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Precis

Charge:  

The Director of Proceedings charged that Dr Ian Lindsay Breeze was guilty of disgraceful conduct or in the alternative professional misconduct.

The particulars of the charge were as follows:

1. On or about 16 December 1999, Dr Breeze failed to ensure the adequate preparation of the patient’s bowel prior to surgery in that he failed to ensure that adequate corrective bowel preparation agents were administered to the patient on becoming aware that the patient had broken his fast; and/or
2. He failed to adequately assess the patient post-operatively; before 1200 hours on 18 December 1999; and/or
3. He failed to adequately and appropriately respond to the patient’s clinical presentation in that he failed to re-operate, at any time after 0700 hours and between 2400 hours on 17 December 1999; and/or
4. Between 1100 hours on 17 December 1900 and 1200 hours on 18 December 1999 he failed to consult with, and/or transfer care of the patient to an appropriately qualified specialist surgeon in a timely manner; and/or
5. He failed to adequately, and in a timely fashion, document in the clinical notes [his] operative and/or post-operative care in relation to the patient.

Background: 

The patient was a 65 year old with diet controlled diabetes. The patient was referred to Dr Breeze with a history of passing blood with his faeces. Dr Breeze saw the patient on 6 December 1999 when it was revealed the patient had a polypoidal cancer of the rectum.

The patient had a colonoscopy on 15 December prior to scheduled bowel surgery on 16 December, which did not reveal any other tumour. It would appear that the nurse discharging the patient on 15 December advised the patient to have a sandwich before leaving the hospital and a light meal that evening.

When the patient arrived at hospital on 16 December he told the admitting nurse that he had eaten a light meal the previous evening. The nurse telephoned Dr Breeze’s rooms but was unable to speak to him directly. The message relayed to the nurse from Dr Breeze was that the patient should receive a Microlax enema. A Microlax enema only cleans the rectum, not the colon or caecum. The fact that only a Microlax enema was administered is clearly documented in the nursing notes. Dr Breeze maintained that he instructed that the patient be given a Fleet enema as it is a fast acting colonic laxative.

The procedure followed by Dr Breeze involved a lower anterior resection and the formation of a loop ileostomy. The rectum was divided below and above the tumour and rejoined. The joined section of the rectum is called an anastomosis. It is critical that the surgeon ensure the anastamosis is intact. If the anastamosis is not complete and leakage occurs there is a real risk of infection and complications. Part of the technique involves a simultaneous slicing of a small portion of the ends of the rectum that are joined. These cut portions are called “donuts”. Each donut is about the size of a 1 cent coin and the surgeon should check the donuts to ensure they are intact. A donut that is not complete indicates that the anastamosis may not be intact and may leak.

Dr Cooke, who was the anaethetist for the surgery, was concerned that one of the donuts was equivocal. Dr Breeze was standing approximately four feet from Dr Cooke. Dr Breeze suggested he could see the donuts and was satisfied they were intact. Dr Breeze also said he examined the donuts at the end of the operation when they were in a container. His handwritten operation note was extremely brief and comprised just ten words.

The patient was transferred to the ward at 1900 hrs. The duty nurse telephoned Dr Breeze at 2210 hrs concerning pain in the left side of the patient’s abdomen and shivering. Dr Breeze gave no new instructions.

Dr Breeze visited the patient at 0700 hrs the next day before going to Tauranga Hospital to perform two operations. There is no record of any clinical observations or assessments made by Dr Breeze at 0700 hrs. The records do however show Dr Breeze prescribed some medication including further antibiotics (Flagyl and Gentamicin).

At approximately 1115 hrs Dr Breeze was telephoned by a nurse concerning the patient’s laboratory blood test results. The laboratory reported that the blood tests showed a very toxic looking picture which needed triple antibiotic cover. It showed the white blood cell count had fallen dramatically and indicated neutrophil toxic changes. Dr Breeze telephoned back at 1150 hrs when he was made aware of the lab results and the patient’s low blood pressure. He told the nurse that the patient’s bowel preparation was not very good so it was likely there was some contamination.

Dr Cooke visited the patient at 1250 hrs and was told there could be faecal material in the pelvic drain. Dr Cooke assessed the patient’s condition and determined an immediate transfer to the ICU at Tauranga Hospital was necessary.

Dr Cooke telephoned Dr Breeze at approximately 1330 hrs. Dr Cooke stressed to Dr Breeze that his patient was very sick. Dr Breeze explained he wished to follow a “conservative” approach in treating the patient, that is to say, he did not want to re-operate but chose instead to deal with the infection by drainage and antibiotics. The patient was transferred to the Tauranga Hospital ICU at approximately 1500 hrs on 17 December.

After the patient was admitted, a doctor at Tauranga Hospital, Dr Jackson, telephoned Dr Breeze who by this stage was approximately 10 minutes drive from Tauranga Hospital. Dr Jackson told the Tribunal that when he spoke to Dr Breeze he told Dr Breeze of his assessment and diagnosis. Dr Jackson was in no doubt Dr Breeze was made aware of the patient’s deteriorating condition and in particular:

• The profound septic shock that would necessitate inotropic support,
• That respiratory failure would likely require artificial ventilation in the near future,
• The depressed white blood cell count, and
• The extreme (500mls) faecal material that had been drained.

Dr Jackson said he asked Dr Breeze about an exploratory laparotomy and washout but was told this was definitely not indicated.

During the course of this telephone conversation Dr Breeze indicated he would visit the patient the next day and that he would contact the surgical registrar on call who in turn would be expected to contact Dr Breeze if there was any deterioration in the patient’s condition.

Dr Breeze believed he telephoned the acute general surgical registrar on call, Dr Martin and that together they planned to trial conservative management. Dr Martin gave evidence in which he was adamant Dr Breeze did not contact him. Dr Martin relied on the fact that there is no record in the clinical notes of his speaking to Dr Breeze and he is certain that he would have made an entry in the notes if he had been asked to participate in the patient’s management.

Dr Breeze went home soon after 1700 hrs and he went out to an end of year function that evening.

During the night of 17 December the patient’s condition continued to deteriorate. At 0245hrs on 18 December the patient required resuscitation but his condition was so bad that Dr Jackson decided no further resuscitation attempts would be made.

Dr Breeze visited the patient on 18 December but by this time the patient’s fate was sealed. The patient’s life was maintained in the Tauranga ICU until the morning of 21 December when he passed away.

A post mortem was carried out on 22 December. The pathologist’s report noted that:

“In the region of the rectum, there is an 18mm defect, which has surrounding staples. There are fibrous adhesions in the lower abdominal cavity. Approximately 150mls of brown stained fluid and admixed faecal material are present in the abdominal cavity.”

Finding:

The Tribunal found Dr Breeze guilty of professional misconduct.

The Tribunal was not satisfied Particular 1 of the charge was established. The Tribunal was satisfied that Dr Breeze was justified in asking that the patient be given a Fleet enema after he learned his patient had broken his fast. The Tribunal was concerned Dr Breeze appeared not to have appreciated the patient was in fact administered a Microlax enema. It would appear Dr Breeze did not read or properly read the nurses’ notes before operating on his patient. The Tribunal was of the view that this oversight did not in itself justify a disciplinary finding against Dr Breeze.

The Tribunal was very satisfied Particular 2 was established and that his failing in this regard amounted to professional misconduct. The Tribunal considered Dr Breeze should have personally attended upon and assessed the patient well before he visited his patient on the morning of 18 December. The Tribunal considered Dr Breeze had a responsibility to personally assess and monitor his patient’s progress, particularly as Dr Breeze had resolved to pursue a conservative course of management. The Tribunal found Dr Breeze should have attended upon, examined and carefully assessed his patient as soon as his operation commitments finished on 17 December 1999, and was very concerned he gave priority to an end of year function over attending to his critically ill patient. The Tribunal did not believe Dr Breeze spoke to the surgical registrar on call on 17 December. However even if he did, the Tribunal considered Dr Breeze needed to fully assess and monitor his patient’s condition.

The Tribunal believed Dr Breeze’s failure to personally attend and assess his patient for at least 26 hours from 0700hrs on 17 December was a serious abrogation of his duties.

When considering Particular 3 the Tribunal was in no doubt that Dr Breeze failed to adequately and appropriately respond to the patient’s clinical presentation between 0700hrs and 2400hrs on 17 December 1999. However, the Tribunal considered Particular 3 was based on the belief that re-operation was mandatory between 0700hrs and 2400hrs on 17 December. Whilst the Tribunal strongly suspected that re-operation was necessary, the Tribunal also accepted that ultimately the decision to re-operate or not had to be a clinical judgment and that accordingly the Tribunal should not conclude re-operation was mandatory. It considered Dr Breeze’s critical error was he failed to give adequate consideration to re-operating, not that he failed to re-operate. In these circumstances the Tribunal could not make an adverse finding against Dr Breeze in relation to Particular 3.

When considering Particular 4, the Tribunal was satisfied Dr Breeze failed to consult with, and/or transfer the care of the patient to an appropriately qualified specialist surgeon. The Tribunal had no hesitation in concluding that if Dr Breeze was unable to attend to and personally assess his patient then he had a duty to ensure his care was transferred to another consultant surgeon.

The Tribunal was unanimous in its finding that the Director of Proceedings had established Dr Breeze failed to consult with and/or transfer the care of the patient to an appropriately qualified specialist when he should have done so. However, only a majority of the Tribunal considered that Dr Breeze’s breaches of duty as established in Particular 4 justified a disciplinary finding against him. The majority was satisfied that in relation to Particular 4 Dr Breeze was guilty of professional misconduct.

The Tribunal was unanimously of the view that Particular 5 had been established. The Tribunal considered Dr Breeze’s records were grossly inadequate. It considered Dr Breeze’s lack of professionalism in this regard justified a finding of professional misconduct.

The Tribunal carefully considered whether the cumulative effect of its findings in relation to Particulars 2, 4 and 5 constituted disgraceful conduct in a professional respect. It concluded that Dr Breeze’s shortcomings, even when viewed cumulatively, fell short of disgraceful conduct in a professional respect.

Penalty:

The Tribunal ordered Dr Breeze pay a fine of $12,500 and costs of $37,825.94. It further ordered publication of the Tribunal’s findings in the New Zealand Medical Journal.