|
Decision No: | 01/88C | |
---|---|---|
Practitioner: | Dr Warren Wing Nin Chan | |
Charge Characteristics: | Failure
to obtain informed consent Inadequate notes Inadequate history Inadequate care Inadequate consultation Inadequate follow-up Inadequate advice Practising medicine while suspended Misled patient Inadequate treatment Failure to follow patient instructions Failure to attend |
|
Additional Orders: | Application for interim suspension of
registration granted:
0188cfindingssuspension Application for revocation of suspension of registration denied: 0188cfindingsrevocation Application for Orders of Discovery granted in part: 0188cfindingsdiscovery Application for amending of charges granted: 0188cfindingsdiscovery Application, filed on behalf of one complainant, for lifting of her name suppression granted (name suppression granted at the hearing): 0188cfindingsnamesupplift |
|
Decision: | 0188cfindingslaw | |
Penalty Decision: | 0188cfindingssup | |
Appeal: | Complaints Assessment Committee appealed Decision - appeal upheld. Court referred two matters back to the Tribunal in respect of penalty (CAC v Dr W Chan (District Court, Auckland, No. 2942/02, 20 March 2003, Tompkins DCJ)) | |
Supplementary Penalty Decision: | 0188cfindingssup2 |
Charge:
A Complaints Assessment Committee (CAC) laid eight charges based on individual complaints against Dr Chan. The charges were laid at the level of disgraceful conduct in a professional respect (Lisa Clement, Ms A, Ms B, Ms C and Mr D), professional misconduct (Ms E) and conduct unbecoming a medical practitioner and that conduct reflects adversely on the practitioner’s fitness to practise medicine (Miss F and Ms G). The CAC laid a ninth charge against Dr Chan which was a composite charge. The particulars of the composite charge related to individual complaints by Lisa Clement, Ms A, Ms B, Ms C, Ms E, Miss F and Ms G. This charge was laid at the level of disgraceful conduct in a professional respect.
Background:
Finding – eight individual charges:
In all eight charges Dr Chan was charged with failing to convey the fact that he was not vocationally registered as a plastic surgeon in New Zealand. The Tribunal considered, in relation to all eight complainants, while it was clear that Dr Chan did not convey that he was not vocationally registered as a plastic surgeon in New Zealand, this was not a disciplinary matter. It was clear that Dr Chan pointed out particular certificates that he had received in respect of cosmetic surgery, but he did not appear at any stage to have indicated that he had qualifications which he did not hold. It was also noted that in a number of instances, the complainants contacted Dr Chan’s practice as a result of perusing the Yellow Pages. Dr Chan’s practice was listed under cosmetic surgeons and it may well be that a number of the complainants did not distinguish between a cosmetic surgeon and a plastic surgeon.
Lisa Clement:
The particulars were as follows:
Dr Chan failed to adequately inform Lisa Clement of the anaesthesia process, and surgical procedure and the risks and complications associated with that procedure and the operation thereby he failed to:
Obtain Ms Clement’s informed consent of the proposed anaesthesia process and surgical procedure; and/or
- Obtain Ms Clement’s informed consent to the procedure at the time of surgery.
- He failed to provide adequate information to Ms Clement about the nature or effects of the anaesthetic that she was to receive; and/or
- He failed to obtain an adequate preoperative medical history from Ms Clement and to ascertain the correct name of the medication she was taking, hence could not have been aware of potential drug interactions; and/or
- He failed to notate or document the amount of local anaesthetic used in this procedure thus compromising patients safety.
- He failed to adequately monitor Ms Clement’s condition during the surgical procedure; and/or
- He failed to monitor Ms Clement’s condition adequately post-operatively; and/or
- He failed to ensure that the normal discharge criteria had been met prior to Ms Clement’s discharge after surgery, thereby potentially compromising patient safety.
Background
Lisa Clement had a breast augmentation carried out by Dr Chan in October
2000. Ms Clement was assessed by a nurse and she did not meet Dr Chan
until the morning of the proposed surgery. She had sent photos to Dr Chan
to assist with choosing the implant.
Finding
The Tribunal found Dr Chan guilty of conduct unbecoming a medical
practitioner which reflects adversely on his fitness to practise medicine.
The Tribunal was satisfied particular 1 was established and it was
concerned by the inadequacy of pre-operative assessment and clinical
examination of Ms Clement.
When considering the issue of informed consent (particulars 2, 3(a) and
3(b)) the Tribunal found that as there was such a short period of
interaction between Ms Clement and Dr Chan it was unlikely that Ms Clement
received the information necessary for her to be able to give informed
consent to the process and procedures.
The Tribunal was satisfied particular 3(c) was not established. Dr Chan
did keep notes for the amount of local anaesthetic although the
infiltration rates were not noted. The Tribunal considered that the
keeping of infiltration rates is good practice, but on this occasion the
failure to do so was not a safety issue.
The Tribunal was satisfied on the facts that 3(d) and 3 (f) were not
established. However, it was satisfied that particular 3(e) was
established as the records showed only one recording taken 20 minutes
after the operation.
The Tribunal was satisfied that particular 4 was not a disciplinary
matter.
Ms A:
Charge
The particulars were as follows:
- Obtain Ms A’s informed consent to his proposed treatment, including the anaesthesia and surgical procedure; and/or
- Obtain Ms A’s informed consent to the procedure at the time of surgery.
- He failed to provide adequate information to Ms A about the nature or affects of the anaesthetic that she was to receive; and/or
- He failed to carry out an adequate or proper anaesthetic assessment of Ms A prior to surgery including taking a satisfactory history of her asthma; and/or
- He failed to record the amount of local anaesthetic used thus compromising patient safety; and/or
- Dr Chan failed to monitor Ms A’s condition adequately during the surgical procedure; and/or
- Including monitoring her fluid balance.
- Responding appropriately to her concerns about her condition after the operation.
- Being aware of the possibility that Ms A’s post-operative symptoms may be due to the large amount of fluid removed in the operation and thus very serious.
- Refused to see her (to assess her condition) when she asked him to do so, thus compromising her safety.
Background
Ms A had liposuction carried out by Dr Chan on 13 June 2000. On the day
of the procedure Ms A signed the consent for the operation in front of the
receptionist. Ms A said she filled in her medical check list at the time
including the fact that she was asthmatic and that she had had a previous
bad reaction to Hypnovel. Photos were then taken of Ms A and she was given
a sedative pill. Ms A then saw Dr Chan for the first time when he drew
circles on her body.
Ms A recalled waking during the procedure to find another doctor
working on her thigh. She stated that she woke because she had sharp
stabbing pains that increased as the liposuction probe was advanced. She
recalls crying and did not see Dr Chan but tried to gain the attention of
the other doctor.
Ms A left the Australasia Cosmetic Surgery Clinic without a follow up
appointment despite the fact that there was a clear leakage of blood. Ms A
was feeling very unwell and returned to a friend’s place where she
continued to bleed. Her friend rang the Australasia Clinic and was told
that that was normal and when asked to see Dr Chan the following day, was
told that everything was okay. Ms A’s friend rang a plastic surgeon in
Auckland who spoke to her friend over the telephone and arranged
antibiotics for Ms A, but was unable to see her before Ms A left Auckland.
Ms A said that she was very uncomfortable for a further two and a half
weeks on her return home.
Finding
The Tribunal found Dr Chan guilty of professional misconduct. The
Tribunal was concerned at the inadequacy of the pre-operative patient
assessment and clinical examination of Ms A and was satisfied particular 1
was established. Ms A was an asthmatic and had advised of a previous
allergic reaction to Hypnovel. There was no reference or indication that
there was any concern regarding this reaction.
The Tribunal was satisfied that Ms A did not give her informed consent
to the procedure and therefore it considered that the first part of
particular 2 and all of particular 3 were established. While Ms A received
a pamphlet put out by Dr Chan concerning liposuction, that pamphlet did
not inform fully of the risks and benefits of the procedure. The pamphlet
essentially was an advertisement for liposculpture. The Tribunal did not
consider that the second half of particular 2 was established. One of the
few matters that the pamphlet did specifically address was that
liposculpture is not a treatment for obesity.
The Tribunal considered particular 4 was not a disciplinary matter.
The Tribunal was satisfied particular 5(b) was established. However, it
did not consider 5(a), (c) and (d) were established as Ms A had received
the information about the anaesthesia process and it was clear that from
the patient records that notes of the amount of local anaesthetic were
kept.
When considering particular 6 the Tribunal was very concerned at the post-operative care Ms A received. In terms of monitoring her fluid balance, this fell short of accepted standards. A bleeding problem was identified. Ms A, through her friend, raised this issue and nothing appeared to have been done. There was no appropriate response to Ms A’s concerns about her condition after the operation. The lack of adequate monitoring of her fluid balance post-operatively put Ms A’s renal function at significant risk.
Particular 6(d) was not established as Ms A was unsure as to whether Dr
Chan knew she was there when she returned to the clinic the following day.
The Tribunal found particular 7 was established. The Tribunal
considered Dr Chan was responsible for all the staff he employed at his
clinic and in this instance Ms A was bleeding and was discharged with no
further instructions as to what to do if the bleeding continued.
Ms B:
Charge
The particulars were as follows:
- He failed to provide information to Ms B about the nature or effects of the anaesthetic that she was to receive; and/or
- He failed to carry out an adequate or proper anaesthetic assessment of Ms B prior to surgery; and/or
- He failed to carry out a proper pre-operative history and assessment particularly with respect to her stated history of smoking and asthma; and/or
- He failed to record in the patient records the details of the amount of local anaesthetic used, thus compromising patient safety; and/or
- A drug (Maxolon) was administered despite documentation of Maxolon allergy, thereby placing Ms B at serious risk; and/or
- He failed to monitor Ms B’s condition adequately during the operation and post-operatively;
Background
Ms B had a mastoplexy carried out by Dr Chan on 5 March 2001. She
understood that she would have dissolvable stitches. Ms B told the nurse
that she was allergic to Maxolon. Ms B also suffered from asthma and was a
smoker. It would appear that initially her operation sheet stated that she
had no allergies and that had been changed, most likely on the day of the
operation. The references on the operation sheet to allergies and current
medications appeared to be in Ms B’s handwriting. It was not clear whether
the decision to use Maxolon on this occasion was made with any awareness
of her previous reaction or any idea of preventing a reoccurrence.
Finding
The Tribunal found Dr Chan guilty of professional misconduct.
When considering particular 1(a), (b) and (c), the Tribunal was
satisfied some information was given to Ms B and she had signed the form
saying that she understood the issues relating to the anaesthetic.
However, it considered Dr Chan failed to carry out an adequate or proper
anaesthetic assessment prior to surgery. Dr Chan did not listen to Ms B’s
chest or ask any questions at all about her asthma which in the Tribunal’s
view fell well short of a proper anaesthetic assessment.
When considering particular 1(d) the Tribunal was satisfied that
although the amount of local anaesthetic was not recorded, it was not a
matter that warranted disciplinary action.
The Tribunal found particular 1(e) was established. There was a failure
to document the recognition of the allergy, the reasons for using the drug
and the methods for combating the allergy. In the absence of any such
reference, it appeared that further information was not obtained in
respect of the allergy and that it was merely fortuitous that Ms B did not
experience an adverse reaction. The Tribunal considered it notable that Ms
B was not asked at all about the type of reaction she had had to Maxolon.
Ms B suffered a severe post-operative infection. However, the
post-operative infection was not an infrequent complication and changes
were made to her antibiotics in an attempt to deal with the infection.
Therefore particular, 1(f) was not established.
The Tribunal did not consider particular 3 was a disciplinary matter.
Ms C:
Charge
The particulars were as follows:
- Dr Chan misled and/or failed to provide adequate information to Ms C about his anaesthetic management.
- Dr Chan failed to provide adequate anaesthesia during the procedure, resulting in Ms C suffering severe pain during surgery.
- Dr Chan operated without an anaesthetist present during the procedure and drugs were administered by him contrary to the accepted guidelines laid down by the Australian and New Zealand College of Anaesthetists.
Background
Ms C had liposuction performed by Dr Chan in March 1998. During the
operation Ms C experienced intense pain and asked Dr Chan to stop the
process. Her arms were held down and she was told to lie back down and to
calm down. She visited another plastic surgeon four months later and had
further surgery done under general anaesthetic as she was dissatisfied
with the results from the surgery by Dr Chan.
Finding
The Tribunal found Dr Chan guilty of conduct unbecoming a medical
practitioner and that conduct reflected adversely on his fitness to
practise medicine.
The Tribunal considered particular 1 was not a disciplinary matter.
The Tribunal was satisfied particulars 2, 3 and 4(a) were established.
The Tribunal considered that Dr Chan did fail to carry out an adequate
pre-operative assessment and clinical examination prior to surgery. He had
one brief appointment prior to the surgery with the patient who did not
seem to have any further contact with Dr Chan until just before the
operation. Ms C confirmed that Dr Chan did not listen to her chest or
listen with a stethoscope or take blood pressure. The Tribunal was
satisfied Dr Chan failed to inform Ms C about the risks and possible side
effects and outcomes, therefore affecting her ability to give informed
consent.
The Tribunal was satisfied particular 4(b) was established. Ms C had
awoken during the surgery. The Tribunal considered adequate anaesthesia
was not provided.
The Tribunal was not satisfied that particular 5 was established.
Mr D:
Charge
The particulars were as follows:
Background
Mr D had a rhinoplasty procedure carried out on the 3 July 2001 at a
time when Dr Chan was suspended from practising. At the first consultation
Dr Chan had explained the procedure and on the day of the surgery, Mr D
was seen by a nurse and was taken into a room and given pre-operative
medication. Mr D saw Dr Chan one week later and the plaster was taken off
his nose. Mr D was clearly unhappy with the results of the surgery.
Finding
The Tribunal dismissed the charge against Dr Chan in respect of the
treatment of Mr D.
The Tribunal was satisfied at the time of Mr D’s operation, Dr Chan was
suspended from practice as a result of an order of the Tribunal. The CAC
asked the Tribunal to determine that the fact that Dr Chan should not have
been practising medicine at this stage was in itself disgraceful conduct
in a professional respect. The Tribunal was satisfied that such an
argument may have gained some support if section 109(1)(g) relating to the
breach of an order of the Tribunal did not exist. The Tribunal considered
this was a matter that could have been the subject of a charge under
section 109(1)(g) of the Act or section 9 of the Act. A charge under
section 109(1)(g) or prosecution with regard to section 9 of the Act were
not brought in respect of Dr Chan practising while suspended, and
therefore the Tribunal was unable to deal further with the matter. It was
this Tribunal’s view that practising while suspended does not amount to
disgraceful conduct in terms of section 109(1)(a) as a matter of law, and
therefore particular 1 was not established.
The Tribunal was satisfied particular 2 was not established. Mr D had
the benefit of being accompanied by a partner with a nursing background.
She acknowledged in her evidence that she had asked Dr Chan about the
complications and there had been discussion of them.
The Tribunal was satisfied particular 3 was not a disciplinary issue.
It considered particular 4 related to a subjective cosmetic issue and did
not warrant a disciplinary finding.
Ms E:
Charge
The particulars were as follows:
- Giving the consent form for surgery to the patient to sign after Ms E had been given her pre-operative sedation.
- Using foreign implants in the procedure despite his assurance prior to surgery that no foreign implants would be used.
Background
Ms E had a rhinoplasty procedure done during 1995, Dr Chan was to
operate by using cartilage from behind Ms E’s ear. Ms E had stated she did
not want a silicon implant and she was told that the operation would be
done with cartilage from behind her ear. Five years after the operation,
Ms E had a boil on her nose and it was found that it had been caused by a
silicon implant protruding through the skin which had to be removed.
Finding
The Tribunal found Dr Chan guilty of professional misconduct.
The Tribunal was satisfied particular 4(b) was established. The
Tribunal considered it a matter of grave concern that Dr Chan felt he was
able to undertake a procedure so clearly against the wishes of the
patient. The Tribunal found in all other respects the remaining
particulars were either not relevant or not proven.
Miss F:
Charge
The particulars were as follows:
- He failed to provide adequate information to Miss F about the nature or effects of the anaesthetic that she was to receive; and/or
- He failed to undertake a pre-operative clinical examination of Miss F; and/or
- He failed to obtain an adequate pre-operative medical history from Miss F.
- The method of sedation he used was inappropriate for the procedure, resulting in more pain than necessary for Miss F and in any event the method of local anaesthetic used was administered contrary to the accepted guidelines laid down by the Australian and New Zealand College of Anaesthetists.
Background
Miss F had a breast reduction performed by Dr Chan on 15 June 2000. She
had the surgery undertaken under local anaesthetic and was told that she
would feel no pain but she awoke several times during the surgery due to
the pain she felt. She was not satisfied with the results which were
supposed to move her to a C cup sized bra. She is still wearing E cup
sized bras.
Finding
The Tribunal found Dr Chan guilty of conduct unbecoming a medical
practitioner which reflected adversely on his fitness to practise
medicine.
The Tribunal was satisfied particular 1 was established as although
Miss F had at least two consultation visits with Dr Chan it was clear that
some risks and complications were not explained.
The Tribunal was satisfied particular 2 was established. Miss F
suffered from asthma and there was no reference of discussion relating to
the asthma and no examination of the chest in terms of the asthma.
The Tribunal was concerned that the method of sedation was
inappropriate for the surgery. It was clear from the expert evidence
submitted to the Tribunal that those undertaking that surgery consider
that it is a matter best done under general anaesthetic. The Tribunal
found there has been a failure to perform this surgery to a reasonably
competent standard, and therefore particular 3 was established.
The Tribunal did not consider particular 4 was a disciplinary matter.
Ms G:
Charge
The particulars were as follows:
- Obtain Ms G’s informed consent for the proposed anaesthesia process and surgical procedure.
- Obtain Ms G’s informed consent to the procedure at the time of surgery.
Background
Ms G had liposculpture performed by Dr Chan in August 1994. Ms G had a
very brief consultation with Dr Chan and was reassured that she would feel
no pain. The pain that she suffered both during and following the surgery
was intense and was not her expectation in respect of the surgery.
Following the surgery, Ms G contacted the Australasia Cosmetic Surgery
Clinic was told to take Panadol. She then approached her general
practitioner and was given a prescription for a stronger pain killer. Ms G
was bedridden for about three weeks and was off work for about six weeks.
Finding
The Tribunal found Dr Chan guilty of conduct unbecoming a medical
practitioner which reflected adversely on his fitness to practise
medicine.
The Tribunal was satisfied particular 1 was not established as this was
a matter prior to the Medical Practitioners Act 1995 and prior to the
Health and Disability Commissioners Act 1994. It considered the issues
about informed consent were within a different context.
The Tribunal was satisfied particulars 2 and 4 were established. There
were serious deficiencies in his anaesthetic practice given the pain
experienced by Ms G. It was also concerned at the poor post-operative care
given to Ms G.
As the patient notes were not available the Tribunal could not find
particular 3 proven and it considered particular 5 was not a disciplinary
matter.
Composite Charge:
Charge
The particulars were as follows:
Finding
The Tribunal dismissed the charge.
This charge was laid as an additional charge not an alternative charge. The Tribunal was concerned that what was proposed by the CAC was essentially charging Dr Chan twice in respect of the same incident. The Tribunal considered that Duncan v MPDC [1996] NZLR 513 did not provide that charges can be assessed on an individual basis and then again on a cumulative basis.
Penalty:
The Tribunal ordered:
- That Dr Chan has a fully qualified anaesthetist present when he undertakes any surgical procedure.
- That Dr Chan is required to attend medical education courses on consent and patient and practice management at the direction of the Medical Council.
Appeal:
The Complaints Assessment Committee appealed two aspects of the Tribunal Decision:
The Court upheld both aspects of the appeal. (CAC v Dr W Chan (District Court, Auckland, No. 2942/02, 20 March 2003, Tompkins DCJ)).
The Court concluded that in respect of Mr D, Dr Chan was guilty of disgraceful conduct in a professional respect. The Court referred the matter back to the Tribunal to consider penalty, after affording Dr Chan an opportunity to be heard.
The Court found that the Tribunal should have made a finding on the 'composite' charge as well as the individual charges, but the Tribunal would need to take care to avoid duplicity of penalty. The Court when considering the composite charge concluded that Dr Chan was guilty of disgraceful conduct in a professional respect. It also remitted this matter back to the Tribunal for penalty, again after affording Dr Chan an opportunity to be heard.
Supplementary Penalty Decision:
As the District Court found that two charges of disgraceful conduct were established against Dr Chan, the Tribunal revoked some orders and substituted others. The following is a summary of all the orders made in respect of Dr Chan:
The Tribunal also endorsed the addendum to the Tribunal’s Decision
228/02/93C and expressed its view that the removal of Dr Chan’s name
should be permanent.