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Decision Number: 97/10C
Practitioner: Dr M
Charge Characteristics: Proceeded when should not have
Incorrect care
Additional Orders: None
Full Decision: 9710cfindingslaw



A CAC charged that Dr M, a urology registrar, was guilty of professional misconduct. It alleged his management and treatment of his patient (a 2 year old boy) was inadequate in that:

  1. Having experienced difficulty identifying the anatomical structures in the course of operating on his patient, for a left hydrocele repair, he failed to wait for the assistance he had summoned to arrive, and proceeded with the operation when he should not have done so; and
  2. Having so proceeded, he divided the spermatic cord which resulted in the non-viability and removal of the left testicle.



The patient, a two year old boy, was admitted to hospital for two operations, a left hydrocele repair and an operation to correct an umbilical hernia. The parents of the child thought a consultant would be doing the surgery. The consultant was away sick and the operation to repair the hydrocele was performed by Dr M, a urology registrar. Another registrar was to correct the umbilical hernia at the conclusion of the hydrocele operation.

Dr M experienced difficulty in observing the actual landmarks for the procedure and asked for assistance from a surgeon. Before the surgeon arrived Dr M recommenced careful dissection. He believed, incorrectly, he had successfully re-established the landmarks and therefore continued the operation. He divided the spermatic cord which resulted in the non-viability and removal of the left testicle. Due to the difficulties Dr M experienced the operation took much longer than the parents had been told it would take. No-one came and spoke to the parents until the surgeon requested to see them in theatre, to discuss the removal of the left testicle.



The Tribunal found Dr M was not guilty of professional misconduct.

The respondent acknowledged that he had made a mistake in not adequately identifying the anatomy before proceeding. There was a marked difference in the evidence of medical experts. The Tribunal accepted expert evidence that what had occurred could well have happened "even in the best and most experienced hands". The Tribunal found that the most unfortunate accident which had happened must be classified as a non culpable error.



The Tribunal made the following recommendations:

  1. The patient's parents were not properly informed of the risks involved in the procedure prior to the patient being admitted. The Tribunal found the risk of damage to the blood supply of the testes and of damage to testicular vessels or the vas should have been discussed with the parents.
  2. Parents with a clear expectation that surgery is to be performed by a consultant should always have it explained if the person performing the operation will be a registrar.
  3. Every effort should be made for a professional person to communicate as comprehensively as possible with relatives so they are kept informed of what is happening.
  4. It was of some concern to the Tribunal that it seemed to be unclear who was responsible for the immediate supervision of Dr M. The Tribunal thought it wasn't necessary to make a specific recommendation relating to the issue of consultant cover for the operating list provided the review system for supervision of trainees in the operating theatres at the Hospital is on going and proceeding satisfactorily.