|Practitioner:||Dr Leon van Rhyn|
|Charge Characteristics:|| Proceeded
when should not have
Failed to obtain informed consent
Failed to refer
|Interlocutory Issues:||Application by the doctor for
of the charge as filed in the Tribunal by the CAC - upheld. (R v CAC,
(High Court, Wellington CP No. 183/01, Durie J, 9 November 2001))
Appeal filed by the CAC, of the decision in the High Court allowed in part. (CAC v R, Court of Appeal, CA 282/01, Fisher J, 20 June 2002)
A Complaints Assessment Committee charged Dr Leon van Rhyn with disgraceful conduct in a professional respect. The particulars of the charge alleged Dr van Rhyn:
… failed to obtain Margaret van Rhyn’s informed consent to forcibly administer psychotropic medications and antidepressants to her when no committal order was in existence at the time and/or;
… failed to inform Waikato Hospital by admission note when Margaret van Rhyn was admitted on or about 3 February 1997 that he had been prescribing benzodiazapines for a prolonged period and/or;
… failed to keep a full and accurate record of Margaret van Rhyn’s mental state, his diagnosis and his prescribed treatment plan for her;
… self prescribed Imovane, a sleeping tablet for a few months without any supervision or monitoring by another practitioner, and/or;
… administered to Margaret van Rhyn, psychoactive drugs, antidepressants and tranquillisers from drug company samples without the drugs being formally prescribed and documented;
… treated Margaret van Rhyn in circumstances where his clinical judgment was or could have been impaired, and where it was in the best interests of the patient to refer on to an independent general practitioner.
In the latter half of 1996 and early 1997 Mrs van Rhyn had a major depressive illness. Dr van Rhyn was Mrs van Rhyn’s general practitioner. Dr van Rhyn maintained he had no alternative other than to treat his wife. He said that his wife failed to appreciate the seriousness of her illness and resisted all of his efforts to have her assessed and treated by other doctors. He treated her with a variety of medications including Aropax (an antidepressant) and Oxazepam (a benzodiazepine).
Mrs van Rhyn’s condition did not improve. On 3 February 1997 Mrs van Rhyn went to a psychiatrist in Hamilton who concluded Mrs van Rhyn was very depressed and needed assistance urgently. The following day Dr van Rhyn took his wife to Waikato Hospital, where she remained until 2 April 1997. For a part of that period she was admitted under the Mental Health (Compulsory Assessment and Treatment) Act 1993. She was administered ECT on 8 occasions whilst in hospital.
The CAC alleged Dr van Rhyn continued to act as Mrs van Rhyn’s general practitioner when she was in hospital and provided input into Mrs van Rhyn’s care whilst she was in hospital. After Mrs van Rhyn’s discharge from hospital Dr van Rhyn continued to provide psychiatric care to his wife even though she was at that stage under the care of the Community Mental Health Service, an outpatients clinic of Waikato Hospital.
The CAC alleged Dr van Rhyn administered medication to his wife in a haphazard way and that he failed to keep proper records of the treatment he was providing.
Dr van Rhyn prescribed Imovane, a sleeping tablet, for himself without supervision or monitoring from another practitioner. He denied his conduct justified a disciplinary finding against him because the medication he took was for a short period of time.
The Tribunal found Dr van Rhyn guilty of professional misconduct.
The Tribunal was in no doubt Dr van Rhyn was fully cognisant of his ethical duty not to treat his seriously ill wife. He could not simultaneously discharge his functions as a husband and comply with his professional obligations as a doctor when he elected to treat his wife from at least September 1996 to December 1997. The Tribunal was unanimously of the view Dr van Rhyn seriously breached his ethical obligations by treating his wife’s serious illness during that period. However, it was of the view that while his breaches of his ethical obligation were serious his conduct did not deserve “the strongest reprobation” which a finding of disgraceful conduct in a professional respect would have indicated.
A majority of the Tribunal was satisfied that Particular 1 was established. The Tribunal considered there was a minor deficiency in the wording of this aspect of the charge. Antidepressants are “psychotropic medications”. It would have been better to describe the medication administered to Mrs van Rhyn as “psychoactive drugs”.
Dr van Rhyn cajoled, threatened and intimidated Mrs van Rhyn into taking Aropax and Oxazepan. He did not physically restrain her and physically force her to ingest these drugs but he did go to extraordinary lengths to ensure she took the medication he was prescribing her.
A majority of the Tribunal was of the view Dr van Rhyn failed to adhere to the standards which the profession and the community expect of a doctor when he forced his wife to take medication against her wishes. The Tribunal considered he could not suggest that when he forced his wife to take medication he was acting solely in his capacity as her husband. When it came to the administration of medication he could not say that he was her husband for some purposes and her doctor for others. The Tribunal found it was Dr van Rhyn’s failure to draw appropriate boundaries between his role as husband and his role as a doctor which was the central point of this case.
A majority of the Tribunal believed Dr van Rhyn’s actions and omissions relating to Particular 1 of the charge constituted professional misconduct and justified a disciplinary finding.
The Tribunal found that Particular 2 was not established. The Tribunal noted that while it was correct Dr van Rhyn did not provide Waikato Hospital with an admission note concerning his wife, he did attend with his wife when she was admitted and explained to the Registrar on duty the circumstances which led to her admission, including the medication she had been prescribed. The Tribunal found the failure to record this in an admission note did not constitute a disciplinary offence.
The Tribunal was satisfied Particular 3 was established. It considered the records Dr van Rhyn kept on his wife were totally inept. He appeared to have only made two clinical notes relating to his wife’s treatment during the period he was managing her very serious illness. The Tribunal considered it is a fundamental component of a doctor’s duty to fully and accurately record their diagnosis and treatment plans – particularly in cases of serious mental illness.
A majority of the Tribunal found that Particular 4 was not established. It was not satisfied to the requisite standard Dr van Rhyn was taking sleeping tablets for a few months and/or that his taking of sleeping tablets in the circumstances without supervision or monitoring by another practitioner constituted a disciplinary offence. Although Particular 4 was not established the Tribunal wished to stress that any medical practitioner taking sleeping tablets on a regular basis should consult with another practitioner to ensure they are safely prescribing.
When considering Particular 5 the Tribunal considered a formal finding in relation to this particular would in essence constitute a repetition of the findings made in relation to the third particular of the charge. Accordingly the Tribunal made no finding in relation to Particular 5 of the charge.
The CAC explained that the allegation contained in Particular 6 was the “crux of the case” against Dr van Rhyn. The Tribunal was in no doubt Dr van Rhyn was under considerable stress during the latter part of 1996 and 1997. His family were struggling to come to terms with their new country. Mrs van Rhyn’s health deteriorated to the point where she became seriously unwell. Dr van Rhyn was endeavouring to establish a medical practice in a new environment. The van Rhyns' marriage may also have been under stress at this time.
Dr van Rhyn blurred the boundaries that he needed to maintain between being a doctor and fulfilling his role as Mrs van Rhyn’s husband. His judgment in these circumstances could well have been impaired. It was certainly not in Mrs van Rhyn’s best interest for her husband to continue to be her general practitioner. The circumstances surrounding her being coerced into taking medication illustrate the difficulties in Dr van Rhyn treating his wife.
The Tribunal was satisfied Particular 6 was established and that Dr van Rhyn’s acts and omissions constituted professional misconduct.
The Tribunal ordered Dr van Rhyn be censured, fined $5,000 and practise subject to a condition that for a period of one year from the date of the Decision he identify and manage ethical issues in a manner consistent with the standards expected of a general medical practitioner in New Zealand as part of the continuing education component of general oversight.
He was further ordered to pay costs of $28,054.83 (25% of the total costs in relation to the inquiry, prosecution and hearing of the charge).
The Tribunal further ordered publication of the above orders in the New Zealand Medical Journal.