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
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 (6thDecember), 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 notexamined 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.