Findings

Charge Characteristics

Additional Orders

Commonly
Cited Cases

Precis

Charge:  

A CAC charged that Dr Williams was guilty of conduct unbecoming a medical practitioner which reflects adversely on his fitness to practice medicine in:

1. Failing to recommend or implement an active management plan for managing his patient's condition following (a) a gastroscopy and (b) histology which were at variance with the symptoms presented and described by the patient of dysphagia (difficulty swallowing).
2. Failing to recognise the diagnosis of oesophagitis made of the patient's condition in the knowledge that his clinical and histological assessment and response to treatment did not reconcile with the symptoms presented and described by the patient.
3. Failing to provide a system for adequate monitoring and follow-up of the patient's condition, that allowed all contact and treatment to lapse prior to satisfactory diagnosis and management.
4. Failing to specifically perform an undertaking to communicate with the patient after he had obtained a second opinion from another specialist about the presence or otherwise of disturbed oesophageal motility.
5. Failing to respond promptly or at all to telephone messages and messages left after personal visits to the surgery.

Background:

The patient was referred to Dr Williams in June 1996 with a six-month history of dysphagia. Dr Williams performed a gastroscopy and took tissue specimens for biopsy from three sites, the oesophagus, the gastric antrum and the gastric body. On the basis of his examination of the patient and the test results Dr Williams' initial diagnosis was reflux oesophagitis. Dr Williams prescribed a one month course of Losec (available only under special authority). There was a delay in the patient starting treatment because the initial application for special authority was not received by the Health Benefits Authority and it was necessary to forward a second form. Approximately 8 days after the patient commenced this treatment Dr Williams, in response to telephone calls from the patient, spoke to the patient who indicated that his symptoms were unchanged. Dr Williams asked the patient to continue the medicine for the full one month period. The patient contacted Dr Williams again at the end of the 4 week trial and again advised there had been no improvement in his symptoms. Dr Williams undertook to discuss the matter with another specialist. He failed to do so and had no further contact with the patient. In late August 1996, the patient reported a worsening of his symptoms to his GP and was referred to a second specialist. The specialist arranged a repeat endoscopy which revealed a tumor. Biopsies confirmed adenocarcinoma. The patient underwent radiotherapy and chemotherapy. The patient died in October 1997.

Finding: 

The Tribunal found Dr Williams was not guilty of conduct unbecoming a medical practitioner which reflects adversely on his fitness to practice medicine.

The Tribunal, when considering particular 1, was not satisfied that the results obtained on gastroscopy and from the biopsy were "at variance" with the symptoms presented and described by the patient. It considered the medical evidence was not sufficient to impugn Dr William's initial diagnosis, or his decision to try the patient on a 4 week trial of Losec.

The Tribunal for the reasons above found particular 2 was also not proven. The period of the therapeutic trial was within the parameters of accepted clinical practice.

Dr Williams admitted particulars 3 and 4. The Tribunal was satisfied that Dr Williams did put in place a system for monitoring the patient's care at least at the outset. Clearly there was no follow-up or review of the patient's condition at the conclusion of the four week therapeutic trial. Dr Williams admitted he failed to contact the specialist, despite undertaking to do so, and that he allowed all contact with and treatment of the patient to lapse.

The Tribunal when considering particular 5 accepted that the patient and his wife did experience difficulties contacting Dr Williams on three occasions. It considered his failure to attend more promptly to the matter of the Special Authority Application form was unacceptable. However, it was not satisfied in the circumstances that Dr Williams' conduct in this regard constituted conduct unbecoming which reflects adversely on Dr Williams' fitness to practice medicine. As with particulars 3 and 4, Dr Williams admitted his failure to contact the patient at the conclusion of the therapeutic trial.

The Tribunal considered the analysis in CAC v Edwards (97/1) particularly apt. In that case the Tribunal referred to the requirement that "there be 'something more' than mere error or omission, indicating lack of professional care and skill which reflects adversely on the practitioner's fitness to practice medicine". Dr Williams made an error in forgetting his undertaking to the patient to discuss his case with the specialist and to report back to him. The Tribunal found this omission occurred in circumstances where Dr Williams had almost no opportunity to remedy the oversight as the patient returned to his GP and was referred to another specialist Dr Williams did not have the opportunity to put matters right and to review the patients case. The Tribunal found that Dr Williams' omission did not constitute conduct warranting sanction. The Tribunal was influenced by the fact that Dr Williams clinical care of the patient was not significantly criticised by clinicians giving evidence at the hearing. The Tribunal also acknowledged Dr Williams's prompt acknowledgement of his error, his apology to the patient's wife as soon as he was advised of the complaint, and steps he had taken to ensure the error did not happen again.