|Practitioner:||Dr Lynne John|
|Charge Characteristics:|| Failure to
recognise significance of test results
Failure to refer
The Director of Proceedings charged that Dr John was guilty of conduct unbecoming a medical practitioner and that conduct reflected adversely on her fitness to practise medicine. The particulars of the charge were as follows:
Dr John accepted the factual basis of all the particulars but she contested whether those failures and/or omissions amounted to conduct that reflected adversely on her fitness to practise medicine.
Dr John was a general practitioner in Rangiora, which is located approximately 45 minutes north of Christchurch. It was accepted that, in 1997, Rangiora Hospital was 'one step up' from a home birth in that it was not equipped to carry out a complicated birth, or emergency caesarean operation if that became necessary. It could not provide any specialist paediatric care. Dr John had an access agreement with Christchurch Women's Hospital and was able to transfer patients there for care and/or treatment, if necessary.
The patient was pregnant with her third child, which was due on 11 May 1997. The patient had had two previous normal pregnancies and had not required pain relief for either labour. Her first two babies weighed 3.7kg and 3.75kg respectively.
The patient had a paternal family history of diabetes. A glucose challenge test was performed when the patient was 28 weeks pregnant. The lab report, as a result of that test, suggested the patient may have gestational diabetes and indicated a full glucose tolerance test was desirable.
Dr John arranged for a full glucose tolerance test to be performed. The laboratory report recorded a fasting blood glucose of 5.8mmol/L. The guidelines under which Medlab in Christchurch was operating provided that a reading of 5.5 or above was diagnostic of gestational diabetes. It also noted that no one-hour blood sample had been received, and that a further test was desirable. Dr John accordingly referred the patient for a further fasting glucose test. A fasting blood test indicated a glucose level in the normal range at 5.0. Dr John considered that this test result excluded gestational diabetes.
One of the risks associated with gestational diabetes is macrosomia (large baby). Both Dr John and the midwife agreed that the patient was carrying a large baby. At term Dr John considered the baby to be larger than normal and estimated its weight to be around 4.0kgs.
On 22 May 1997, at 40 weeks plus 10 days, devliery was induced at Rangiora Hospital.
In 1996 a new section 51 notice (Maternity Notice) under the Health and Disability Services Act 1993 had been issued and it set out the criteria for referral to specialist obstetric services. The notice criteria required the Lead Maternity Carer to recommend to her patient that a specialist consultation was warranted prior to an induction of labour. Dr John did not consult a specialist about the decision to induce or discuss referral with the patient.
At 8.00am Dr John began the induction of labour using a Prostin pessary. Contractions commenced between 4.00pm and 5.00pm. An artificial rupture of membranes was performed at 8.25pm and the liquor was clear. Dr John told the patient that she expected her to deliver her baby by midnight. At 10.30pm the patient's cervix was 5cm dilated. It is recorded in the clinical notes by the midwife that the head was at station minus 2.
At approximately 11.15pm the cervix was 7cm dilated and the baby's head still at station minus 2. The patient asked to transfer from Rangiora Hospital to Christchurch Hospital as she was becoming concerned about her lack of progress, her level of pain and that the labour seemed harder than in her previous pregnancies.
The midwife discussed this request with Dr John by telephone at 11.30pm. Dr John instructed the midwife to offer Pethidine for pain relief. The patient agreed, and the pain relief was given at 11.50pm. The patient was not transferred to Christchurch Hospital.
At 1.20am the midwife considered that the patient was almost fully dilated, with an anterior lip remaining. The station was recorded at minus 2. Dr John, assuming that the patient would be about to deliver (on the basis of information provided by the midwife), arrived at Rangiora Hospital at approximately 1.30am. She performed a vaginal examination at 2.00am and found the cervix to be less dilated than the midwife had judged. The cervix was assessed at 8 - 9cm dilated. She considered that there was substantially more than the anterior lip remaining. Progress of labour continued to be slow. At 3.45am the cervix was fully dilated. The patient commenced pushing and was still pushing without much change at 4.35 am. The uterine contractions had slowed to one every 5 minutes.
The patient agreed to continue trying until 5.00am, at which time Dr John decided to attempt delivery using a ventouse. The position of baby's head was recorded as station zero. The ventouse was first applied at 5.10am. Foetal bradycardia was noted at 5.20am when the heart rate was noted at 90 to 110 beats per minute. A final traction was applied at 5.21am and, with good maternal effort, the head descended much more easily to crown.
The baby's head was delivered at 5.25am. The baby's shoulders became impacted (shoulder dystocia), Dr John was unable to complete the delivery of the baby and a local GP was called to assist. Dr John also contacted Christchurch Women's Hospital for assistance. Some 15-20 minutes later a private obstetrician who resided in the Rangiora area was called and the baby was delivered at 5.52am by the obstetrician. On delivery he was floppy, with no discernible heart rate or respiratory effort. He weighed 5.6kgs. Resuscitation was commenced immediately and the baby was transferred to Christchurch Women's Hospital by ambulance with Dr John in attendance. The baby died that evening.
The Tribunal found Dr John guilty of conduct unbecoming and that conduct reflected adversely on her fitness to practise medicine.
In considering Particular 1, the Tribunal took into account that during the patient's pregnancy Dr John carried out at least 12 urine tests, none of which showed the presence of glucose that might have indicated gestational diabetes. The Tribunal was satisfied that while Dr John may have made some small error of judgment or done something differently, she nevertheless acted reasonably and within appropriate and accepted professional standards. The Tribunal made this finding on the basis of the information available to Dr John at the time and came to the view that if it were to find Particular 1 established, it could only do so with the benefit of hindsight and applying the counsel of perfection.
The Tribunal found that Particular 2 was established. The Tribunal was satisfied that Dr John should have discussed the patient's induction with a specialist obstetrician prior to inducing her, and her failure to do so constituted an unacceptable discharge of the professional obligations she owed to the patient. It also constituted a failure on Dr John's part to meet acceptable and appropriate professional standards.
The Tribunal took into account the possibility that a specialist obstetrician would have accepted Dr John's assessment and agreed that the induction should proceed. However, the Tribunal considered it equally likely that had all of the relevant facts and the patient's clinical presentation been accurately and completely reported, the specialist obstetrician would have either asked to see the patient, or offered information or advice which Dr John did not consider.
The Tribunal found that Particular 3 was established. The Tribunal considered that, by 4.30am at the latest, it had become obvious that labour was obstructed and that Dr John should have realised that meaningful progress had ceased. By that point at the latest Dr John should have made a diagnosis of obstructed labour and to apply the ventouse with the baby's head at station zero, or even at minus-one, was ill-advised.
The Tribunal ordered that Dr John be censured; pay a fine of $2,000; pay $10,789.33, being 20% of the costs and expenses of and incidental to the inquiry, prosecution and hearing of the charge.
In view of Dr John's decision to give up her obstetric practice, the Tribunal did not consider that there was any purpose in ordering that conditions be placed on her practice.
The Tribunal further ordered a notice of the hearing be published in the New Zealand Medical Journal.