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Decision No: 00/60D
Practitioner: Dr Ngaamo Russell Thomson
Charge Characteristics: Inadequate notes
Failure to recognise significance of symptoms
Inadequate care and treatment
Lack of informed consent
Proceeded when should not have
Failure to refer
Additional Orders: None
Decision: 0060dfindings
Penalty Decision: 0060dfindingssup

 

Charge:  

The Director of Proceedings charged Dr Thomson with professional misconduct. The particulars were as follows:

  1. He failed to recognise the seriousness of the patient's medical condition when he attended upon her;
    AND/OR
  2. He failed to establish and follow an appropriate treatment plan consistent with the symptoms of the patient;
    AND/OR
  3. He failed to refer the patient immediately to hospital;
    AND/OR
  4. He inappropriately administered an oral preparation to the patient;
    AND/OR
  5. He failed to obtain the patient's informed consent to his proposed treatment plan;
    OR
  6. He failed to take reasonable steps to ascertain the patient's view on his proposed treatment plan, including taking into account the views of the patient's whanau as to what was in the patient's best interests;
    AND/OR
  7. He failed to keep a full and accurate clinical record of his attendance on the patient and his proposed treatment plan.

 

Background: 

The charge related to Dr Thomson's treatment of a patient on 3 September 1996. He attended her at her home. The patient was suffering from a subarachnoid haemorrhage (a leaking blood vessel bleeding in to the membranes surrounding the brain), and complications of that condition led to her death on 16 September 1996.

Dr Thomson had seen the woman as a patient earlier in 1996 when his clinic was offering free health checks. As a result of some tests he advised the patient she should make some lifestyle changes as she was at risk of a stroke. Dr Thomson said that after he told her this the patient told him if she ever got into that condition she did not want to be left in hospital and would rather stay home.

Early in the afternoon of 3 September the patient was at home with a friend when the patient very suddenly became seriously unwell. An ambulance arrived quite quickly. The Tribunal concluded the ambulance staff:

  • Observed that the patient was experiencing a fit or seizure,
  • Put the patient into a safe position (the recovery position - on her side on the floor),
  • Established from the people present that she had not been unwell until the sudden collapse, she had no   known history of epilepsy or seizures, and was not known to be taking medication or subject to allergies,
  • Administered oxygen,
  • Took the patient's blood pressure (systolic only - by palpation), pulse, and ECG and blood sugar levels.

Dr Thomson arrived and was briefed by the ambulance officers and then instructed the ambulance officers to stop administering oxygen. Dr Thomson carried out motor tests and the patient was able to function normally. Dr Thomson then allowed the patient to go to the toilet. The ambulance officers told Dr Thomson they did not consider that this was appropriate. They thought she should remain on the floor as they were concerned the patient could have some type of intracranial haemorrhage. While in the toilet the patient had another collapse or fit, with lessened level of consciousness.

The patient regained consciousness after being assisted from the toilet. Dr Thomson told the ambulance staff to leave as the patient would not be transported to hospital. Before the ambulance staff left they made it clear to Dr Thomson that they believed the patient's condition was serious and she should be in hospital. The patient asked for a Koromiko leaf infusion to drink. Dr Thomson arranged for the infusion to be made, it was not materially (if any) more viscous than water. The patient drank a small quantity of the infusion and vomited. Dr Thomson arranged for the patient to be put into her bed.

Dr Thomson left the patient and told the people at her home that if anything untoward should happen they were to ring him and that in any case he would return later.

One of the ambulance officers was very concerned about the management plan Dr Thomson had set up for the patient so she contacted another practitioner. The other practitioner considered he could not go to the patient's home without an invitation from the patient or her family. About 1 hours later the patient's daughter called the other practitioner requesting that he attend the patient. The ambulance brought the patient to a hospital where the other practitioner examined her. He made a provisional diagnosis of cerebral haemorrhage. The patient had another seizure and became deeply unconscious. The other practitioner contacted the air ambulance service and asked that they transport the patient to a larger hospital.

Dr Thomson, as he had said he would, returned to the patient's house some time after 4 pm. When he got to the house, Dr Thomson was told a second opinion had been obtained, and that the patient had been admitted to hospital.

The patient did not regain consciousness, and she died on 16 September 1996.

 

Finding:

The Tribunal found that Dr Thomson was guilty of professional misconduct.

The Tribunal concluded particular 1 was not established. The Tribunal were satisfied that Dr Thomson knew the patient's condition was serious and that it was very likely to be an intracranial haemorrhage.

The Tribunal concluded particulars 2 and 3 were established and determined that those particulars were in themselves sufficient to establish the charge of professional misconduct. In reaching that conclusion the Tribunal has regard to the following facts:

  • Urgent definitive diagnosis was demanded by the symptoms the patient presented when examined by Dr Thomson. That could have led to important medical or surgical intervention, though as it transpired in the patient's case nothing that could alter the outcome was possible - but Dr Thomson could not know that when he examined the patient.
  • The patient was in extreme pain, and she was likely to be able to be made more comfortable in hospital.
  • It was not safe to leave the patient with no medical professional in attendance when she was vomiting and experiencing varying levels of consciousness.
  • The inappropriateness of failing to urgently transfer the patient to a hospital, and leaving her unattended is all the more grave due to the fact that Dr Thomson dismissed an ambulance and the attending staff. The ambulance staff were preparing to transfer the patient to hospital, and they specifically drew Dr Thomson's attention to the seriousness of the situation. This was not a case were Dr Thomson was simply tardy in taking appropriate action, he actively intervened to stop the appropriate, necessary and conventional response to the patient's circumstances.

The Tribunal did not consider particular 4 established as they found Dr Thomson's actions appropriate.

The Tribunal considered the issue of informed consent (particulars 5 and 6) and was satisfied lack of informed consent was not made out as an element of the charge. The patient was not in a position to give informed consent to a treatment plan as she was in too much pain. Her capacity for sound decision making was severely compromised by her condition, and in addition full consultation with her whanau was not immediately possible. The Tribunal found Dr Thomson's obligation was to provide the most appropriate care unless and until the patient and/or her whanau were in a position to give informed consent to do otherwise.

Dr Thomson raised informed consent (in a discussion some six months earlier) as a justification for not providing the patient with the optimum care. The Tribunal concluded that claim must fail on the facts. The discussion Dr Thomson and the patient had some six months earlier did not amount to informed consent that excused Dr Thomson from having the patient transported to hospital urgently.

The Tribunal found particular 7 was established and that it is a professional obligation to keep adequate clinical records. Dr Thomson's notes were inadequate.

 

Penalty:

The Tribunal noted Dr Thomson had been found guilty of professional misconduct before in March 1996.

The Tribunal ordered Dr Thomson be censured, pay a fine of $5,000 and $23,225.38 towards the costs and expenses of the investigation, prosecution and the hearing of the charge.

The Tribunal also ordered that Dr Thomson practise for three years, on the condition that he works under the supervision of another registered medical practitioner who is engaged in general practice, and works for the time being on a full-time basis in the same premises in which Dr Thomson's practice is located. Any medical practitioner in the supervision role shall be supplied with a copy of the initial decision, this decision, and a copy of such materials relating to the competence review that the Medical Council sees fit; that practitioner shall also have full and free access to all clinical records maintained by Dr Thomson subject to any limitations the practitioner in the supervising role considers appropriate to preserve reasonable patient confidentiality.

The Tribunal further ordered publication of the hearing in the New Zealand Medical Journal.