Findings

Charge Characteristics

Additional Orders

Commonly
Cited Cases

Precis

Charge:  

A Complaints Assessment Committee charged Dr Deryck Thomas Pilkington was guilty of conduct unbecoming a medical practitioner and that conduct reflects adversely on his fitness to practise medicine in that he erred in his clinical management of the labour of a patient and the delivery of her baby in that he:

1. Erred in clinical judgement by not performing a scalp pH at an earlier stage when it was apparent that delivery of the unborn baby was not imminent and a CTG trace was abnormal.
2. Erred in his judgement in commencing syntocinon infusion to his patient rather than facilitation delivery.
3. Erred in not monitoring the baby's foetal heart beat during the twenty-two minutes prior to delivery of the baby.

The above charge is as amended by consent of both parties at the conclusion of the case for the CAC.

Background: 

Dr Pilkington was at all relevant times responsible for the patient's care and treatment, and for the safe delivery of her baby. The patient had another child who was born by caesarean section three years earlier. He first saw the patient when she was 34 weeks pregnant with her second child. During that first consultation he explained to the patient that there was a risk, for a women undergoing a trial of labour after a previous caesarean section, that the uterus could rupture at the site of the caesarean operation scar.

The patient did not go into labour by herself and at 42 weeks gestation her labour was induced by a midwife at 6.00 am. The midwife was unable to feel her cervix, with the result that no baseline recordings for the foetal heartbeat and no accurate assessment of the cervical state prior to the onset of labour or spontaneous uterine activity were available.

Dr Pilkington reviewed the patient's progress at 12.00 noon and at 5.55 pm but was otherwise not immediately available during the day as he was operating at a private hospital some distance away. The midwives attending the patient had to communicate their concerns regarding the CTG trace to him by telephone and fax, which they did twice, at 12.00 noon and at 2.00 am the following day. He came in on both occasions and examined the patient. After he was called in at 2.00 am by the midwives he remained in the hospital and kept an eye on the patient's progress.

At 3.10 am the patient's contractions stopped and Dr Pilkington was advised. He ordered syntocinon infusion be commenced. Prior to the patient's contractions stopping her records indicated that there had been some blood loss pv and there were deep decelerations in the baby's heart beat. At 3.30 am the syntocinon infusion was increased and variable decelerations were recorded. After this, a decision was made to deliver the baby and at 4.05 am the baby was born. The baby was flaccid and unresponsive and a paediatric specialist was immediately summoned. The baby was subsequently transferred to a larger hospital for more specialised care and as a result of the trauma suffered at his birth, the child is severely brain injured.

Immediately after the baby's delivery Dr Pilkington diagnosed a rupture of the uterus and the patient was taken to the operating theatre for emergency surgery. He was able to carry out a successful repair of the uterus and the patient made a good recovery.

Finding:

The Tribunal found Dr Pilkington guilty of conduct unbecoming a medical practitioner and that conduct reflects adversely on his fitness to practise medicine.

The Tribunal held the central issue for its inquiry was to ascertain whether or not Dr Pilkington's conduct and management of the case (at the relevant time) constituted an acceptable discharge of his professional and clinical obligations. The issue as to whether or not the outcome might have been different had the practitioner's management of the patient's care been different would not determine whether or not a charge is proven. The Tribunal found that only if it identified any shortcoming or errors could it go on to determine if those shortcomings or errors are culpable, and warrant the sanction of a finding against Dr Pilkington.

The Tribunal considered each of the particulars of the charge and then the charge in its totality.

The Tribunal was not satisfied Particular A was established. The Tribunal was satisfied that the appropriate course was to expedite delivery, rather than delay matters by obtaining a fetal blood sample.

The Tribunal considered Particular B was established and was satisfied that this error of judgment on the part of Dr Pilkington, in the circumstances of this case, was a culpable error and warranted the finding of the charge of conduct unbecoming. The Tribunal considered he was aware of the risk of uterine rupture in a women with a previous caesarean section scar and he was aware of the signs and sentinel events of uterine rupture. When labour stopped, three of the well documented signs of possible uterine rupture were present; blood loss pv, an abnormal CTG (the Tribunal accepted that by this stage the CTG was at least "non-reassuring") and the cessation of a relatively rapid and effective second stage of labour. The Tribunal was satisfied that Dr Pilkington should have expedited delivery at, or around the time that labour stopped. The Tribunal considered the decision to attempt to re-start labour by syntocinon infusion appeared to ignore, or at least simply fail to adequately take into account, the accumulation of sentinel events and this increased the level of risk of uterine rupture and jeopardy for his patients. The Tribunal found the outcome which eventuated could have been avoided by Dr Pilkington intervening at a much earlier time, rather than adopting a 'wait and see' approach that ultimately required emergency action.

The Tribunal was not satisfied Particular C was established, principally because the timing recorded on the CTG trace, and the time of the sentinel events recorded in the clinical records is inconsistent and imprecise. The Tribunal could not determine with a sufficient degree of certainty the actual period between the cessation of the fetal heart monitoring and the delivery of the baby.

Although the Tribunal's ultimate determination of the charge was made on the basis of its adverse finding in relation to Particular B only, it considered, given the seriousness of the finding of culpable error on the part of Dr Pilkington in relation to that Particular, that his management of the patient's labour did not constitute an acceptable discharge of his professional obligations.

Penalty:

The Tribunal ordered that Dr Pilkington be censured, pay a fine of $700 (maximum $1,000) and pay 35% of the costs of and incidental to the inquiry, prosecution and hearing of the charge. It further ordered that a notice pursuant to section 138(2) of the Medical Practitioners Act 1995 be published in the New Zealand Medical Journal.

Appeal:

Dr Pilkington appealed the Tribunal's decision to vacate the name suppression order. The District Court dismissed the appeal (P v MPDT (District Court, Auckland ND 3380/00, 30/01/01, Cadenhead DCJ)). Dr Pilkington appealed the District Court decision. The High Court dismissed the appeal (F v MPDT (High Court, Auckland, AP21-SW01, 5 December 2001, Laurenson J)).  The High Court granted costs to the MPDT and CAC (F v MPDT (High Court, Auckland, AP21-SW01, 8 March 2002, Laurenson J)).