Findings

Charge Characteristics

Additional Orders

Commonly
Cited Cases

Precis

Charge:  

The Director of Proceedings charged that Dr Graham Keith Parry was guilty of disgraceful conduct in a professional respect. In particular that:

1. He failed to carry out an adequate clinical assessment and examination of his patient on 22 August 1997; and/or
2. He performed an unnecessary and/or clinically unjustified cone biopsy on his patient on 19 January 1998; and/or
3. Despite receiving a pathology report on or about 9 January 1998 confirming the diagnosis of invasive carcinoma Dr Parry did not refer his patient to the Oncology unit at National Women's Hospital (NWH) for further treatment until 9 February 1998.

Background: 

The patient, a 45 year old female, was first referred to Dr Parry in 1991 after experiencing some mid-cycle, post-coital genital tract bleeding. Dr Parry, a specialist gynaecologist and obstetrician, considered the bleeding was due to a small cervical ectropian. He did not consider further treatment was required. Between 1991 and 1996, the patient had regular cervical smears which reported no abnormalities. The patient was referred to Dr Parry again in August 1997 after reporting further incidents of post-coital bleeding and one of heavy bleeding. A smear, taken by her general practitioner, showed atypical squamous cells of uncertain significance. The general practitioner's referral letter recorded that: "the cervix looked slightly inflamed and it bled to the touch. I have repeated smears and swab, but I think their value may be diminished by blood contamination. On bimanual palpation, her uterus seems anteverted, but quite bulky". Dr Parry saw the patient on 22 August 1997. He carried out a trans-abdominal ultrasound scan. He did not carry out a vaginal examination of the cervix or genital tract or any other examination. Dr Parry did not consider further treatment was necessary at that stage.

In December the patient was referred to Dr Parry as a matter of urgency after suffering a severe post-coital bleed and several occasional episodes of bleeding since August. Dr Parry saw the patient on 31 December 1997. He carried out a vaginal examination, took another smear and performed a large punch biopsy. The biopsy showed invasive poorly differentiated squamous cell carcinoma of the cervix. On 19 January 1998 Dr Parry performed a laser cone biopsy. The patient suffered a severe post-operative haemorrhage and had to undergo emergency surgery involving a total abdominal hysterectomy. As a result clinical options for treating the patient's carcinoma were significantly compromised. On 9 February 1998 Dr Parry referred the patient to the Oncology unit at National Women's Hospital.

Dr Parry accepted that his care and management of his patient fell below the standard expected of a specialist gynaecologist but denied that his conduct constituted disgraceful conduct in a professional respect.

Finding:

The Tribunal found Dr Parry guilty of disgraceful conduct in a professional respect.

The Tribunal reviewed the law relating to the test for disgraceful conduct in a professional respect. It found the test is objective and the assessment is one of degree. The central issue is whether or not the practitioner's conduct and management of the case, at the relevant time, constituted an acceptable discharge of his or her professional and clinical obligations. The Tribunal considered the issue of whether the outcome might have been different had the practitioner's management of the patient's care been different will not determine whether or not the charge is proven. The Tribunal was satisfied that findings of disgraceful conduct are not limited to sexual misconduct, exploitation of patients for personal gain, fraud or dishonesty. The Tribunal considered disgraceful conduct in a professional respect may encompass conduct involving clinical care and/or clinical issues without any element of 'moral turpitude', particularly in circumstances where the doctor's conduct exposes patients to risk and/or he or she ignores fundamental rules or clinical management principles. A high degree of culpability is required.

The Tribunal found Particular 1 was established at the level of disgraceful conduct in a professional respect. This finding by the Tribunal was unanimous. The Tribunal found Dr Parry's failure to carry out an appropriate or any investigation of his patient's principal and ultimately potentially fatal presenting symptom was "indefensible and inexcusable". The Tribunal was satisfied that Dr Parry's failure to undertake what is possibly the most basic investigation required of him as a specialist gynaecologist in the circumstances of the patient's referral was grossly negligent and was conduct the Tribunal considered to be significantly more culpable than professional misconduct. It was an omission by Dr Parry that was reckless and it disregarded his responsibilities to his patient and her GP. The Tribunal considered that Dr Parry's conduct was such a significant departure from accepted standards that it could not be characterised as 'mere negligence' or a 'mistake', nor as one involving a 'mistaken' or 'missed' diagnosis. Dr Parry made no adequate or reliable diagnosis. He made no attempt to establish or exclude the most serious causes of post-coital bleeding. He did not record an adequate history or carry out a proper examination and investigation of the symptoms and clinical signs referred to him by the patient's GP.

The Tribunal found Particular 2 was established at the level of disgraceful conduct in a professional respect. This finding was made by a majority of the Tribunal. The Tribunal considered in the context of the clinical picture, Dr Parry's decision to carry out the laser cone biopsy on 19 January 1988 was inexplicable, and was at the very least a grave error of judgment on his part.

The Director of Proceedings suggested Dr Parry knew he made serious errors in his management of the patient's case and that he attempted to cover-up the extent of the deficiencies in his care and treatment of the patient. Dr Parry denied this suggestion. The Tribunal determined that in relation to his motives for undertaking the cone biopsy Dr Parry exercised poor judgment but the Tribunal was unable to establish, to the requisite standard of proof, that he was deliberately attempting to cover up his mismanagement of the patient's case, or to mislead anyone. However, in relation to the contents of letters sent to the patient's GP and the specialist at National Womens' Hospital, the Tribunal was satisfied Dr Parry did deliberately mislead the two doctors regarding his management of the patient's case.

The Tribunal found Particular 3 was established at the level of professional misconduct. This finding by the Tribunal was unanimous. The Tribunal found Dr Parry was in breach of his duty of care to the patient by delaying her referral to the hospital. The Tribunal considered the reasons for Dr Parry's inaction were inexplicable in clinical terms and the delay was unacceptable.

The Tribunal also expressed some general concerns regarding Dr Parry's practice. It regarded Dr Parry's clinical notes of his consultation with the patient and his operating notes as grossly inadequate. It was concerned by Dr Parry's "excessive" and inappropriate reliance on ultrasound in the context of his gynaecological practice. The Tribunal expressed concern that Dr Parry's treatment of this patient was symptomatic of a general lack of understanding and application of fundamental principles of modern gynaecological practice and that he still might not understand the need to adequately examine women referred to him with lower genital tract symptoms or abnormal smears.

Penalty:

The Tribunal ordered that Dr Parry's name be removed from the register, that he be censured, fined $15,000 and pay 40% of the costs of and incidental to the investigation, prosecution and hearing of the charge. The Tribunal further ordered publication of the hearing in the New Zealand Medical Journal.

The Tribunal made an interim order suspending Dr Parry's registration in the event of an appeal pending final determination of the charge.

Appeal:

Dr Parry's counsel lodged an application in the District Court that the identity of the minority Tribunal member be disclosed. The District Court held that the identity of the minority Tribunal member was to be disclosed. In addition the Court stated that the weight to be given to any opinion would be affected by the status and expertise of the person expressing the opinion. (Parry v MPDT, Auckland District Court, NP 4412/00, 10 May 2001, Hubble DCJ).

The District Court decision was appealed to the High Court. The High Court upheld the decision that the name of the dissenting Tribunal member in the decision be known but held that equal weight is to be given to all members of the Tribunal. Priestly J stated "the reason for a party's entitlement to know that identity was nothing, in my judgment, to do with assessing the weight which ought to be given to that minority opinion". (MPDT v Parry (High Court, Auckland, AP 49/SW01, 11 May 2001, Priestly J)).

The substantive Decision of the Tribunal was also appealed to the District Court. The Court upheld the overall finding of disgraceful conduct in a professional respect, but allowed the appeal on particular 2 of the charge. It set aside the finding of disgraceful conduct on that particular and in its place substituted a finding of professional misconduct.

The Court also allowed the appeal on penalty. The fine was reduced to $5,000 and Dr Parry's name was restored to the register with general registration on condition that his practice is restricted to obstetrics and ultrasound and subject to the following conditions:

1. That Dr Parry for a period of three years from the date of the order (with leave to apply to the Medical Council for removal or variation of conditions not before the expiry of one year after the practitioner commences practice) practise only in the areas of obstetrics and ultrasound.
2. That Dr Parry for a period of three years from the date of the order (with leave to apply to the Medical Council for removal or variation of conditions not before the expiry of one year after the practitioner commences practice) is permitted to practise only as a registrar under the supervision of a person holding vocational registration as an Obstetrician and Gynaecologist with current experience in ultrasound. (Leave to reapply to the Court).
3. That Dr Parry be referred to the Medical Council of New Zealand for a review pursuant to s 60 Medical Practitioners Act 1995 of his competence to practise medicine under the conditions herein set out.

The Court further ordered that publication of the orders in the New Zealand Medical Journal be modified to include publication of the orders of the Court and in particular the conditions under which Dr Parry is to practise medicine.

The District Court decision was appealed to the High Court by the Director of Proceedings and a notice of cross appeal filed on behalf of Dr Parry .  In Director of Proceedings v Parry and MPDT (Auckland High Court, AP 61-SW01, 15 October 2001, Paterson J) the High Court confirmed the penalty decision of the District Court.