HCCC v Dr Theodore Potts
[2007] NSWMT 8
•17 August 2007
New South Wales
Medical Tribunal
CITATION: HCCC v Dr Theodore Potts [2007] NSWMT 8 TRIBUNAL: Medical Tribunal PARTIES: Health Care Complaint's Commission
Dr Theodore PottsFILE NUMBER(S): 40022 of 2006 CORAM: Ainslie-Wallace, DCJ - Wright, Dr J M - Howle, Dr S - Houen, Ms J CATCHWORDS: Capacity to practise medicine - Cognitive deficits LEGISLATION CITED: Medical Practice Act 1992 S36 & S37 CASES CITED: Briginshaw v Briginshaw (1938) 60 CLR 336;
HCCC v Litchfield (1997) 41 NSWLR 630;
Grant v HCCC [2003] NSWCA 73DATES OF HEARING: 16.7.2007. 17.7.2007, 18.7.2007 DATE OF JUDGMENT: 17 August 2007 LEGAL REPRESENTATIVES: P Griffin of Counsel
M Bozic SCORDERS: 1. The respondent's name forthwith be removed from the Register of Medical Practitioners; 2. The respondent be not permitted to make an application for re-registration for two (2) years from the date of this order; 3. The respondent pay the applicant's costs.
JUDGMENT:
THE MEDICAL TRIBUNAL Friday 17th August 2007
OF NEW SOUTH WALES
AT SYDNEY
No. 40022 of 2006
BETWEEN
Health Care Complaints Commission
Complainant
Dr Theodore Potts
Respondent
Deputy Chair: Judge A M Ainslie-Wallace
Members: Dr J M Wright
Dr S Howle
Ms J Houen
Orders and Reasons for Determination
Order:
Pursuant to Clause 6 of Schedule 2 to the Medical Practice Act 1992 the Tribunal has made a Non Publication Order in respect of the names of the patients referred to in the proceedings.
Introduction:
The Health Care Complaints Commission (the "HCCC") brings two complaints against the respondent, a medical practitioner.[1]
Complaint 1 alleges that the respondent is impaired in that he suffers from physical and/or mental disorders, namely cognitive deficits, which detrimentally affect or are likely to affect his physical and/or mental capacity to practise medicine.
Complaint 2 alleges that the respondent is guilty of unsatisfactory professional conduct and/or professional misconduct within the meaning of sections 36 and 37 of the Medical Practice Act, 1992 in that he has demonstrated that the knowledge, skill or judgment possessed, or care exercised by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.
The respondent conceded each of the particulars of the second complaint and conceded that in respect of each particular, the conduct alleged amounted to unsatisfactory professional conduct.
Background
1 The respondent is aged 57. He graduated MBBS from the University of NSW in 1975 and completed an internship and residency at Prince Henry and Wollongong hospitals. Between 1977 and 1979 he worked as a general practitioner in locum tenens in country NSW and in 1981 he worked in the United Kingdom in various hospitals. He obtained a Diploma of Obstetrics and Gynaecology from the Royal College of Obstetrics in 1981 and in 1982 a Diploma of Tropical Medicine and Hygiene. In 1986 he was admitted as a Fellow of the Royal Australian College of General Practitioners. In 1992 he obtained a certificate in Advanced Training in Sports Medicine and in Child Health. In 1996 he gained a Certificate in Diving Medicine. In 2002 the respondent was awarded a Masters Degree in Psychological Medicine from the University of NSW.
2 After working in Queensland hospitals for 4 years, the respondent returned to NSW and worked with his father in general practice in Glebe. During this period he also worked in hospitals in the Accident and Emergency Departments in country NSW and Queensland. The respondent continued the general practice after his father died but closed it in 2004.
History of Complaints
3 It is necessary to traverse the history of complaints made about the respondent's practise of medicine to give a context the present complaints and the hearing before the Tribunal.
4 A chronology prepared by the HCCC[2] shows that from about 1994 concerns were expressed about the clinical competence of the respondent. Between March 1995 and May 1996, 6 complaints were made about the respondent's conduct as a medical practitioner. Those complaints concerned the respondent's clinical judgment, inappropriate or inadequate treatment and inappropriate manner with patients. These complaints were investigated and in September 1997 the Conduct Committee of the NSW Medical Board recommended that the respondent be counselled about these complaints.
5 The respondent was counselled in October 1997 about his relationships with patients, relationships with professionals, record keeping and writing and repeating prescriptions.
6 According to a report of the counselling session,[3] the respondent said that at the time that the complaints were made about his relationships with patients and other professionals, he and his wife were considerably stressed by the premature birth of their son. He said that he normally had good relationships with his patients. The respondent addressed the perceived deficiencies in his record keeping and his prescribing. The counsellors apparently formed the view that the matters had been satisfactorily addressed and no further action was taken in relation to the complaints.
7 In 1998 two further complaints were made about the respondent's clinical care and relationship with patients - one patient complained that he was administered drugs which were out of date and another patient complained that the respondent had conducted a breast examination without explaining the reasons for the examination and had made inappropriate comments during the course of the consultation.
8 After investigation of these complaints,[4] the Conduct Committee of the Medical Board recommended that the respondent again be counselled to explore his failure to check the expiration dates of drugs, adequately explain the need for breast examinations and to note the results of the breast examination in the patient's notes. Another purpose of the counselling was to have the respondent discuss the appropriate technique to be used when performing breast examinations, the questions to be asked to ensure full and informed consent and the behaviour to be displayed to ensure a high professional standard is demonstrated.
9 The counselling took place in March 2001.[5] It was reported that the respondent acknowledged that his notes were deficient. In relation to the breast examination, the counsellors discussed with the respondent the need for full and informed consent from patients and the respondent agreed that it would be part of his practice in future. The panel of counsellors considered the matters to be have sufficiently discussed.
10 In 2003 another complaint was received concerning the respondent's inappropriate manner when dealing with a patient during an examination. The Conduct Committee referred the matter to the Performance Committee.
11 The respondent was subject to a Performance Review in November 2003. Conditions were imposed on his practice by the Performance Review Committee. The conditions required the respondent to provide copies of patient records, to undertake an Intensive Communication Skills Program, address organisational defects in his practice and spend time as an observer with an experienced general practitioner. The conditions were directed to the issues of basic clinical skills, patient management skills, prescribing and communication skills.
12 In February 2004 another complaint was made about the respondent's inappropriate manner when consulting with a patient.
13 In May 2004 a complaint was received from Ms C about the respondent's conduct when she presented to the Emergency Department of Bateman's Bay Hospital. This complaint was referred to the Medical Board.
14 In July 2004 the Deputy Director of Medical Services complained about the respondent's treatment of 7 patients when he worked at Moruya Hospital over the long weekend of 12-14th June 2004.
15 In July 2004 the Conduct Committee considered the complaints of Ms C and those relating to Moruya hospital and referred them to the Medical Board where an Inquiry pursuant to section 66 of the Medical Practice Act was convened.
16 The Section 66 Inquiry[6] was conducted on 13th September 2004. The report of that Inquiry considered the complaints about the respondent's treatment of patients at Moruya Hospital and Ms C at Bateman's Bay (these complaints form the particulars to Complaint 2).
17 The Inquiry found that there were deficiencies in the respondent's record keeping, recognition and management of patients, professional practice and relationships with peers, obtaining consent and in his interaction with patients and concluded that the respondent should be permitted to continue to practise with further conditions imposed on his registration.
18 The Section 66 Inquiry referred to the report of the Performance Review Panel Inquiry in July 2004 which commented on the manner in which the respondent answered questions during the review inquiry. The members of the Section 66 Inquiry made similar observations and said:
"The overall impression was that his responses to the complaints mostly missed the central issue of the complaint and he digressed readily into somewhat glib and specious explanations... In other responses Dr Potts appeared to minimise and even trivialise the complaint.
Dr Potts' essential response was that he was under great emotional stress due to difficulties in his personal life and family. It was evident from this that when under "emotional stress" he was more likely to be impaired in his medical practice in the manner revealed in the complaints. The delegates observed that Dr Potts became somewhat rapid and pressured in his account of his personal difficulties and was at times quite tangential and circumstantial so as to cause the delegates to wonder what point he was making. The Inquiry came to the view that when under such emotional stress and under the pressure of heavy clinical demand he was likely to become similarly disorganised in his thinking and that this probably leads to errors in his clinical judgment...
As with the Performance Review Panel inquiry, this Section 66 inquiry raises the issue as to whether Dr Potts' cognitive and personality style is one of exaggerated personality traits or a developing neuro-cognitive or psychological impairment."
19 On the recommendation of the inquiry, conditions were imposed on the respondent's registration that he not work in a private or public hospital in any capacity, that he nominate a supervisor and meet fortnightly with that supervisor. The respondent was also directed to attend a psychiatrist for treatment.
20 The respondent complied with these conditions and in September 2004 Dr Karthigesu was nominated as his supervisor.
21 The respondent attended Dr Bruce Westmore for psychiatric assessment. Dr Westmore recommended neuropsychological testing which was performed by Ms Alexandra Walker. Ms Walker reported to the Board that her tests revealed impairment in some areas.
22 A further Section 66 Inquiry was held on 28 July 2005 to consider the whether the respondent was impaired and also considered 4 complaints about the respondent's conduct during the period of his supervision as reported to the Board by the supervisor. At the conclusion of the Inquiry, the respondent's registration was suspended.
23 The respondent's registration remains suspended and he has not practised medicine since that time.
Complaint 1 - that the respondent is impaired
24 Although this complaint and the particulars were denied by the respondent, in the result, it was conceded that the respondent has some form of impairment.
25 In April 2005, Ms Alexandra Walker assessed the respondent to determine his cognitive function. Her assessment consisted of interview and the administration of psychometric tests.[7] The respondent told Ms Walker that in the early 1970's while still a medical student, he had been in a car accident in which he was injured and as a result was unconscious for 2 weeks. He returned to his studies the following year and successfully completed his medical degree and post degree training. The respondent told her that he had some personality and behavioural changes after the accident.
26 Ms Walker reported that the respondent said that he suffered post-traumatic stress disorder as a result of being detained in Kenya in 1980. He and his wife separated followed by an acrimonious divorce and property settlement which, he said, caused him extreme stress.
27 The tests administered by Ms Walker revealed deficits in some of the respondent's cognitive functions which, she said, were consistent with the cognitive profile of traumatic brain injury. Ms Walker found that his personality style and aspects of his communication were consistent with the effects of traumatic brain injury.
28 Based on the results of the tests administered by her and the presentation of the respondent during the assessment process, Ms Walker concluded that while the deficits in cognitive function were relatively mild, they may become more pronounced as a result of increased stress or long working hours.
29 She said
"Given that Dr Potts displays some inability to self monitor at times, he may be less able to cope with increased stress and pressure, eg by reducing his working hours or taking other measures to reduce his stress."[8]
30 Ms Walker, while agreeing that the deficits in the respondent's cognitive functioning were mild, said that when taken in the context of the accident and the history and nature of the complaints made about the respondent, supported her findings of impairment of executive function.
31 The respondent was tested by Dr Sunny Lah, a clinical psychologist, in October 2005.
32 Dr Lah reported that in some tested areas the respondent performed relatively poorly. For example, in situations requiring memory and self-monitoring. The respondent reported normal levels of stress to Dr Lah. Based on the test results, Dr Lah concluded:
"The identified neuropsychological difficulties, on the other hand, are likely to have interfered with Dr Potts' work, especially with his ability to utilise his skills and knowledge flexibly and efficiently. Together, the long history of complaints lodged with the Medical Board and the pattern of difficulties obtained on the neuropsychological assessments are suggestive that the difficulties are likely to be secondary to the long standing condition, namely severe head injury sustained in the 1970's."
33 Through his lawyers, the respondent sought a further opinion from Professor Shores[9] who conducted psychometric tests in July 2006. The respondent told Professor Shores that he was "exhausted" when tested by Ms Walker to which he attributed the test results. He said that when he was assessed by Dr Lah he was more relaxed albeit surprised that her results were similar to Ms Walker's. Professor Shores reported test results which showed an improvement in performance in areas of deficit identified by Ms Walker and Dr Lah which Professor Shores said:
"...lends some support to his explanation for the poor results in 2005 having been due to his feeling exhausted at the time of the assessment. However, some degree of practice effect cannot be excluded".
34 Professor Shores concluded that his test results did not support the view that the respondent has brain damage resulting from the car accident. Although the respondent has some weaknesses in some tested areas, Professor Shores thought that they were: "unlikely to be of any clinical significance". Professor Shores commented:
"Dr Potts has personality traits and an interpersonal style which may not be conducive to good social interactions especially when he is tired and stressed".
35 Unfortunately, Professor Shores was overseas during the hearing and was unavailable to give evidence in explanation or amplification of his report. There are obvious areas in which explanation would have assisted the resolution of the apparent divergence between the reported test results.
36 Ms Walker's view was that the respondent's improvement in test performance was referrable to the "practice effect", that is, the degree to which a person remembers the tasks between tests and the performance in that test is enhanced. In this case she said that the respondent had been tested using essentially the same tests three times in 15 months. She agreed that the literature on the effect of repeated testing was not conclusive and did not address repeated testing over 15 months, nonetheless she still preferred the view that this was the explanation for the apparent improvement.
37 Professor Shores identified that his results may have contained a practice effect but did not amplify to what extent it would be apparent.
38 Ms Walker's tests included an assessment of anxiety, which was negative and the respondent told her that his mood was "fine". Ms Walker said that, in any event, there was no evidence that exhaustion can cause particular deficits to be detected during testing.
39 She was supported in her opinion by there being no evidence of stress detected by her during the testing process either reported or revealed in tests. At no time during the testing did the respondent claim to her that he was "exhausted". Professor Shores' report does not address the results obtained by Dr Lah, when the respondent himself said he was feeling much more relaxed.
40 That Professor Shores was unable to be cross-examined on his report and explain the matters to which we have referred, causes the Tribunal to place less weight on his report. In coming to this conclusion, it should be understood that the Tribunal does not challenge the undoubted expertise of Professor Shores but finds that the lack of explanation causes the Tribunal difficulty in reconciling his findings with those of Dr Lah and Ms Walker. The Tribunal prefers the findings of Dr Lah and Ms Walker which are supported by the evidence of the severity of the accident and the history of complaints.
41 There was no dispute that the accident caused a severe head injury. According to most accounts, the respondent was unconscious for 2 weeks and following that had post traumatic amnesia for at least another 5 weeks. It was accepted that this was an indicator of a very severe head injury.
42 The Medical Board ordered that the respondent consult a psychiatrist and the respondent commenced seeing Dr Andrew McPherson in February 2005. Dr McPherson continues to have regular sessions with the respondent in which he said that the main focus has been the problems which have arisen for the respondent in his practice of medicine.
43 Dr McPherson referred the respondent to Dr Jungfer, a psychiatrist with expertise in traumatic brain injury who conducted an assessment of the respondent.
44 In Dr McPherson's letter of referral to Dr Jungfer he commented that the respondent had a tendency to excessively circumstantial speech and poor judgment which Dr McPherson believed supported the neuropsychological findings of impairment and reduced insight.
45 Dr Jungfer[10] referred to the respondent's manner of interaction. She observed that during the assessment he was "grandiose" and "entitled". She said his manner was "quite aggressive and inappropriate". Dr Jungfer felt that the respondent had frontal lobe damage and, as a result was unaware of how his conduct affects others. Dr Jungfer concluded that the respondent had executive impairment which affected his functioning.
46 Dr McPherson made a report for the purposes of the Tribunal hearing[11] in which he said;
"... considering the history of the complaints and their natures, the history of a severe head injury, the neuropsychological testing results all be they somewhat conflicting, the psychiatric history and the mental state of Dr Potts observed during treatment over last few years, in my view the most likely cause of such an impairment would be a mild organic disorder consequent to a head injury suffered in 1971 with features of relatively mild personality trait exacerbations, judgment difficulties and interpersonal and communication problems. This disorder may have been aggravated by stress intermittently with an exacerbation of impairment."
47 Dr McPherson did not believe that the respondent was suffering from an anxiety disorder and did not believe that an anxiety disorder would have produced the pattern of complaints and practice difficulties.
48 Dr Westmore made two assessments of the respondent. The first was in December 2004.[12] Dr Westmore commented that while giving his history, the respondent was disjointed and dislocated and talked "off" and "around the point". In giving his medical history, while the respondent told Dr Westmore about the motor car accident in 1970, he did not tell Dr Westmore that he had sustained a head injury with associated unconsciousness and post traumatic amnesia. At this point, Dr Westmore provisionally concluded that the respondent had an anxiety disorder. He thought that the respondent's speech patterns which he had observed, while unusual fell short of a formal thought disorder.
49 Dr Westmore concluded:
"I think it is likely that his interpersonal style and perhaps personality issues (as yet not clearly identified) results in a degree of impairment in terms of how he relates to others including patients."
50 After concluding that the condition was most likely chronic, Dr Westmore said that the current stressors are likely to be aggravating his condition.
51 Dr Westmore saw the respondent again in May 2007 (by which time he had been provided with the report of Dr Jungfer and the report of Professor Shores). At the start of the interview he noted that the respondent again exhibited the unusual speech patterns he had noted at the earlier assessment. Dr Westmore interrupted the respondent and asked him to keep his answers to point. The respondent was able to contain his answers during the balance of the interview of about 45 minutes.
52 Dr Westmore believed that because the respondent was able to contain himself during this interview, his previous presentation was more likely to be the result of stress and personality characteristics rather than an underlying organic impairment. Nonetheless, he said that the test is whether the respondent would be able to modify his behaviour in the long term.
53 Most relevantly, Dr Westmore concluded:
"This is a difficult case, there is clearly some very significant differences in disputes in the psychological opinions regarding Dr Potts. Ultimately it is his clinical presentation which is of relevance. If Dr Potts cannot, for whatever reason, modify his behaviour in such a way that he does not continue to attract the attention of the Board, then that is obviously a functional problem which needs to be addressed."
54 During the course of his evidence, Dr Westmore considered that Dr McPherson's view of the underlying problems may be correct, that is, personality dysfunction together with an underlying organic impairment. Dr Westmore was reticent to diagnose a personality disorder in the respondent because he only had two interviews with the respondent. He said that the respondent was impulsive, bombastic, possibly narcissistic. He is not particularly socially aware nor is he particularly receptive to feedback or social sensitivities.
55 Dr Westmore thought that these personality issues were exacerbated when the respondent is outside a structured environment. Dr Westmore believes that the respondent has some insight but said that the key factor in the respondent being able to work as a medical practitioner was whether he could adopt a different style of interaction with the patients.
56 Dr McPherson said that the respondent disputed that he had any organic impairment and cited his successful completion of his medical degree and subsequent courses as support. Dr McPherson said that well preserved intellectual functioning can exist with significant executive impairment which presents judgment difficulties and lack of insight. Dr McPherson said that given the severity of the head injury suffered by the respondent, 2 weeks of unconsciousness followed by 5 weeks of post traumatic amnesia, he would expect neuropsychiatric sequelae.
57 Dr McPherson said that the respondent would have difficulty in containing his behaviour in an unpredictable situation and where judgments had to made constantly.
Capacity for the respondent to work as a medical practitioner
58 Neither Dr Westmore nor Dr McPherson believed that the respondent could practise medicine without conditions. Based on the capacity of the respondent to contain himself in the 2007 interview, Dr Westmore thought that the respondent could work in a "highly structured and supervised and supported environment"[13] and eventually suggested that he could work in a hospital subject to "level 1" supervision (being the level of supervision given to a first year intern when working in a hospital setting). Dr Westmore accepted that it would be difficult for the respondent to change his behaviour which prompted his suggestion that he be supervised to receive ready feedback on his performance. Dr Westmore accepted the respondent's difficulties in the way he interacts with others and how he responded to patients in a hospital setting would be a source of potential difficulty.
59 Dr McPherson thought that the respondent "possibly" could work in a hospital under close supervision although the position could be stressful. Whether the respondent was successful would depend on the nature of the work and that he would need a close level of supervision.[14] Even so, Dr McPherson noted that the respondent has problems with general judgment skills which would still pose a problem even with close supervision. He could not say whether supervision and the presence of others around the respondent would be sufficient to make his working reasonably tenable. When asked about the capacity of the respondent to control his speech as observed by Dr Westmore, Dr McPherson said;
"There would be a difference between controlling yourself perhaps half an hour under a specific direction and in interview compared to controlling yourself in a clinical situation over a long period of time where there's lots of unpredictable ...things happening. All different sorts of judgments to be made or things to be weighed up".[15]
60 Dr McPherson thought that the respondent might be able to cope if he worked in a "relatively quiet setting where things were well ordered and more methodical..".
61 The effect of the evidence of both Dr Westmore and Dr McPherson was, that whatever the cause of his problems, the respondent lacked insight and judgment skills. Whether he could successfully work as a medical practitioner required him to be closely supervised and monitored and for there to be a degree of control and predictability of the type of work he was to do and depended on whether the respondent could manage to contain his style of interaction with patients. When asked whether the respondent could contain or change his way of dealing with patients, Dr McPherson said;
"...it's hard to be sure. I think ...his record speaks for itself...when someone's got a psychiatric disability or problem the best assessment of what they can or can't do is usually by trial of putting the people into a work situation and seeing how they go. He's been in a work situation on and off for many years and that's in a sense the best record of what he can cope with or how he copes.....If he hasn't had an appreciation that he suffered from a disorder, if he gained that appreciation, it was ..impressed on him, he may be able to make some changes by being more careful possibly".
Complaint 2
62 This complaint concerned the respondent's treatment of seven patients at Moruya Hospital over the weekend of 12th June 2004 and his treatment of a patient, Ms C, at Batemans Bay Hospital on 18th April 2004.
63 Patient PG: PG is an elderly lady who was brought into Moruya hospital by ambulance with confusion following a fall. The respondent assessed her and recorded: "confused (? LT) admit". The respondent did not contact the visiting medical officer (VMO) about this patient and a medical assessment of this patient was not conducted until some 24 hours after her admission and that was by the VMO. During the Section 66 Inquiry the respondent was asked about his treatment of this patient and agreed that he had not ordered any tests for her to determine the cause of her confusion.
64 In his evidence to the Tribunal, the respondent was asked to reflect on how his treatment of this patient was defective. He said that his note was inadequate. He said he could not obtain a history from the patient but said that he had looked at her old notes which had provided him with some information but that information was not recorded in the hospital notes. He said that in the usual course he would have ordered investigations - blood tests, x rays and urinalyses and requested that these be done urgently.
65 When asked why he had done none of these things, the respondent said that he was very busy in the hospital seeing patients who were sicker than he was used to seeing in a normal weekend in hospital. He said that he was: "bouncing from one patient to the next, passing them on to the ...for the notes to be taken care of by the GP in the ward." He conceded that he should have telephoned the doctor and discussed the cases with him.
66 Patient AS: This patient, aged 66 was brought to hospital by ambulance after collapsing and vomiting blood at home on 12 June 2004. When he first arrived at hospital, nursing staff recorded blood pressure of 86/53. According to the nursing report, the patient was placed in a resuscitation room because of the perceived gravity of his condition. The respondent saw the patient and the hospital notes contain a very brief, largely illegible medical assessment. The nurses noted that the respondent asked why the patient should be admitted. Nurses arranged cross matching of blood and for the patient to receive 3 units of packed cells. The VMO was not notified of the admission. When the VMO attended this patient on the 14th June, arrangements were made to transfer him to Canberra Hospital but he died shortly afterwards.
67 The respondent told the Section 66 Inquiry that he ordered antibiotics to treat pneumonia and fluid replacement. During the s66 Inquiry, in response to the suggestion to him that his treatment of the patient's shock was inadequate, the respondent said that he had worked for 3 months in an Intensive Care Unit and knew how to handle shock.
68 The respondent was questioned about his treatment of this patient during the Tribunal hearing. He said that when he read the recorded blood pressure he understood that the patient was: "heading towards shock...possibly associated with dehydration".[16] He said that his decision to treat the patient's shock solely with replacement fluid was wrong and conceded that he had overestimated his experience in Intensive Care. He said that he should have recorded a history and examination and should have ordered tests.
69 Patient JM: This patient had acute myeloblastic leukaemia and was brought to hospital by ambulance with nausea and vomiting and collapse. The respondent entered a three-line history: "weak, barely able to arise without dizziness. Frail. Lives alone. Admit". There is no record of any examination or investigations ordered by the respondent. The VMO was not notified. The VMO attended later that day and assessed the patient who died some days later.
70 During the s66 Inquiry, the respondent said that he had in fact made a more extensive examination but was too busy to make a note of it. He told the Section 66 Inquiry that he had not made any arrangements nor any investigations. The nursing notes record that no pathology was ordered until the patient was admitted to the ward and seen by the VMO.
71 Patient TT: The patient had chronic renal failure and was brought to hospital with worsening swelling and redness around an infected peritoneal dialysis access site. The respondent administered antibiotics and apparently ordered blood tests but sent the patient home before the results of the blood tests were available. The blood tests showed that the patient's renal functioning was deteriorating. According to the statements made by the nurses who were on duty with the respondent during this time, neither they nor the patient's wife believed that he was well enough to discharge. Nurse Lecher who was on duty at this time said that she told the respondent that the patient should be admitted to hospital. He was nevertheless discharged home. Later the abscess ruptured and he was taken to Canberra Hospital.
72 The respondent said that he decided to discharge this patient rather than admit him because he did not look so very unwell and the patient himself preferred to be sent home. He said that in future he would admit patients like this because: "considering the importance that people are placing on this matter and I'm sending people home, I would certainly be more aggressive bringing people into hospital".[17]
73 Patient EG: had been prescribed Warfarin for a deep venous thrombosis and came to hospital on 14th June complaining of increased swelling in his right calf. The respondent's note of examination and attendance occupies three lines and was indecipherable to the Section 66 Inquiry. The respondent apparently ordered no tests or treatment for the patient.
74 The respondent told the Section 66 Inquiry that he should have ordered treatment and said that he considered the patient to have a strained calf but later agreed that perhaps the patient had a calf muscle haematoma.
75 Patient PG: came to the hospital with vaginal discharge. She was 30 years old and 29 weeks pregnant. The respondent recorded a number of pregnancy risk factors including decreased foetal movement and a foetal heart rate of 200. The respondent noted: "vag candidiasis/obstetric disaster in waiting, pre eclampsia, small for dates, reduced foetal movements and single umbilical artery". He further noted "obstet hosp stat". He discharged the patient home. He did not consult with the on-call obstetrician nor contact the patient's treating hospital in Sydney. The respondent told the Section 66 inquiry that he offered the patient an obstetric review at Moruya but she refused. He did not arrange for her to be assessed either in Canberra or in Sydney.
76 The respondent told the Section 66 inquiry that he had recorded foetal heart rate of 200 which he regarded as: "reasonable" and which the members of the inquiry panel regarded as: "clearly abnormal"[18] which warranted urgent referral, further investigation and monitoring.
77 Patient GR: this patient was brought to the hospital after he lost consciousness after being tackled during a rugby game. There is no record in the hospital notes of any medical assessment on arrival nor any treatment or investigations. The respondent's note of any medical assessment is: "more alert, toes (( still". Although the nurses' notes record the presence of dried blood in the patient's nostril, the respondent said that he had not seen that note. It was accepted that the presence of blood in the nostril could be indicative of a cerebro-spinal fluid leakage. The respondent discharged the patient home after 2 hours observation rather than the usual minimum period of 4 hours.
78 The members of the Section 66 inquiry formed the view that the respondent was not aware of the significance of a possible cerebro-spinal fluid leak.
79 When asked about his treatment of this patient, the respondent said that after 2 hours of observations the patient was coherent, able to speak and his pupils were: "fine". He said that the patient had made a: "spectacular" recovery while under observation (a comment which is difficult to assess given that the respondent did not record observations of the patient other than those referred to) and he said that the patient preferred to go home. The respondent said that he told the patient's father: "the usual head injury instructions".
80 When asked what he would do differently, the respondent said that he: "didn't realise the rule is that ...a head injury patient has to be observed for four hours" and in future would observe the patient for four hours in compliance with the rule. He said that he was not aware of that usual practice at the time.
81 The nursing notes record that no neurological observations were commenced on the patient until Nurse Dwyer started them 40 minutes after the patient arrived at hospital. Those notes also record that Nurse Morris told the respondent that the hospital protocol required the patient to be kept in for 4 hours, and the respondent nonetheless discharged the patient.
82 Patient C: This patient attended the Bateman's Bay Hospital on 18th April 2004 when the respondent was working there. When she arrived it was observed by nursing staff that she was dehydrated and had been vomiting and her oxygen saturation levels were low. She was assessed by the respondent who ordered that she be discharged with a prescription for oral antibiotics. According to the notes and statement of the nurse on duty, Nurse Graham told the respondent that she was concerned about the patient's oxygen saturation levels and suggested that she had a chest X ray. She made this suggestion again before the respondent agreed to order it. The respondent spoke to the VMO who asked for a pathology test to be conducted. A nurse attempted to withdraw blood from the patient without success because the patient was dehydrated. She asked the respondent to take the blood.
83 According to both the nurse's report and the letter of complaint of the patient, the respondent turned the patient's wrist over and prepared to withdraw blood from the underside of her wrist. At this point the patient said to the respondent that she did not consent to him taking blood from her wrist. She said that the respondent held her arm down and proceeded to take the blood. The patient said that she was shouting and crying and considerably distressed. The nurse present confirmed the patient's distress and her refusal of consent for the procedure.
84 The patient was eventually admitted to the ward and when she went past the respondent some time after he had taken the blood he said to her "are you over it, are you talking to me yet" and then offered to tell her the details of a meal he had eaten at a local restaurant. The patient was distressed by the respondent's attitude to her refusal of consent and distress.
85 The respondent told the Section 66 hearing that he had been asked for a "D Dimmer" (the pathology test requested by the VMO) and so he felt he had to take the blood. He said that her response to his actions were not as negative as her complaint indicated. When asked about his comments to her, he said that his approach to patients was to "jolly them along" and commented that he could not please everyone. The Inquiry considered that the respondent expressed no contrition for his actions in relation to this patient and felt that he had no insight into the seriousness of his conduct.
86 In his evidence to the Tribunal the respondent said that he took the blood from the patient because he was asked to have some pathology tests done and was: "paying too much attention to the wishes of the admitting doctor"[19]. The respondent was asked why he took blood from the patient when he knew it was against her consent. He said: "...I was trying to do my job properly and the GP VMO under whom I was admitting her had specifically requested a D-Dimmer". The respondent said that although he knew the patient did not give consent to the procedure, he was "balancing her wishes against the medical request of the VMO under whom I was admitting her and I made the wrong call"[20]. The respondent recognised that it was an error and referred to being under considerable stress, working 16 hour days over a weekend. The respondent was adamant that he would not again act against a patient's wishes.
Peer Review
87 The doctor who was asked to comment on the respondent's treatment of the patients in Moruya Hospital and Ms C in Bateman's Bay in relation to the patients at Moruya Hospital, said that in each case the respondent's care fell significantly below that reasonably expected of a practitioner of an equivalent level of training and experience. In each case he expressed his moderate criticism of the respondent's conduct. Equally in relation to his treatment of Ms C, the reviewer said that this was a significant departure from the expected standard and would invite his moderate to severe criticism.
Report of supervisor
88 On 29th September 2004, the Medical Board ordered the respondent to submit to supervision of his practice. The order required him to work at a suburban medical practice and only at times when the supervisor was present. As part of the supervision the respondent and the supervisor had weekly meetings and she was available for consultation. In the course of that supervision, the supervisor prepared reports for the Medical Board. She identified four incidents of concern.
89 The first matter related to a consultation in which the respondent examined two children. According to the report[21] the respondent examined the mother's chest: "without prior warning or consent". The supervisor raised this matter with the respondent who said that because he was busy he commenced the examination of the mother and the explanation for it at the same time.
90 The respondent was asked about this during his evidence before the Tribunal. He said that he had examined the children's chests and thought that since the mother had a cough too, he should examine her chest as well.[22] He believed that he had said this to the mother but conceded that perhaps he had not spoken sufficiently clearly for her to understand.
91 The same patient also complained that the respondent told her that the children had chest infections. She sought the opinion of another doctor in the practice who told her that their chests were clear and there was no sign of infection. The respondent said that this complaint was brought to his attention shortly after the incident. He said that he did not speak to the other doctor about the conflicting diagnoses.
92 The supervisor received complaints from several patients that the respondent had ordered pathology tests including tests for sexually transmitted diseases (STD) when the consultation did not relate to the tests performed. In response to the supervisor, the respondent said that he usually asked patients whether they would like to be: "checked for everything" and if they agreed them he would order extensive pathology. In his evidence to the Tribunal, the respondent indicated that there were times when he specified to patients that this included "STD's, HIV, okay".[23] The respondent said that he would order such tests even when there was no cause in the consultation to warrant them as a general screening of patients and said that in the past he had turned up syphilis which had been undiagnosed. He said that in the future he would not order tests for STD and HIV and when asked why if he thought it necessary would he not order those tests, the respondent replied:
"well it seems...the patients are objecting to it".
93 Although the respondent agreed that a patient must give consent for a procedure to be performed and a patient may not consent to a test being conducted for STD or HIV, the clear implication was that the respondent believed that he had obtained the patient's consent to these tests. His evidence in this regard was somewhat confusing. He agreed that he made a general enquiry whether the patient wished to be checked for everything, then later added that his consultations were slow and long and at the end of the consultation: "just an almost throw away comment like that can easily be forgotten".[24]
94 Whether or not the respondent directly asked patients about testing for STD and HIV, a serious question arises of whether he had obtained informed consent from any patient. His concession of the need to change that practice was because people were critical of his approach not from any consideration of good clinical practice.
95 The Tribunal was not persuaded that the respondent understood the basis of the complaints nor the reason why it was inappropriate to order tests as he had done.
96 The supervisor noted that another doctor in the practice complained that the respondent, having seen one of her regular patients for the first time, changed long term medication or directed medication be stopped without speaking first to the doctor who had the long term management of the patient. The supervisor observed that this communication is necessary to avoid confusion in patients and misdiagnosis. She commented: "an offer of clinical support of help in any area was offered, but not taken up by Dr Potts".
97 The respondent said that he had seen several patients at this practice where he believed their current medication was not appropriate and he changed it without consulting the regular doctor. He did not consult the regular doctor because the reason the patient saw him implied that the regular doctor was either busy or away. He did not consult the doctor about the change after he had seen the patient but said that the change would be apparent on the patient's computer generated records.
98 The respondent said that if he was able to return to practise he would consult the other doctor in similar circumstances because he had obviously offended the other doctor. He added that at the time he thought what he did was reasonable. He was asked in what way not consulting the other doctor was not good patient care and he said: "well the other doctors were unhappy with what I did, ...so there must have been a problem. I don't know".[25] The respondent did not speak to the doctors who complained about his conduct, nor did they raise it with him.
99 The final matter of concern to the supervisor related to the respondent seeing a patient in June 2005 and advising her that she was in congestive heart failure. The patient returned to see her regular doctor 2 days later and no signs or symptoms consistent with that diagnosis were present. It is clear from the report of the supervisor that she believed that the respondent had made a misdiagnosis.
100 The respondent said that the absence of signs consistent with congestive heart failure 2 days later meant that: "my medication worked". The respondent said that he understood the supervisor to believe it was a wrong diagnosis. He said that he told her that lack of signs meant his treatment plan worked but did not know whether she accepted that despite his understanding that she proposed to report to the board.
101 It is to be understood that the matters to which the supervisor referred in her complaint do not form part of the complaints against the respondent. They are relevant to a consideration of the effectiveness of supervision of the respondent and his attitude to supervision.
102 The particulars of complaint 2 broadly concern inadequate clinical judgment (assessment, plan of management, ordering of tests and treatment, discharge of patient), inadequate notes and records, failure to notify or consult with other professionals and failure to obtain informed consent.
103 All of these concerns have been expressed about the respondent's clinical practise before. In 1997 the respondent was counselled about his relationships with patients and other professionals and his record keeping. In 2001 he was counselled about the need to obtain informed consent.
104 The respondent was questioned about the incident in 2001 which led to the counselling. The patient had complained that the respondent had conducted an inappropriate breast examination.
105 The respondent said of this incident:
"She presented at hospital with urinary retention after a boozy lunch and as it was a gynaecological case I thought examination of the breast was a reasonable part of this examination. I did not specifically ask her permission for this or explain it adequately I admit it."
106 He was then asked:
Q "So not only did she not consent but it certainly wasn't a question of informed consent to that examination ?"
A "No, but once again it was a gynaecological admission".
107 The respondent agreed that the counselling he underwent in 2001 after that complaint concerned the need for full and informed consent and, moreover, that he gave an undertaking to the counsellors that in future he would ensure that he obtained proper consent from patients.
108 When asked how his treatment of Ms C at Bateman's Bay reflected that counselling and undertaking, the respondent said that he was fatigued and stressed in his life at the time and this caused him to make the "mistake" of not getting consent from Ms C.
109 The respondent has consistently maintained that the problems and complaints about his practice have occurred when he was under personal and professional stress. He said that he and his wife were very stressed after the premature birth of their son who had some disability and the subsequent breakdown of the marriage. For a considerable period the respondent was working during the week in a general practice and would work on weekends in the Accident and Emergency Department of rural hospitals, often without assistance and sufficient rest.
110 The respondent said that over the years in which he had been under this stress, he had done nothing to help himself although it appears that he recognised that he was under stress. He said that he was now able to recognise the signs that he was under stress, for example, he said that he became terse with people and feel that he had to push himself forward. If he were to be in practise and recognised the signs of stress he would: "step back" and have a few days off work.
111 The respondent attributed the inadequacies of his work while at Moruya to his personal stress and the stress of a busy emergency department.
112 It seems clear from the counselling reports and indeed from the respondent's evidence, that on every occasion when he has been challenged about his approach to practice he has agreed to change. The Tribunal accepts that the respondent had genuinely attempted to alter his mode of practice.
113 However, it was apparent that, while the respondent said that he would conduct himself differently if he was permitted to practise in the future, he did not understand why it was necessary for him to change. For example in relation to not consulting with other doctors, he said he would do it in future because the doctors had been: "offended" and would obtain informed consent for all pathology testing because: "patients were complaining". The Tribunal felt that this is an indication of the lack of insight to which the psychiatrists referred when discussing the respondent's cognitive function and may explain why the respondent's efforts to change his approach to clinical practice have been unsuccessful in the past.
114 A continuing source of complaint about the respondent's practise has been his interaction with patients and this has been the subject of counselling of him under the direction of the Medical Board. He believed that the stress he experienced for many years contributed to the complaints about him although he said that he was blunt and that he appreciated that his demeanour was not acceptable.[26] He believes that having done a communication course ordered by the Medical Board, he would be: "a lot softer and gentler" if he returned to practise.
Discussion
115 The Medical Practice Act defines "impairment" as:
"A person is considered to suffer from an impairment if the person suffers from any physical or mental impairment, disability, condition or disorder which detrimentally affects of is likely to detrimentally affect the person's physical or mental capacity to practise medicine."
116 Although unnecessary to define with precision what condition underlies the impairment,[27] the Tribunal finds that it is more probable than not that the respondent has traumatic brain injury. The evidence cannot exclude the existence of personality dysfunction.
117 The history of complaints and respondent's inability to rectify the behaviour which led to the complaints supports the finding that he has executive function impairment. The Tribunal accepts that when the respondent is under stress his judgment and behaviour are adversely affected to a greater degree.
118 As a result, the respondent has difficulties in making judgments and lacks insight.
119 There is no evidence that, whatever the underlying cause whether organic or personality or both, there will be any improvement either through treatment or the passage of time.
120 The Tribunal is satisfied that the respondent lacks sufficient insight or self-awareness to monitor (and change) his behaviour and, in the result, could not prevent a recurrence of the behaviours which drove the history of complaints.
121 It is appropriate to consider the particulars that form the second complaint - those relating to the respondent's treatment of 6 patients in Moruya Hospital and Ms C in Bateman's Bay in a discussion not only of the respondent's underlying condition but his capacity to practise as a doctor and the suggestion that he be subject to supervision.
122 It is undoubted that considered alone, the particulars of Complaint 2 are very serious indeed and reflect clinical practice which falls below the standard reasonably expected of a medical practitioner. It is also appropriate in this case to consider them as indicators that the respondent's condition is such as to detrimentally affect his capacity to practise.
123 Based on the medical evidence, the Tribunal is satisfied to the requisite standard [28] that the respondent has an impairment as defined by the Act.
124 Unsatisfactory Professional Conduct is defined in section 36 of the Medical Practice Act as:
(a) Any conduct that demonstrates that the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience:
(b) Any contravention by the practitioner (whether by act or omission) of a provision of this Act of the regulations.
(c) Any other improper or unethical conduct relating to the practice or purported practice of medicine.
125 The Tribunal finds each particular of Complaint 2 proved and is also satisfied, again to the requisite standard, that the particulars of Complaint 2 amount to unsatisfactory professional conduct.
126 The jurisdiction of the Tribunal is a protective not punitive one. [29] The purpose of disciplinary proceedings is to maintain proper ethical and professional standards in protection of the community and also to protect the good standing and reputation of the profession.
127 The applicant argued that if the Tribunal found that the respondent was impaired to such an extent that it detrimentally affected his capacity to practise, then the appropriate order was that he be de-registered. The case for the respondent was that he ought to be permitted to resume practise with conditions requiring close supervision.
128 Dr Westmore thought that the respondent could practise medicine in a highly structured, supervised setting, for example in a public hospital under "Level 1" supervision.
129 Level 1 supervision is that given to residents in their first year in practice and involves:
"supervision of all aspects of practice as would occur with an intern and supervisor must be at the same location as the supervised doctor at all times".
It is intended that the supervision may include:
"observed practice, case presentations, regular, structure meetings, case reviews, record reviews and reports to the Medical Board."[30]
130 Dr McPherson considered that the respondent could possibly work in a relatively quiet, well-ordered and methodical setting. Even in such a setting, he thought that the respondent's difficulties with judgment would continue to pose problems and Dr Westmore thought that the respondent's difficulties in changing his behaviour and style of interacting would require people to be available to give immediate feedback.
131 The respondent has had feedback about his clinical practise and interaction with patients on a number of occasions. He has not been able to address either sufficiently to prevent complaints.
132 The respondent also has been supervised in general practice which, despite the supervision, still produced complaints about his conduct. From his evidence, it is clear that the respondent did not accept the criticisms of his clinical practise made by the supervisor or the other doctors in the practice, nor did he take up the offer of the supervisor for consultation and advice.
133 During his weekend work in Moruya it seems, from the nursing notes, that on at least two occasions the nurses suggested a different approach to that which the respondent was taking, which he ignored.
134 It seems to the Tribunal that the only way in which the respondent could safely practise medicine would be if he was monitored and supervised one on one in every aspect of that practise. Even if a supervisor was readily available in the sense of working in the same area as the respondent, the Tribunal is not satisfied that this would address the respondent's problems. This has been demonstrated by the previous period of supervision.
135 This finding then raises the question of whether the need for the respondent to be, in effect, personally supervised at all times during his conduct in clinical practice, should be reflected in conditions on his right to practise.
136 In HCCC v Litchfield [31] the Court of Appeal held:
"The majority thus found that the appellant could not be trusted to observe proper professional standards in his conduct towards female patients unless a female chaperone was present throughout. With the greatest of respect the necessity for imposing such conditions on the appellant's registration demonstrated that he was unfit to practise medicine....".
137 While it is not to be suggested that the respondent's conduct in any sense equates to that of the practitioner in Litchfield, the conditions on his practice of medicine necessary to allow him to practise safely amount to his being chaperoned.
138 The Tribunal is satisfied that the respondent's impairment and its detrimental effect on his capacity to practise as a doctor is such that the only appropriate order is that his name be removed from the register of medical practitioners. The Tribunal will order that he not apply to be re-registered for a period of 2 years. While it is understood that the respondent's difficulties arise from an impairment which, on the evidence, is unlikely to change it would not be appropriate to make an order for any greater duration and it is appropriate to allow the respondent an opportunity to seek the support of his treating psychiatrist in future to found an application for re-registration.
Orders:
1. The respondent's name forthwith be removed from the register of Medical Practitioners.
2. The respondent be not permitted to make an application for re-registration for 2 years from the date of this order.
3. The respondent pay the applicant's costs.
Endnotes
1 Annexure A to these reasons for determination
2 Exhibit B tab 1
3 Exhibit B tab 6
4 Exhibit B tab 7
5 Exhibit B tab 8
6 Exhibit A tab 2
7 Exhibit C tab 6
8 Report 29th April 2005 page 5
9 Exhibit 1 tab 4
10 Report 28 August 2005 Ex F
11 Exhibit 1, 11th July 2007
12 Report 6th December 2004
13 transcript page 38 line 26
14 transcript page 122 line 10
15 transcript page 129 line 15
16 transcript page 78 line 23
17 transcript page 76 line 10
18 Section 66 Inquiry report, page 10
19 transcript page 63 line 30
20 transcript page 65 line 47
21 Exhibit C tab 19
22 transcript page 91 line1
23 transcript page 92 line 8
24 transcript page 95 line 24
25 transcript page 98 line 40
26 transcript page 143 line 48
27 Grant v HCCC [2003] NSWCA 73
28 Briginshaw v Briginshaw (1938) 60 CLR 336. The Tribunal must be comfortably satisfied on the balance of probabilities but that having regard to the serious nature of the charge and the consequences that follow, the satisfaction cannot be produced by "inexact proofs, indefinite testimony or indirect references"
29 Health Care Complaints Commission v Litchfield (1997) 41 NSWLR 630 at 637D and F
30 Exhibit G
31 (1997) 41 NSWLR 630 at 639 F
ANNEXURE ‘A’ TO THE REASONS FOR DETERMINATION AND ORDERS OF THE
MEDICAL TRIBUNAL OF NEW SOUTH WALES
HCCC v Dr Theodore Potts 40022 of 2006
dated 17th August 2007
IN THE MEDICAL TRIBUNAL
CONSTITUTED UNDER SECTION 146 OF THE MEDICAL PRACTICE ACT 1992
NO. 40022 of 2006
IN THE MATTER OF Dr Theodore Potts,
A Person Registered under the Medical Practice Act 1992
NOTICE OF COMPLAINT
TAKE NOTICE THAT the Medical Tribunal has received a complaint from the Health Care Complaints Commission following consultation with the New South Wales Medical Board in accordance with sections 39{2} and 908(3) of the Health Care Complaints Act 1993 and section 51 (1 ) of the Medical Practice Act 1992 ("the Act") THAT Or Theodore Potts of 1 College St, St Ives, New South Wales, 2075 {"the practitioner"} being a medical practitioner registered under the Act:
COMPLAINT ONE
Suffers from an impairment.
PARTICULARS OF COMPLAINT ONE
The practitioner suffers from physical and/or mental disorders, namely, cognitive deficits, possibly the result of a traumatic brain injury suffered by the practitioner in the early 19705, which detrimentally affect or are likely to detrimentally affect his physical and/or mental capacity to practise medicine.
COMPLAINT TWO
Has been guilty of unsatisfactory professional conduct within the meaning of section 36 of the Act and/or professional misconduct within the meaning of section 37 of the Act in that he has demonstrated that the knowledge, skill or judgment possessed, or care exercised, by him in the practice of medicine is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.
PARTICULARS OF COMPLAINT TWO
Between 12 and 14 June 2004 whilst working in the Emergency Department at the Moruya Hospital in Moruya NSW as a Career Medical Officer the practitioner:
Patient PG -Date of Presentation 12/06104
(1) Performed an inadequate clinical assessment of Patient PG,
(2) Formulated an inadequate management plan for Patient PG,
(3) Failed to adequately document a history, examination and management plan for Patient PG in the medical record,
(4) Failed to notify or arrange to notify the Visiting Medical Officer of PG's admission to hospital,
(5) Failed to order appropriate tests and/or investigations including X rays and/or blood tests.
Patient JM -Date of Presentation 12/06104
(6) Performed an inadequate clinical assessment of Patient JM,
(7) Formulated an inadequate management plan for Patient JM,
(8) Failed to adequately document a history, examination and management plan for Patient JM in the medical record,
(9) Failed to notify or arrange to notify the Visiting Medical Officer of JM's admission to hospital,
(10) Failed to seek advice and/or assistance from the Visiting Medical Officer in the management of Patient JM,
(11) Failed to order appropriate tests and/or investigations including blood tests,
(12) Failed to instigate appropriate treatment for Patient JM including: adequate fluid resuscitation and/or blood transfusion.
Patient TT - Date of Presentation 13106/04
(13) Performed an inadequate clinical assessment of Patient TT,
(14) Formulated an inadequate management plan for Patient TT,
(15) Failed to adequately document a history, examination and/or management plan for Patient TT in the medical record,
(16) Failed to seek advice and/or assistance from the Visiting Medical Officer in the management of Patient TT,
(17) Inappropriately discharged Patient TT home:_
(a) prior to reviewing the patient's blood test results,
(b) in circumstances where the patient's clinical condition warranted admission to hospital.
Patient PGW - Date of Presentation 13/06/04
(18) Performed an inadequate clinical assessment of Patient PGW,
(19) Formulated an inadequate management plan for Patient PGW,
(20) Failed to adequately document a history, examination and management plan for Patient PGW in the medical record,
(21) Failed to order and/or perform appropriate investigations and/ or tests including foetal CTG monitoring,
(22) Failed to arrange for Patient PGW to be assessed by a midwife and/or an obstetrician before discharging her.
Patient GR- Date of Presentation 13/06/04
(23) Performed an inadequate clinical assessment of Patient GR PG,
(24) Formulated an inadequate management plan for Patient GR PG,
(25) Failed to consider the significance of the history of bleeding from the nose in his assessment of Patient GR,
(26) Failed to adequately document a history, examination and management plan for Patient GR in the medical record,
(27) Failed to order and/or perform appropriate investigations and/or tests and/or observations including X rays and/or CAT scan and/or neurological observations,
(28) Failed to ensure Patient GR was monitored for a minimum period of four hours before discharging him from hospital.
Patient AS -Date of Presentation 14/06/04
(29) Performed an inadequate clinical assessment of Patient AS,
(30) Formulated an inadequate management plan for Patient AS,
(31) Failed to adequately document a history, examination and management plan for Patient AS in the medical record,
(32) Failed to notify or arrange to notify the Visiting Medical Officer of AS's admission to hospital,
(33) Failed to seek advice and/or assistance from the Visiting Medical Officer in the management of Patient AS,
(34) Failed to instigate appropriate treatment for Patient AS including: adequate fluid resuscitation and/or cardio vascular medication
Patient EG - Date of Presentation 14/06/04
(35) Failed to adequately document a history, assessment, examination and/or management plan for Patient EG in the medical record
(36) Failed to instigate appropriate treatment for Patient EG including rest, ice and/or compression,
(37) Failed to order an/or perform appropriate investigations and/or tests including blood tests.
On 18 April 2004 whilst working in the Emergency Department at Bateman's Bay Hospital NSW as a medical officer the practitioner:
Patient TC - Date of presentation 18/4/04
(38) Took a blood sample from patient TC after the patient had refused consent for the procedure.
Karen Mobbs Director of Proceedings
Health Care Complaints Commission
Dated this _____ day of __________, 2006
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