's wife and her family. This apology is to be sent to the Commissioner who will forward it to the consumer's wife and her family.
A copy of this opinion will be sent to the President of the Medical Council of New Zealand.
This matter will be referred to the Director of Proceedings under section 45(f) of the Health and Disability Commissioner Act 1994 for the purpose of deciding whether disciplinary proceedings should instituted.
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