Findings

Charge Characteristics

Additional Orders

Commonly
Cited Cases

Precis

Charge:  

The Director of Proceedings charged that Dr Katherine Maryanne McKenzie was guilty of professional misconduct.

The charge alleged that, on or about 16 July 1996 whilst providing medical services to her patient, Dr McKenzie failed to act as a responsible obstetric registrar and failed to adequately assess or monitor her patient during her labour in that:

1. Dr McKenzie failed to take responsibility and fulfil the role expected of a registrar when supervising junior staff.
2. Upon being advised of the patient's admission and her previous history Dr McKenzie failed to personally assess the patient.
3. Having identified high risk factors for the patient, Dr McKenzie failed to notify the consultant on duty and discuss with him the management plan.
4. Dr McKenzie failed to ensure that the fetal heart rate was appropriately monitored.
5. Dr McKenzie failed to review the CTG tracings.
6. Upon identifying the high risk factors, Dr McKenzie failed to have a consultant perform an artificial rupture of membranes/get consultant to perform artificial rupture.
7. Upon being informed that there was thick meconium liquor following an artificially ruptured membrane, failed to personally assess the patient.
8. Upon being informed of the results of the vaginal examination failed to prepare for imminent delivery and failed personally to assess the patient.
9. Upon being informed of a request for an epidural by the patient Dr McKenzie failed to assess her.

Background: 

In December 1995 Dr McKenzie was appointed as a Registrar at National Womens Hospital (NWH) in Auckland. In June 1996, Dr McKenzie transferred to the NWH's "Blue Team". The Blue Team at NWH is the team to which high risk patients are usually allocated. Prior to taking up her appointment to Blue Team, Dr McKenzie met with the medical staff co-ordinator in the HR Department at NWH. Dr McKenzie was relatively inexperienced as a Registrar and she was concerned about the level of backup in the Blue Team that would be available to her.

Dr McKenzie was told that there were other more experienced registrars in the Team who would be supportive, as well as the consultant there was a new House Surgeon, Dr Saba Abdul Karim, who had also recently been appointed to Blue Team. Dr McKenzie was told that Dr Karim was a very experienced doctor and in fact had more obstetrics and gynaecology experience than her and, given her experience, Dr Karim would be considered for a registrar's position in the next intake.

Dr Karim obtained her medical qualifications in Iraq. It now appears that the information that was available about Dr Karim's qualifications and experience was scanty at best. It appears that as at 16 July 1996, Dr Karim had practised under supervision in New Zealand for approximately 5-6 weeks and had been with the Blue Team for about 3 weeks.

The patient's pregnancy was a high risk pregnancy. She was a large woman, had had six previous deliveries. She was aged 42 and had had two previous post-partum haemorrhages and a pregnancy complicated by severe fetal distress. She was also past her due date, 10 July 1996. Given these factors, the patient required close monitoring and supervision to ensure the safe delivery of her baby. She was admitted to the care of the Blue Team.

NWH had published Guidelines for Obstetric Care (1995 ed) which, in relation to women who have had a previous caesarean section delivery, provided:

"On admission to delivery suite:

• assessment by the Registrar on duty;
• discussion with Consultant on duty regarding his management plan. This plan should be documented in the patient's clinical notes;
• group, save and I.V. access."

The patient was admitted at 9.30am by an experienced midwife. It appeared most likely that Dr McKenzie and Dr Karim saw the patient shortly after her admission (probably between 9.39 - 9.47am). The patient was seen again by Dr Karim at 10.05am and then formally admitted by Dr Karim at 10.20am.

During the course of the patient's labour after admission there was no continuous fetal heart monitoring. The CTG recording indicates that in all there were five observations of the fetal heart rate made over a 2 hour 25 minute period. All of the recordings indicate an abnormal fetal heart rate.

At 13.55 Dr Karim performed a vaginal examination and an artificial rupture of membranes. "Thick Meconium" was recorded and a fetal scalp electrode was applied. Dr McKenzie was informed at least that "meconium stained liquor" was seen, and a paediatrician was also informed.

At 14.39 the fetal heart rate dropped to 60, and then 50 BPM. Dr McKenzie was informed and at 14.42 she performed a vaginal examination. Both the paediatrician and the consultant on duty were called and the baby was born at 14.54 in very poor condition with no heartbeat. The baby died on 26 July 1996 as a result of severe ischaemic hypoxic injury which was likely to have occurred in labour.

Finding:

A majority of the Tribunal found Dr McKenzie not guilty. The Chair of the Tribunal departed from the majority decision and would have found Dr McKenzie guilty of conduct unbecoming a medical practitioner and that conduct reflects adversely on Dr McKenzie's fitness to practise medicine.

The Tribunal was satisfied that particular (a) was established. This finding was unanimous, however the majority of the Tribunal did not consider that Dr McKenzie's conduct in this regard fell so far short of acceptable standards as to warrant the sanction of an adverse professional disciplinary finding.

When considering particular (b) the majority of the Tribunal was satisfied that Dr McKenzie did "personally assess" the patient on admission and therefore particular (b) was not established.

When considering particular (c) the Tribunal was unanimously satisfied that Dr McKenzie did not formally notify the consultant on duty of the patient's admission and discuss with him the management plan she agreed with Dr Karim. The majority of the Tribunal considered this omission did not constitute a professional disciplinary offence.

When considering particulars (d) and (e) the majority of the Tribunal was satisfied that when Dr McKenzie initially assessed the patient the CTG monitor was attached and Dr McKenzie reasonably expected that the CTG recording would be commenced and maintained in accordance with the management plan she agreed with Dr Karim.

The Tribunal was unanimously satisfied that particulars (f), (g), (h) and (i) were not established. It is generally accepted that the performance of an artificial rupture of membranes is within the competence of registrars, midwives and SHO's. The Tribunal considered there was conflicting evidence on particular (g) and it was not proved to the requisite standard of proof. The Tribunal accepted that while Dr McKenzie did not personally attend and assess the patient's labour prior to being urgently summoned it was satisfied that she did remain in the vicinity and was available to act promptly if summoned.

Appeal:

The Director of Proceedings appealed the Decision of the Tribunal.  The District Court upheld the appeal and found Dr McKenzie guilty of professional misconduct.  The judge noted Dr McKenzie is today regarded as a competent and dedicated member of her profession .  The Director of Proceedings did not seek the imposition of any penalty.  The judge agreed the finding that Dr McKenzie was guilty of professional misconduct carried its own punishment because of the stigma associated with such a finding and did not order the imposition of any penalty.  (DP v Dr McKenzie (District Court, Auckland, NP 762/02, 14 August 2002, Doogue DCJ))

An appeal of the District Court Decision was filed on behalf of Dr McKenzie in the High Court.  The High Court upheld the District Court Decision in that a disciplinary offence had been committed and it warranted the sanction of an adverse finding.  However, it considered it was appropriate to substitute a finding of conduct unbecoming a medical practitioner and that conduct reflects adversely on the practitioner’s fitness to practise medicine for the finding of professional misconduct.  (McKenzie v DP and Anor (High Court, Auckland Registry, CIV 2002-404-153-02, 12 June 2003, Venning J))