|Practitioner:||Bodiabaduge Camillus Leonard Annesley Perera|
|Charge Characteristics:|| Inadequate
care and follow-up
Failure to refer to a specialist and/or seek specialist advice
Failure to act on significant symptoms
|Additional Orders:||Doctor denied interim name
Doctor denied interim name suppression after re-consideration of Tribunal's initial Order: 0186dfindingsreviewnamesup
|Appeal:||Doctor appealed the Decision and
the Penalty Decision to the District Court.
District Court upheld Tribunal findings. Further it upheld the penalty but reduced the fine. Perera v MPDT (District Court, Whangarei, MA 94/02, Hubble DCJ, 10 June 2004)
The Director of Proceedings charged Dr Bodiabaduge Camillus Leonard Annesley Perera with professional misconduct in that:
He failed to investigate, or adequately investigate, causes of the patientís clinical presentation at any time following the Computerised Topography (CT) scan of her head; and/or
He failed to act upon suspected meningococcal disease and/or meningitis by commencing treatment with the administration of antibiotics; and/or
Between 4.00am and 6.00am on 17 July 1999 he failed to consult with, and/or transfer care of the patient to an appropriately qualified specialist in a timely manner; and/or
Prior to leaving the hospital between 5.00am and 6.00am on 17 July 1999 he failed to adequately communicate his diagnosis and management plan to family and staff.
On 14 July 1999, the patient, then aged 14 years, had an accident at school during a P.E. class. Her friend let go of a barbell which landed on the bridge of the patientís nose. On the evening of 15 July, she had a headache. She took some Panadol and was fine the next morning.
Around midnight on 16 July 1999 the patient started vomiting and she had a very bad headache. Her mother, an enrolled nurse, took her to hospital where she was put into a wheelchair as she was unable to walk. At around 2 am on 17 July 1999 a Senior House Officer (SHO) saw the patient. He noted that when she arrived at the hospital she had had normal observations for blood glucose, oxygen saturation, respiratory rate, heart rate, and temperature. Her Glasgow Coma Score (GCS) was initially 13/15. Her blood pressure was recorded in the notes initially as 74/49. The nurseís notes showed a deteriorating GCS score: at 0200 it was 12, at 0340 it was 6, and then 5.
The SHO considered that the patientís deterioration in consciousness, was probably due to a space-occupying lesion, most likely a haemorrhage, or perhaps a brain tumour. Meningitis was his second differential diagnosis but he felt it was unlikely in view of the history of head trauma, normal temperature and absence of haemorrhagic rash or neck stiffness.
By about 3.30 am the patient was not responding to verbal commands and her oxygen saturation level was poor. It was decided to put in a guedal airway to assist her breathing and to call an anaesthetist as she would need intubating and ventilating in order to manage the CT scan. The patient was too restless to lie still for a long enough period.
The SHO telephoned the on-call anaesthetist, Dr Perera. Dr Perera said that at the Emergency Department he immediately assessed the patient and conducted a physical assessment. He said that on examination she was in extreme extensor spasm and in decerebrate rigidity. He noted her Glasgow Coma Score to be 4-5/15. He said he looked at her face and those areas not covered by clothes but could not see any rash.
The CT scanning was completed at 4.25am. The result of the scan was that it was a normal scan, there was no compression of the brain, no evidence of bleeding, and the ventricles were normal. As they were moving out of the CT unit the patientís mother recalled a male voice saying while Dr Perera was present that the patient must be suffering from some sort of infection. She asked ďwhat sort of infection?Ē but no-one responded. Dr Perera said he had no recollection of that being said at that time.
The SHO said he was surprised at the time that the scan was normal and asked Dr Perera if a lumbar puncture for meningitis was indicated. The SHO recalled Dr Pereraís reply was ďno, not at the momentĒ. Dr Perera said he would take the patient to the Intensive Care Unit where she would spend the night ventilated.
The patient was transferred to the Intensive Care Unit (ICU) where she arrived some time between 4.30 and 4.40am. A nurse (Nurse C) helped to transfer her from the Emergency Department bed to the ICU bed. She noted that the patient did not respond to being moved. She enquired about her sedation and was told she had been given no further sedation since being intubated. She thought it unusual that the patient did not respond to being moved if she had not received further sedation.
Nurse C checked her pupils as she was concerned about the patientís failure to respond. They were dilated, 4mm in diameter and reacted sluggishly. She connected the patient to the ECG monitor leads and printed out one or two ribbon strips. Her heart rhythm was sinus tachycardic (a normal beat but a fast rate) with ventricular ectopics (where every 3rd or 4th beat was abnormal). Nurse C was concerned as it was unusual for a previously fit and well young person to have a heart rhythm like that in the absence of any underlying heart condition. The patient was connected to a non-invasive blood pressure cuff (NIBP) which showed a very high blood pressure of 180/110 and mean arterial pressure (MAP) of 130.
Nurse C noted that Dr Perera administered intravenous morphine and intravenous labetolol following which the patientís blood pressure dropped to 150/93, MAP 115.
Nurse C brought the ECG trolley to the patientís bed as she wanted a 12 lead ECG to obtain base line data of her heart rhythm given that it was in runs of normal and abnormal rhythms. She said that Dr Perera asked her what she was doing and why. She said she explained and Dr Perera replied that the patient was now in a normal rhythm and told her not to activate this. She said she showed him a copy of the heart trace but no orders were given.
She requested an arterial and central line be inserted into the patient and brought the necessary equipment trolleys to the bedside. She explained that an arterial line gives a continuous blood pressure reading as well as a port for drawing blood. The NIBP can be read every minute. The patient had only one peripheral line in her left arm on arrival and Nurse C thought it would be better to insert a central line as it would give a wider line in a blood vessel to give fluids or drugs to the patient. She explained most drugs to control heart rate must go through a central line. Dr Perera declined to insert the lines saying that the patient was to be ventilated for a short time only and that she would be weaned and woken in the morning.
Nurse C said she asked Dr Perera ďweaned from what?Ē to which he did not answer and walked away. She said she asked that question because the patient was not on a sedation infusion and she was concerned about her condition at that stage. The management plan of ďwake and weanĒ did not, to her, seem congruent with the patientís condition. All she was aware of regarding the patient was that her CT was normal and she was for wake and wean in the morning. Dr Perera said in his view the patient was critically ill but stable.
The patient was assigned to Nurse CD, who was new to the ICU. He believed that because it had been said that the patient would be in for intubation for a short time only and for ďwake and wean in the morningĒ it was appropriate to assign her to his care. He too noted that the patient was sedated and unconscious but was twitching. He had not seen twitching before in sedated patients. He remembered the nurses commenting on it and he knew it was mentioned while Dr Perera was still in the ICU. He said the patientís pupils were 3-4mm in size and reacted sluggishly.
Nurse CD said it was apparent before Dr Perera left the ICU that the patient had very high blood pressure, her heart rate was tachycardic with some ectopic beats which, to him, was a sign of concern in a 14 year old child and that those readings were evident from the screen monitor to which she was connected. He said he expressed his concern about her blood pressure to Dr Perera who then gave the patient an anti-hypertensive drug and more sedating and paralysing drugs.
Nurse CD said that other nurses asked Dr Perera to insert an arterial line and an in-dwelling catheter and a nasogastric tube but that Dr Perera declined saying that those measures were not necessary because the patient was for wake and wean in the morning.
The patientís mother said that on arrival at ICU, the nursing staff were ready with all necessary emergency equipment but Dr Perera said that the patientís oxygen saturation levels were fine and there was no need for an arterial line. She said he told her that the patient ďwas fineĒ and that she would be woken in the morning. She said that was the only plan she knew of and that Dr Perera did not say anything further to her about the patientís condition nor make any mention of meningitis.
Nurse CD said that he was not told of a diagnosis and had no views regarding one. He was busy getting the patient settled when he suddenly realised Dr Perera was not in the Unit. He did not know Dr Perera was leaving and first became aware he had left the Unit about 20 minutes after the patient had arrived in the ICU. He was uncomfortable that Dr Perera had gone without telling him and without talking to him about the patientís condition. He did not feel that Dr Perera had completed things and he was not really sure what he was supposed to be doing. Dr Perera did not give him any management plan. He checked the medical notes but found Dr Perera had not left him any instructions there either.
After Dr Perera had left, Nurse CD continued to examine the patient. Her pupils were dilated and barely reacting. Her pulse was high (160bpm) and her blood pressure was very high. He became so concerned he consulted the other ICU nurses, who advised him to call Dr Perera at home. Nurse CD called him and communicated his concerns. He told Nurse CD to administer morphine and labetalol and to keep the MAP at 80.
Nurse CD administered the doses of both drugs at the lower end of the range following which the patient had wildly fluctuating blood pressure, either very high or very low. Her pupils were virtually non-reactive and appeared to be enlarging slightly.
Nurse CD spoke to Nurse C who told him to ring Dr Perera again and tell him to come back to the ICU. Nurse CD did so, and from then on other senior nurses assisted in the patientís care. Nurse C catheterised the patient and collected a urine sample. As she did this she noticed for the first time a small cluster of little red spots on the patientís inner right thigh. On returning to the patientís bedside she noticed that her oxygen saturation level had dropped and that there was white frothy liquid in her endotracheal tube. She immediately suctioned the patient and obtained a large amount of white frothy aspirate which quickly dissolved into dirty brown liquid. She noticed that the patientís blood pressure was very labile.
Dr Perera returned to the ICU between 5.40 and 5.50am. He asked Nurse C what she was doing and she explained. The patientís oxygen saturation reached 100% after being suctioned. Dr Perera listened to the patientís chest, said it was clear and told her to put the suction catheter away. At that point he commenced to manually ventilate the patient. More liquid was noted in the endotracheal tube and she was suctioned again. Nurse C suggested a chest x-ray be done in order to ascertain underlying cause and obtain baseline data. A radiologist was called.
Nurse C tried to connect the 12 lead ECG again in order to obtain baseline readings of the patientís heart rhythms. As she was connecting the leads, the patientís heart rhythm deteriorated dramatically and began a very slow ventricular rhythm. Resuscitation was commenced immediately.
A paediatrician was called around 6am and arrived around 6.15am. She took charge. After the first resuscitation Nurse C pointed out the spots on the patientís thigh to the paediatrician who immediately diagnosed meningitis. Treatment of intravenous antibiotics was then commenced.
Between 6.15am and 7am there were four resuscitations. Sadly, the patient did not stabilise and, at around 10.50am, was pronounced dead.
The Tribunal found Dr Perera guilty of professional misconduct.
The Tribunal was satisfied particular 1 was established. The Tribunal found Dr Perera failed to appreciate the significance of the results of the CT scan and the need to investigate urgently his alternative diagnosis of meningitis. He failed to do any other investigation which might have elucidated the cause of the patientís deep unconsciousness and he failed to follow up the results of an investigation which had already been carried out (the blood tests ordered by the SHO) and which would have assisted in deciding an appropriate management plan.
Dr Perera stated in his evidence he expected the patient to wake by morning. The Tribunal accepted the evidence of an expert who opined it may have been reasonable to forgo invasive procedures on that expectation but not in the circumstances where Dr Perera ďhad not taken reasonable care to establish a clear diagnosis nor exclude important other diagnoses which could have been reasonably treated.Ē
The Tribunal was satisfied particular 2 was established. Dr Pereraís clinical notes recorded meningitis as a second differential diagnosis. One of Dr Pereraís explanations for failing to commence treatment with antibiotics was, that even though the patient showed no evidence of intra-cranial bleed in the CT scan and little or no evidence of raised intra-cranial pressure, he still considered a head injury the most likely explanation for her condition. He said he considered it appropriate therefore to wait until after the lumbar puncture before empirical antibiotic therapy.
The Tribunal considered if the lumbar puncture were to be delayed, and meningitis was a potential diagnosis, then the patient should have been administered some intravenous antibiotics at the time that the diagnosis of meningitis was first considered and as soon as possible after intra-cranial mass lesions were excluded. The Tribunal found Dr Perera was unable to advance any reasonable explanation why he failed to commence treatment of antibiotics in view of his own admissions that meningitis was his second differential diagnosis.
The Tribunal was satisfied that particular 3 was established. The Tribunal found that Dr Perera was the senior medical officer primarily responsible for the patientís care while she remained in the ICU unless and until he transferred her care to another senior medical officer. He was the only doctor who had up-to-date knowledge of the patientís condition when he left the ICU. He did not transfer her care to any other senior medical officer nor did he ensure that anyone else did so. Until the paediatrician arrived no other senior medical officer was aware of the patientís admission or responsible for her care.
The Tribunal was satisfied particular 4 was established. Dr Perera assumed that the patientís mother, having had some involvement with her daughterís management and having been present, was well aware of the management strategy and the treatment plan.
The Tribunal considered the patientís mother was present, not as an involved health professional, but as an anxious mother with a very sick child. She was not responsible for her daughterís management. Dr Perera had a responsibility to communicate with the family his understanding of the seriousness of the patientís illness, the difficulty with a diagnosis, and his planned approach.
The Tribunal concluded that, at best, the staff were given a partial management plan, that is of extubating the patient and waking and weaning her in the morning.
Dr Perera was censured and fined $12,000.
Dr Perera is no longer practising in New Zealand. The Tribunal ordered that if Dr Perera should return to New Zealand and apply for a Practising Certificate in New Zealand then the following conditions are imposed:
Dr Perera was ordered to pay 25% ($19,122.44) of the costs and expenses of the investigation, prosecution and hearing of the charge.
The Tribunal further ordered publication of the hearing in the New Zealand Medical Journal.
Counsel for Dr Perera filed an appeal against the Tribunal finding of professional misconduct and the penalty decision. Hubble DCJ, upheld the Tribunal finding of professional misconduct. The Court considered whether or not it was open to the Tribunal to make a finding of conduct unbecoming. The Judge was satisfied that the Tribunal could make a finding of conduct unbecoming where the conduct under consideration was inside the professional practice. However, the Judge was satisfied that in this case the Doctor should be found guilty of professional misconduct. The Judge also considered the penalty. He upheld the censure, conditions and costs but reduced the fine from $12,000 to $7,500.