Findings

Charge Characteristics

Additional Orders

Commonly
Cited Cases

Precis

Charge:  

The Director of Proceedings charged Dr Hauptfleisch with professional misconduct in respect of his care and management of a patient between 26 April and 27 April 2001.

The particulars of the charge alleged:

1. On or about 26 April 2001 he failed to consult with, or refer the patient, to a specialist or other medical practitioner in a timely manner for the purposes of excluding or confirming a diagnosis of intracranial haemorrhage or other abnormality in the brain.

AND/OR

2. On or about 27 April 2001, having been advised by his patient’s husband that there was no improvement in his patient’s condition he:

2. failed to refer his patient, or assist referral of his patient, to a specialist in a timely manner.

At the commencement of the hearing Ms Baker withdrew particular (2)(a) of the charge.

Background: 

The patient was 47 years of age and had had epilepsy since she was 11 years old. Although she did experience some migraine headaches at the onset of puberty she had not experienced many headaches and had gone for about 18 years, from 1973 until 1990, without a fit.

In November 1992 she experienced pain in her head while at work. She said it felt as though there was a band right around her head.  It was very sudden.  She  remembered that she was in so much pain that she couldn’t answer the phone. She remained unwell for a number of days and after having two grand mal seizures she was taken to Palmerston North Hospital where she was discharged after two days. A subsequent CT scan revealed that she had an arteriovenous malformation (“AVM”). There was some suspicion that her experience in 1992 was a brain haemorrhage but because of the time between the event and the scan it could not be confirmed. Following that incident the patient has continued to be monitored by Dr Bala Krishnan of the Neurosurgery Department at Wellington Hospital. 

On the 26 April 2001 the patient was at work having returned from a month’s holiday in the South Island. The patient described herself as feeling very relaxed and not feeling particularly stressed.  At about 4.30 p.m she suddenly felt dreadful. She had an instant headache, starting in the back of her head and spreading around her head. She felt as though she had a tight band around her head and she felt really awful.

The patient sought help from the office manager. Her sister picked her up and on the way to the doctor’s surgery the patient vomited. On arrival at the surgery she was placed in the nurse’s room. She could not walk without aid and was holding her head because of the pain.

When Dr Hauptfleisch came to see her she told him that she had had this before. He examined her including feeling the back of her neck and advised her that he considered that she had had a muscle spasm in her neck. The doctor’s notes on that date stated:

“Tight band around back of head unable to hold head properly BP l(arm) 100/80 r (120/70) vomited x 1, Voltaren inj im 75/3 mls L(im).”

Dr Hauptfleisch’s practice nurse said that the patient appeared to be in pain, had her eyes closed and was holding her head. I found it very difficult to get a good history from her and her sister often answered for her. She told me that she had a headache like a tight band around the back of her neck and it was exactly like that she had with an aneurysm several years ago.

It is not clear whether the advice given to Dr Hauptfleisch about the earlier incident was taken into account by Dr Hauptfleisch. The Tribunal did not have the benefit of hearing directly from Dr Hauptfleisch.

On Dr Hauptfleisch’s instructions, the nurse gave the patient a Voltaren injection and was asked to monitor her.

Somewhere between 15 and 30 minutes after the Voltaren injection Dr Hauptfleisch came and asked the patient how she was feeling. Both the patient and her sister, who was with her, gave evidence that she had responded that the pain was alright as long as she didn’t move her head. The nurse gave evidence that the patient’s response was that her pain was less severe. What was clear was that the patient still required assistance to leave the surgery and to get into her sister’s car. She vomited a few times during the night.

In the morning she was still in a great deal of pain. The patient’s husband waited for the surgery to open at 8 a.m. as he wanted to talk to Dr Hauptfleisch. He relayed what had happened during the night and asked him to come and see his wife. Dr Hauptfleisch said that he could not visit as he had a surgery full of patients and asked for no further information. The patient’s husband wanted Dr Hauptfleisch to ring Dr Bala Krishnan. Dr Hauptfleisch agreed to do so but said he could make no promises as to whether it would be that day or the following day. The patient’s husband was somewhat frustrated and asked for Dr Bala Krishnan’s telephone number. He was told to ring the surgery again and speak to the receptionist and get the number from her, which he did. On ringing Wellington Hospital the patient’s husband was told that Dr Bala Krishnan was on leave. When he rang Dr Hauptfleisch again he was told to bring the patient in to see him. As he could not move her the patient’s husband suggested that he bring her in by ambulance. The ambulance arrived and Dr Hauptfleisch came out to see the patient in the ambulance. Dr Hauptfleisch then said that she would have to be admitted to hospital and he wrote a referral letter to Palmerston North Hospital.

On arrival at Palmerston North Hospital a CT scan was performed. It confirmed that the patient had had a brain haemorrhage. She was then transferred to Wellington Hospital by helicopter. During the helicopter flight she had a seizure.

In Wellington Hospital the patient and her husband discussed treatment options and opted for stereotactic treatment. The patient remained in Wellington Hospital for approximately two weeks, was transferred to Palmerston North for one night and then discharged. She underwent stereotactic surgery in Dunedin in June 2001.

It appeared that following these events there was no contact at all between Dr Hauptfleisch and the patient until the hearing before the Tribunal.

Finding:

The Tribunal found Dr Hauptfleisch was guilty of professional misconduct.

The Tribunal was satisfied that there were serious deficiencies in Dr Hauptfleisch’s management of the patient regarding particular 1.

The Tribunal was of the view that Dr Hauptfleisch had before him the patient’s notes, he was familiar with her, and she and her sister had both clearly made the point that this was similar to what had occurred in 1992. Dr Hauptfleisch, for reasons not before the Tribunal, chose to put that information to one side and diagnosed muscle spasm or tension headache.

The overwhelming evidence from expert witnesses was that where a patient was presenting with a headache that had begun from the back of the head and was accompanied by vomiting, there was a need for some diagnostic assistance, particularly a CT scan.

On particular 1 alone the Tribunal found Dr Hauptfleisch guilty of professional misconduct.

When considering particular 2(b) the Tribunal was of the view that Dr Hauptfleisch assisted in the referral of the patient at the insistence of her husband. It is of some concern to the Tribunal that without the patient’s husband’s insistence and, in his own words, “aggressive behaviour” the patient’s referral to hospital might have been deferred for a longer period of time.

The Tribunal however did accept that on 27 April 2001 Dr Hauptfleisch, on assessing the patient in the back of the ambulance, did move in a timely manner to assist with her referral to Palmerston North Hospital.

The Tribunal considered that Dr Hauptfleisch could certainly have done more to assist the referral and to that end, the Tribunal considered particular 2(b) of the charge was made out and it amounted to professional misconduct.

Penalty:

The Tribunal ordered Dr Hauptfleisch be censured; pay a fine in the sum of $7,500.00 and pay 40% of the costs and the expenses that were incidental to the inquiry by the Director of Proceedings in relation to the subject matter of the charge, the prosecution of the charge, and the Tribunal’s hearing of the charge.

It further ordered that a notice under s138(2) of the Act be published in the New Zealand Medical Journal.

Appeal:

The Doctor appealed the substantive Decision to the District Court.  The Court upheld the appeal.  The Court reversed the Tribunal finding of professional misconduct and quashed the penalty order.  (A F Hauptfleisch v Director of Proceedings (District Court, Wellington, CIV-2004-085-151, 18 August 2004, Tuohy DCJ)).