Findings

Charge Characteristics

Additional Orders

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Cited Cases

Precis

Charge:  

A Complaints Assessment Committee charged Dr Graham Keith Parry with professional misconduct in that there were serious deficiencies in his management of his patient namely:

1. He failed to appropriately treat the presenting problem of Lichen Sclerosis with potent corticosteroid ointment; and/or
2. He failed to discuss the chronically recurrent nature of the disease or to recommend a plan for ongoing management of the disease, including follow-up appointments with the patient.

Background: 

The patient was referred to Dr Parry by her GP as she had severe vaginal itching, a small red blotch on the right labia minor, and a small tear at the bottom of the vaginal opening.

On 31 May 1995 Dr Parry examined the patient and made a provisional diagnosis of lichen sclerosis. The patient said she asked Dr Parry what lichen sclerosis was and the only answer she received was that "It is quite common in women of your age, in fact a lot who think they have thrush actually have lichen sclerosis". While there is some uncertainty as to precisely what was discussed and agreed at this consultation, Dr Parry recommended and the patient agreed to a biopsy of the area of the abnormal vulval appearance. It was also agreed that Dr Parry would repair the vaginal tear at the same time.

On 2 June 1995 the patient was admitted to Hospital and Dr Parry carried out a vulval biopsy and a Fenton's procedure of the posterior fourchette. On 9 June 1995, a Pathologist, made an histology report excluding malignancy.

On 20 June 1995 the patient said she telephoned Dr Parry's rooms as she was under considerable stress not knowing whether she had a cancerous condition which might need immediate treatment. She was told by the receptionist that the result was that there was no cancer but it was lichen sclerosis. The patient said she asked if there was any treatment for the problem to which the receptionist said "Haven't we sent you a script for 1% hydrocortisone cream?" to which the patient said she replied "No". On 21 June 1995 the patient said she received a letter from Dr Parry dated 16 June 1995: "This is to let you know that your biopsy came back showing lichen sclerosis. This is a chronic condition but showed no evidence of any malignancy. I would be happy to see you again any time you were concerned."  Enclosed with the letter was a prescription for 1% hydrocortisone cream. No further information was provided at that time.

The patient said that during the next month she used the cream. At times she thought it was helping but the itching had always been spasmodic, being worse during warm weather; and believed that as it was a chronic condition it might take time to improve. On 19 February 1996 the patient again visited her GP regarding the continuation of the vulval itching which she described as severe.

The GP wrote a further referral letter to Dr Parry:

"… You performed a vulval biopsy in June 1995 which showed benign changes of lichen sclerosis. She continues to have some itching and whiteness in this area.

I would be very grateful if you could advise what degree of follow-up should occur with this, whether a further biopsy is necessary at any stage or whether visual or smear type specimens would be appropriate.

The hydrocortisone 1% which she was given does seem to control the symptoms reasonably well ........"

On 8 March 1996 the patient had a further consultation with Dr Parry. There is some disagreement between the patient and Dr Parry as to what was said at this consultation and its purpose. The patient said she asked Dr Parry a number of questions; that he told her her condition was incurable and may become cancerous in time; that he believed it was associated with asthma and eczema; that he did not discuss the use of potent cortico steroid ointments, the need to follow up, nor did he discuss the need for ongoing management of the disease; that he supplied some oestrogen cream, but otherwise gave no other information. Dr Parry said he regarded that consultation particularly as a consultation to answer a number of questions about which the patient was still unclear, and reassured her that by utilising some topical oestrogen cream (Dienoestrol) it might be possible for her to resume intercourse. Dr Parry said that the patient did not express to him that she was unhappy about his treatment or lack of information.

The patient did not seek a further consultation regarding the lichen sclerosis until 22 January 1999 when she saw another GP.

This GP referred the patient to Dr Ronald William Jones at Auckland who is a sub-specialist with an international reputation in vulval disease. Dr Jones prescribed a potent topical cortico steroid ointment (Dermovate) and asked the patient to return in two months time for assessment. Dr Jones said that Dermovate was regarded as the standard form of treatment in 1995, but that in mild cases 1% hydrocortisone was effective. The new treatment controlled the lichen sclerosis well.

Finding:

The Tribunal found Dr Parry not guilty of professional misconduct.

The Tribunal was not satisfied particular (a) was established. Both the expert witnesses who have (and had at the material time) specialist knowledge of vulval disease accepted that 1% hydrocortisone was widely used for the treatment of lichen sclerosis at that time. The Tribunal found that there was no intimation to Dr Parry that matters were not under control which would necessitate a change in management or a referral.

The Tribunal was satisfied particular (b) was established however it was unanimous in finding it did not amount to professional misconduct.

When the patient first consulted Dr Parry, he made a provisional diagnosis of lichen sclerosis but did not discuss its nature in full. The Tribunal considered it would be unfair to criticise him for not giving a full explanation at that point. It was a provisional diagnosis only and had to await the radiologist's report.

It found though he failed to give an adequate explanation of his final diagnosis and recommendations for treatment, the patient saw him again on 8 March 1996. By then Dr Parry had received a letter from her GP which indicated that the treatment which Dr Parry had prescribed did appear to be controlling the symptoms "reasonably well". Moreover, the patient asked Dr Parry a number of questions all of which he answered. Although there was no further follow-up by Dr Parry, as would normally be expected, the Tribunal was not satisfied that in 1996, having regard to the particular circumstances, Dr Parry could fairly be said to have so failed in his duty as to warrant professional sanction.