An elderly patient with pneumonia

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But in some cases, your explanation is unsatisfactory; our in-house advice from Dr Tiller suggests that there are some care deficiencies; and the complainant has unanswered questions. Depending on the gravity of the issues, we may decide to undertake a formal investigation. Last year that happened in only 25 cases, resulting in 9 findings that the GP breached the Code of Patients' Rights. A recent case, triggered by a complaint against a medical officer in general practice, is illustrative of an HDC investigation leading to a breach finding - and highlights the need for care in seeing an unwell, elderly patient for the first time.1

An unwell patient on Friday afternoon

Mrs A, aged 73, was brought into Dr B's surgery (in a provincial city) by her neighbour at 3.30pm on Friday 13 October 2006, having been found unwell at home the day before. Mrs B had been a patient of the surgery since 2002, but had always seen Dr B's partner. According to the neighbour, Mrs A needed her arm to walk into the examination room and "appeared to be very poorly". But Dr B (who kept no records of the consultation, except for a record of the medication he prescribed and a blood test request - a matter discussed further below) recalled that Mrs A was "alert and orientated" with no evidence of confusion or shortness of breath.

Dr B took a history (tiredness and a recent dry cough), and examined Mrs A's chest (from the back), throat and ears. He also claimed that he checked her pulse, and enquired about her passage of urine ("good amounts") and fluid intake. He did not take her temperature or blood pressure. Dr B diagnosed a viral chest infection, arranged for Mrs A to have a blood test, prescribed Panadol and a repeat of Tamoxifen, and told her to drink lots of fluids. He claimed (but the neighbour denied) that he checked that Mrs A had help at home, and said that she should seek further medical review if her condition did not improve.

Deterioration and death

Mrs A's daughter came to stay with her mother that evening. She was shocked to find her "dehydrated and delirious", but trusted the opinion of Dr B who had seen her mother only a few hours earlier. But when Mrs A's condition had not improved the following day, her daughter called an ambulance. On arrival at the Emergency Department of the local hospital, Mrs A was found to be "dehydrated, febrile, unwell for 1 week, coughing … green/brown phlegm". Her blood pressure was 73/46mmHg, temperature 38.8°C, pulse 120 beats per minute, respiratory rate 36 breaths per minute, and oxygen saturations 68%. She was diagnosed with pneumonia and septic shock and transferred to ICU, where she died one week later. The hospital let Dr B's practice manager know a few days later. Dr B was surprised by the news, as he had not thought Mrs A was that unwell, given "how well she appeared the day prior to her admission to hospital".

Complaint to HDC & Dr's response

In January 2007, Mrs A's daughter complained to HDC that Dr B's treatment of her mother had been inadequate. She wrote, "I lost my mother due to [the doctor's] negligence … he failed to return my phone call … he is not fit to, nor should be allowed to practise medicine." Of course it is not HDC's role to determine whether a doctor's acts or omissions caused a patient's death, but we did need to seek Dr B's comments on the complaint.

Dr B advised HDC (in March 2007) that he had inadvertently failed to save his notes of the consultation in the electronic records system (which used MedCen software), even though the record of the medication he prescribed and a blood test request had been saved. But because the death was unexpected, the details were "embedded in his memory". He was able to recall numerous clinical observations, including precise pulse and respiratory rates. Dr B had also failed to record the review he claimed to have undertaken when notified of his patient's death - an obvious opportunity to have made a postdated record of the consultation. (He later said that he thought it was "illegal" to do so.)

Our in-house advice from Dr Tiller was that Dr B's chest examination had been inadequate to exclude secondary chest infection following the flu. And it was obvious that his record-keeping was poor, yet his memory remarkable. In short, Dr B's response raised more questions than it answered, and we decided that the case warranted closer scrutiny. In March 2007, HDC notified Dr B that we had commenced an investigation into "the appropriateness of the care" he provided to Mrs A on 13 October 2006.

HDC investigation

Our investigation took four months, the only delays resulting from Dr B seeking more time for legal advice. His varying explanations stretched credulity. For example, he claimed that he "overlooked" documentation of the consultation because of a "human error" on his part, in opening the door for Mrs A as she left the consultation - "as a courtesy rather than due to a clinical requirement". This led him to fail to save his notes in the electronic patient records ("I discovered the notes of the consultation had not been saved").

As HDC's independent expert, Dr Keith Carey-Smith, pithily observed, Dr B must have "an unusually accurate memory" to be able to recall the details of the consultation some months later, especially as a busy practitioner seeing 20 to 30 patients a day. The lack of records limited Dr Carey-Smith's ability to advise on the standard of care, but some omissions were evident:

"A standard general practice examination of a patient with [Mrs A's] presentation (cough and tiredness) should include:

•    Full chest examination including percussion and auscultation of chest (all areas).

•   Brief examination of cardiac and peripheral vascular system (heart, blood pressure, ankle oedema, peripheral circulation), nervous system (cognition, limb weakness, coordination etc), and abdomen."

Dr B's chest examination was deficient in not checking fully for consolidation, and the failure to take Mrs A's blood pressure was "a significant deficit". As noted by Dr Carey-Smith, "Pneumonia and/or septicaemia can develop insidiously and without clear physical signs and symptoms in elderly people. For this reason a fuller examination than normal, including focus on the general condition of the patient, is necessary." He described Dr B's examination as "cursory and incomplete".

I formed a provisional opinion that Dr B's care and record-keeping had been substandard, and amounted to a breach of the Code of Patients' Rights, warranting referral to the Director of Proceedings. As required by law (and fairness), I notified Dr B of my provisional view. At this stage, he sensibly took legal advice. In his response to the provisional opinion, he acknowledged that he should have conducted a more thorough examination of Mrs A, and stated: "I wish that the notes that I thought I had made had been preserved to support now my recollections of the assessment."

Dr B forwarded advice he had obtained from Dr David Kerr, who had reviewed the case. Dr Kerr noted that Dr B's "memory must be in very good state to recall thus details of the consultation … but possibly the subsequent events have kept his recollections alert". He agreed with HDC's expert that auscultation of the entire chest and recording of blood pressure was required. Dr Kerr commented that Mrs A seemed to have had a rapidly progressive deterioration over the 24 hours from her consultation with Dr B to her hospital admission.

Dr B pleaded a number of factors in mitigation: he had discussed the case with his vocational overseer, initiated procedures to ensure consultation notes are always saved, and arranged an audit of the quality of his clinical assessment. The practice had also instituted daily audits by the receptionist, to check that records have been kept of all consultations. Dr B stated that he had "taken on board very seriously the need for increased vigilance in the assessment of elderly patients". Interestingly, given the total aversion of most doctors to Medical Council competence reviews, Dr B was even "happy to accept the recommendation of a referral to the Medical Council for a review of [his] practice". But he submitted that referral to the Director of Proceedings would be "a draconian response".

HDC findings

I considered it unarguable that Dr B had breached professional standards and the Code of Patients' Rights, concluding:

"Dr B's examination of Mrs A on 13 October 2006 was cursory and incomplete. The deficiencies in his assessment were significant and represent a major failing in the care of an unwell 73-year-old patient who was unfamiliar to the treating doctor."

A full history and examination was "all the more important since Dr B was not Mrs A's usual doctor, and was seeing her for the first time".

And I was singularly unimpressed by Dr B's lack of records and inconsistent explanations, noting:

"Dr B also failed to record his assessment at the time, or retrospectively when he claims he undertook a subsequent review. … Dr B's omissions are compounded by the question marks over the credibility of his responses to Mrs D's complaint and to this investigation."

Nor was Dr B's concern that it took Mrs A's daughter 23 hours to call an ambulance, if she really found her mother "dehydrated and delirious", particularly edifying - after all, the daughter understandably trusted the opinion of the doctor who had seen her mother only a few hours beforehand. One can also imagine how hurtful a comment like this would be for a grieving family member.

Conclusion

It is always hard trying to balance the desire to take a rehabilitative approach with the need for professional accountability. I was willing to give Dr B some credit for the steps he had taken since this case. But I was left with an abiding impression of a practitioner whose care of an elderly, unwell patient had been slack. In my view, he fell well short of the standards expected of a responsible doctor in general practice. I referred him to the Medical Council for a competence review. And, taking into account Dr B's plea for clemency, the family's desire for further proceedings, and the public interest in accountability in appropriate cases, I referred Dr B to the Director of Proceedings. In the event, the Director decided not to issue proceedings, noting evidential difficulties and doubting whether the threshold for professional discipline would be reached. Hopefully, Dr B has learnt a salutary lesson.

Ron Paterson
Health and Disability Commissioner
New Zealand Doctor, 12 September 2007

1 The full case, 07HDC01315, may be viewed at www.hdc.org.nz.