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Informed consent and adequacy of care (11HDC00871)

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(11HDC00871, 11 December 2012)

General practitioner ~ After hours clinic ~ Urinary tract infection ~ Informed consent ~ Privacy ~ Documentation ~ Appropriateness of examination ~ Chaperone ~ Rights 1(1), 4(1), 4(2), 4(4), 4(5), 6(1), 7(1)

A patient presented to an after hours clinic with a history of body aches and burning while urinating. The patient advised the doctor that she suspected she had a urinary tract infection.

The doctor performed an unchaperoned examination of the patient, including an examination of the patient's upper and lower body that involved the doctor touching the patient's legs, groin, breasts and back. During the lower body examination the patient was naked from the waist down. During the upper body examination she was fully naked. The patient was not given any privacy to undress or dress, nor was she provided with a cover. The doctor did not wear gloves during the examination. The patient's clinical notes were altered numerous times following the completion of the examination.

It was held that the doctor breached Right 6(1) for failing to provide the patient with sufficient information about the proposed examination and therefore also breached Right 7(1) for not obtaining the patient's informed consent.

It was also held that the doctor breached Right 4(1) because the examination was not clinically indicated. For failing to wear gloves during an intimate examination the doctor breached Right 4(2), and for failing to inform the patient of her right to have a chaperone present the doctor breached Right 6(1).

The overall manner in which the doctor conducted the examination lacked respect. Therefore, it was held that the doctor breached Right 1(1). For altering the clinical records the doctor breached professional standards and accordingly breached Right 4(2). Furthermore, the doctor's actions may have impaired the ability of other providers to provide continuity of care to the patient and, as a result, the doctor failed to minimise the potential for harm to the patient. Accordingly the doctor breached Rights 4(4) and 4(5). The doctor was referred to the Director of Proceedings. The Director decided to institute a disciplinary proceeding, which is pending.

The clinic was found not to have breached the Code.

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