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Backs, bladders & bowels & a dose of Brains & babies Please inform your Doctor & ask for a diagnosis

#1 User is offline   hukildaspida 

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Posted 01 October 2009 - 03:08 PM

These websites are useful for those who suffer Back, bladder & bowel related issues as a result of Spinal injuries.

It is extremely important you inform your Doctor if you are suffering bladder & bowel issues if you have had a Spinal Injury as you may well have Cauda Equina Syndrome which needs to be treated urgently.

How many have you have ever heard of CES or ever been diagnosed for it who have Spinal/Nerve damage as a result of your Accident causing Personal Injury?

Worse still how many people have been exited from ACC & lost their Earnings Related Compensation through the Vocational & Occupational Medical Experts Opinions who wouldn't have a clue the harm this does to your daily functioning?

How many people have been targeted by ACC contracted Private Investigators who are even less Medically qualified to form opinions about Back related injuries & lost your ERC as a result?

http://www.caudaequina.org/

http://www.emedicinehealth.com/cauda_equin.../article_em.htm

page 10 relating to Prevention is a must read

http://www.medicallegalblog.com

http://www.xcell-center.com

and for the anatomy this has some great Medical Illustrations & Animations

http://www.doereport.com/
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#2 User is offline   Sparrow 

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Posted 01 October 2009 - 10:45 PM

Thanks SPida, you do some interesting research that is helpful
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#3 User is offline   hukildaspida 

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Posted 08 December 2009 - 03:25 PM

Make sure your Doctor & Assessors also correctly diagnose nerve damage & broken bones.

We read recently where someone was diagnosed with a "strained muscle" when in fact they had a hip break & subsequently died.

Shameful of the health systems we have to use worldwide, this despite all the expensive modern technology hospitals have that we have paid funds for.
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#4 User is offline   hukildaspida 

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Posted 07 February 2011 - 08:20 PM

A website with some New Zealand and overseas stories and useful information

http://www.coccyx.or.../2010/fiona.htm

http://www.coccyx.org
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#5 User is offline   not their victim 

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Posted 08 February 2011 - 08:52 AM

thanks for the links Hukildaspida

it doesnt matter that i have many of these symptoms as according to acc, i still dont have a neck injury!
bah humbug!
and the fight continues lol.................
love peace and blessings
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#6 User is offline   hukildaspida 

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Posted 15 August 2011 - 12:05 AM

As embarrassimg as it may be inform your Doctor if you have loss of bowel or bladder function as they are often directly related to your injuries.

Ask those whom you have interactions with about your http://www.acc.co.nz claim how they would feel if they lost control of their bladder or bowel functions whilst out and about without any prior warning.

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#7 User is offline   hukildaspida 

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Posted 01 August 2012 - 08:38 PM

http://www.stuff.co....r-doctors-delay

Woman disabled after doctor's delay
Last updated 17:43 01/08/2012

A doctor exposed a woman, who has been left permanently disabled, to unnecessary risk by failing to ensure she was seen immediately by a specialist, the Health and Disability Commissioner has ruled.

The case was an example of how patients should have "justified confidence" that their doctors will refer them in a timely manner so that their condition does not worsen.

That was not the case when the woman visited her GP in 2009, commissioner Anthony Hill said in a ruling released today.

If the woman had been seen by a specialist immediately after presenting to her doctor, then she would have had a greater chance of recovery and might not have been permanently disabled due to a prolapsed disc, Hill said.

The names of the women, doctor, specialist, medical centre, and district health board were not published.

The woman was 29-years-old when she saw her GP in November, 2009. She had slipped in the shower three weeks earlier, but had been experiencing severe pain in her sciatic nerve and in her right foot for the four days prior to her appointment.

The doctor diagnosed a disc prolapsed, referred her for a CT scan and prescribed her pain relief. But she returned the following day after losing control of her bladder.

Urinary incontinence was a "red flag" that she could possibly have cauda equina syndrome, something which every doctor should be aware of, Hill said in his ruling.

The syndrome affects the nerve tissue and time is of the essence in treating it.

However, while the doctor was aware of the possibility of the woman having the syndrome, and contacted a surgeon and the emergency department, he understood that he could not directly refer his patient to the ED, something which the district health board says is in contrast to its expectation.

The doctor left a message on the surgeon’s phone on a Friday afternoon asking him to bring her CT scan forward, and said he instructed the woman to go to the hospital emergency department (ED) over the weekend if she did not hear from the on-call orthopaedic surgeon, or if her symptoms worsened.

He has been criticised for not being more aggressive in his referral by making sure she was seen that day. The doctor has said on reflection, he should have sent her straight to the ED.

However, the specialist who listened to the phone message and tried to find the woman in ED, also should have been more active in making sure she was seen as soon as possible, Hill said.

The woman said she her doctor told her to take more pain killers and rest until Monday, when she was due to have a CT scan.


"He left it at that," she said.

"I went home and had the worst weekend of my life with the pain and the worry that I might over dose on the pain killers as they weren't doing anything."

She was in so much pain she could barely stand or sit.

After she had the scan on Monday she received a phone call telling her to return to the hospital to meet with the surgeon straight away.

He told her that her situation was a medical emergency and she had 48 hours after the onset of the bladder incontinence to have surgery to have the best chance of recovery.

She had surgery later that day and has had two more surgeries since.

While the medical centre has since taken steps to improve its procedures, Hill said he was concerned that effective procedures weren’t in place to start with and recommended that it send him a progress report later this year.

He found the doctor breached his responsibility of appropriately referring his patient and minimising potential harm to her, and recommended the doctor apologise.


___________________________

General Practitioner, Dr A
A Medical Centre

A Report by the
Health and Disability Commissioner

(Case 10HDC00454)
http://www.hdc.org.n...0hdc00454gp.pdf
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#8 User is offline   hukildaspida 

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Posted 01 August 2012 - 08:39 PM

http://www.hdc.org.n...2012/10hdc00454

Decisions & Case Notes > Commissioner's Decisions > 2012 > 10HDC00454




Decision 10HDC00454

Download the pdf version of this decision. (PDF 316Kb)

Names have been removed (except the experts who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
General Practitioner, Dr A
A Medical Centre



A Report by the Health and Disability Commissioner



Table of contents

Executive summary

Investigation process

Information gathered during investigation

Responses to provisional opinion

Opinion: Dr A

Opinion: No Breach ― The medical centre

Adverse comment - Dr A/The medical centre

Adverse comment - Dr C

Additional comment

Recommendations

Follow-up actions

Appendix A ― Independent clinical advice - Dr David Maplesden

Appendix B ― Independent orthopaedic advice - Dr Garnet Tregonning

Appendix C


Executive summary

Background

On 16 November 2009, general practitioner Dr A examined a 29-year-old woman, Ms B. She reported that she had been experiencing right-sided sciatic pain and tingling in her right foot for four days. Dr A considered that Ms B was suffering from a disc prolapse and consulted orthopaedic surgeon Dr F at the public hospital, who agreed with this diagnosis and approved Dr A ordering a CT scan for Ms B. Dr A referred Ms B to the orthopaedic clinic and provided her with a prescription for pain relief and anti-inflammatories.

On 20 November, Ms B returned to see Dr A because her pain was ongoing and she had developed urinary incontinence. Dr A considered this new development a "red flag" and tried unsuccessfully to contact the on-call orthopaedic surgeon, Dr C. Dr A contacted the hospital radiologist to bring forward Ms B's CT scan appointment and left Dr C a message about his patient. At 2.52pm, Dr A faxed a referral for Ms B to Dr C at his private clinic. Dr A instructed Ms B to go to the hospital emergency department [ED] over the weekend if she did not hear from Dr C or if her symptoms worsened.
At 7pm, Dr C picked up Dr A's message, which did not include contact details for Ms B. Dr C went to the ED and the wards to look for a patient with the symptoms Dr A described. No patient of that description presented to the ED over the weekend.
At 9.15am on 23 November, Ms B presented to the hospital radiology for her CT scan. Meanwhile, Dr A's referral arrived in the mail at Dr C's private clinic. Enquiries were made and Ms B was contacted and asked to present to Dr C's clinic. Dr C operated on Ms B later that day to decompress the L5/S1 spinal disc. Ms B has a permanent disability as a consequence of her disc prolapse.

Decision summary


5. Dr A had a duty to ensure that Ms B received a specialist review on 20 November. Dr A did not fulfil this duty. Dr A did not follow up his telephone message and fax to the specialist, and did not impress upon Ms B the need for a timely review. By not ensuring that Ms B was reviewed by a specialist in a timely manner, Dr A failed to minimise potential harm to Ms B. Dr A also failed to ensure co-operation among providers to ensure quality and continuity of services. Therefore, Dr A was found to have breached Rights 4(4)[1] and 4(5)[2]of the Code of Health and Disability Services Consumers' Rights (the Code).

6. The medical centre was not found to be vicariously or directly liable for Dr A's breach of the Code.

Adverse comment

7. Dr C acknowledged that he had been advised about a patient with a spinal problem who had developed urinary problems. Although Dr C looked for the patient in the hospital ED and on the ward, he should have made more attempts to track down Ms B. Dr C's failure to take a more proactive approach to track down Dr A's patient was an important link in the chain of events that led to Ms B not receiving the timely specialist care that she needed.

8. At the time of these events, the DHB did not have a written protocol for primary care referrals to the ED, and acknowledged that there was no consistent approach from senior medical staff working in specialties with respect to the processing of acute referrals from GPs. Confusion about procedures for GPs to refer patients to hospital specialist services has the potential to affect patient care. Primary care centres and district health boards need to work together to develop clear, unambiguous systems for referring patients between primary and secondary services in their respective areas.

9. In March 2012, the DHB updated its processes for GP referrals to ED. A process document, "Procedure for Acute Admission - GP Referral" was circulated to hospital staff, and displayed in ED. There is now a direct Primary Care Referral Line, which enables primary care providers to speak directly with a senior ED doctor. A new fax number has been introduced for all outpatient departments to enhance primary/secondary care communication. A new ED specialist has been employed, which has improved the number of patients being assessed.

10. The medical centre has made a number of systems changes, ie, improving its method of faxing referrals to the hospital, and organising monthly staff meetings to discuss cases and systems issues.


Investigation process


11. On 16 April 2010, the Commissioner received a complaint from Ms B about the services provided by general practitioner Dr A. The following issue was identified for investigation:

Whether Dr A provided Ms B with services of an appropriate standard on 20 November 2009.

12. An investigation was commenced on 15 September 2010.

13. The parties directly involved in the investigation were:

Ms B Consumer

Dr A Provider/general practitioner

Dr C Orthopaedic surgeon

The medical centre

The district health board

14. Information was reviewed from:

Dr A

Dr C

Ms D, Dr C's private clinic secretary

Ms E, the medical centre's practice manager

The medical centre

The district health board



Also mentioned in this report:

Dr F Orthopaedic surgeon

Dr G General practitioner

15. Independent clinical advice was obtained from general practitioner Dr David Maplesden (Appendix A). Independent orthopaedic advice was obtained from consultant orthopaedic surgeon Dr Garnet Tregonning (Appendix B).


Information gathered during investigation


16 November 2009

16. On Monday 16 November 2009, Ms B (then aged 29 years) presented to medical practitioner Dr A at the medical centre. She reported a history of four days of worsening right-sided sciatic pain following a slip in the shower. She also reported numbness and tingling around her right foot.

17. Dr A examined Ms B and found that she had a loss of her right ankle jerk. She also had reduced straight leg raise of her right leg, with pain occurring at 20 degrees of lift. He found no defect on the left side. Dr A considered that Ms B had "a near 'full house' of symptoms for possible disc prolapse". He recorded in Ms B's clinical records:

"3wk ago slipped backwards & braced herself with arms, acute R [right] leg pain, initially not so bad, kept working but last [4 days], constant day & night, sciatic distribution, numbness & tingling around foot, weakness & loss R AJ [right ankle joint], also SLR [straight leg raise] 20deg on R … L [left] leg ok."

18. Dr A telephoned orthopaedic surgeon Dr F[3] at the public hospital (the hospital) to discuss Ms B's symptoms and management.

Dr F

19. Dr F advised HDC that although Dr A advised him that he would like Ms B to be seen by an orthopaedic surgeon in the Outpatient Clinic "before too long", Dr A did not ask for Ms B to be seen as an emergency. Dr F told Dr A that if he wanted to refer Ms B as an urgent referral to the hospital's orthopaedic outpatient clinic, the referral should be sent directly to him and he would make seeing Ms B a priority when the referral came to his attention. Dr A asked Dr F whether a CT scan would be justified at that stage. Dr F told Dr A that a CT scan would be a "useful" investigation to have and that it would save time if the scan could be arranged before Ms B presented at the outpatient clinic.

Referrals

20. Dr A recorded in the computerised notes for his consultation with Ms B on 16 November 2009, "d/w Ortho … [Dr F] for CT & ref [Dr C] [referral to orthopaedic surgeon Dr C]". Dr A advised Ms B to take a week off work and prescribed analgesic and anti-inflammatory medication. As Dr F had authorised a CT scan of Ms B's lumbar spine, Dr A faxed the CT request to radiology, and a copy of his consultation to the orthopaedic outpatient clinic.

17 November

21. A nurse's comment in Ms B's medical centre clinical records, dated 17 November, notes, "[Telephone] In excruciating pain [and] burning with back pain, does not feel that [prescribed] analgesia is cutting the mustard. [Discuss with Dr A]."

20 November

22. On Friday 20 November, Ms B returned to see Dr A as her symptoms had increased, and she had some urinary incontinence. Dr A was fully booked and initially Ms B was seen by another GP, Dr G.

23. Ms B stated that she told Dr G of her earlier visit to see Dr A regarding her back problem and that she was still waiting for an appointment for a CT scan. Ms B told Dr G that she had lost control of her bladder "since the day before". Dr G asked her if her bowels had moved, and when Ms B replied that they had not but this was not unusual, Dr G told her that she should see Dr A, as he was her usual doctor and knew her history.

24. Ms B recalls that when she was "finally" able to see Dr A he seemed very pushed for time and told her that he needed to pick up his children.

25. Dr A advised that he saw Ms B in the mid to late afternoon, and immediately recognised the new development of loss of bladder control as a "red flag" and an indication that her situation was worsening. Dr A advised HDC that he spoke to the hospital telephonist to ask who was on call for the orthopaedic team, and was told that it was Dr C. Dr A stated, "I called through twice [to Dr C] because I wanted to speak to him to discuss the case, but with no answer."

26. As Ms B had not had the CT scan, Dr A contacted the hospital radiology department to try to expedite the scan. He spoke to the senior radiographer, who advised him that Ms B had a booking for the following week, but that there was an appointment available at 9.15am on Monday 23 November owing to a cancellation. Dr A asked that Ms B be booked in for this appointment. Dr A then telephoned Dr C again and left a message on his telephone regarding Ms B.

Telephone message

27. There is discrepancy about what information Dr A actually left for Dr C about Ms B in his telephone message.

28. Dr A advised HDC that, after talking to the radiologist, he tried again to contact Dr C. When he was unsuccessful on that occasion, he left a message on Dr C's mobile phone, during which he says he identified himself and Ms B, described her symptoms, which included the recent development of urinary incontinence, and stated that her CT scan had been brought forward to Monday 23 November. Dr A stated that he also advised Dr C of Ms B's contact details (which he said he would also fax through) in case Dr C wanted to arrange for her to be seen in the ED.

29. Ms B's recollection of Dr A's message to Dr C was:

"I have a 29 year old female presenting with back and hip pain, with shooting pain down her right leg, I believe that she has sciatic nerve damage. She is otherwise a fit and healthy person, however today she has presented to me with having problems with not been able to control her bladder and the pain is more severe. She is unable to sit or stand for even short periods as the pain is not under control. She is on a high dose of codeine but is not getting any relief. She has managed to get a C.T. scan on Monday morning. If you could please get back to me that would be great. Thanks [Dr A]."

30. Dr C stated that he was in theatre when Dr A telephoned. Dr C recalls that he received Dr A's message after the operation concluded, at about 5pm. Dr C stated that Dr A's message explained that he was concerned about one of his patients with a "three week history of back pain, lower limb weakness and some objective neurology". Dr A stated that he had discussed the case with orthopaedic surgeon Dr F a "few days before", and a decision had been made to refer her electively for consultation and scanning of her lumbar spine. Dr A indicated that the patient had deteriorated in the few days subsequent to his discussion with Dr F, that she had urinary symptoms, and that he was referring the patient more urgently.

31. Dr C stated:

"No details were left regarding the name of the patient or any contact details, nor were any details left with regard to contacting the general practitioner. My assumption therefore was that the patient was being referred to the Emergency Department at [the] Hospital for my assessment which would be standard practice."

32. Dr A advised that his contact details are available at the hospital if Dr C had wanted to get hold of him for more information. Dr A stated that Dr C should have contacted him when Ms B did not present at the ED.

33. The telephone message Dr A left was not retained.


Fax referral and advice to Ms B


34. Dr A stated that after leaving the message with Dr C:

"I then wrote and faxed a copy of my consult & management to the orthopaedic department. My intention in doing these things was to advise them that I was passing responsibility on to them for her care given her presentation. I then told [Ms B] to seek further medical attention if her symptoms got worse over the weekend."

35. Dr A faxed the referral for Ms B to Dr C intending that he should receive it at his private clinic. The referral, a computerised print-out of Dr A's 16 November 2009 assessment of Ms B, stated:

"[Dr C] Private Fax […]

Returned ++ pain

Now loss of urinary control

No saddle anaesthesia

Rung CT & ortho again

Ring "[Dr C] - left message

9.15am CT Mon booked."

36. Dr A annotated the bottom of the print-out referral with Ms B's ACC claim number, and the details of his 20 November assessment. Dr A also stamped the referral with his surgery stamp, writing "from" above the stamp. (A copy of the referral is attached as Appendix C.)

37. Dr A entered his assessment in the computer as:

"Severe lumbar pain into R leg, sciatic, still nil AJ relex.

Lost of control of urine, but no saddle anaesthesia/numbness

Rung and left message with [Dr C]

Rung CT scan

Re Faxed letter/copy consult."

38. Ms B stated:

"… once he had left the message on "[Dr C's] phone [Dr A] told me to take more of the codeine, get some rest and not to drink too much water until my C.T. scan on the Monday after the weekend. He left it at that."

39. Ms B stated: "I went home and had the worst weekend of my life with the pain and the worry that I might over dose on the pain killers as they weren't doing anything."

Dr C

40. Dr C stated that after receiving Dr A's telephone message:

"I continued my afternoon operating list, and, at the conclusion of that, which may well have been around 7pm, I went through to the Emergency Department and the ward at [the] Hospital to determine whether a patient with this problem had been seen. I discussed the case with the attending Medical Officer who had not seen a patient of this nature come through the department during his shift. I left instructions therefore to contact me as soon as such a patient attended the hospital. No such response occurred over the weekend."

41. Ms B did not present to ED and was not seen by a specialist over the weekend.

Monday 23 November

42. There are some inconsistencies between the various recollections about the circumstances of Ms B being seen by Dr C on Monday 23 November 2009.

43. Dr C stated that Dr A's referral did not arrive at either his private clinic, or the hospital's orthopaedic department. He recalled that Ms B arrived at his private clinic on the morning of 23 November. She said that three days earlier her GP had told her to have a CT scan on Monday.

44. Dr C's private clinic secretary, Ms D, recalls that the referral from Dr A arrived in the mail on Monday morning. She said that Dr C had been expecting a patient with this problem over the weekend, and there was a "ring around" on Monday morning to try to locate Ms B. Ms D contacted radiology and found that Ms B had just left. She then contacted Ms B (whose home and mobile phone numbers were on the top of the referral) and asked her to come into the clinic.

45. Ms B corroborated Ms D's recollection. Ms B advised HDC that she was contacted by Dr C's secretary while she was on her way home from having her CT scan. She was asked to go straight back to the hospital as Dr C wanted to see her. Ms B said that she saw Dr C within 30 minutes of arriving at his clinic. Ms B recalls that Dr C told her that he had been expecting her to come into the ED on either Friday or over the weekend. He told her that her situation was a medical emergency and she had 48 hours after the onset of the bladder incontinence to have surgery to have the best chance of recovery. He said that he had been trying to contact her, and that she needed to have surgery that day. Dr C told her to go home and get a bag packed for admission to the hospital.

Subsequent events


46. Dr C booked a theatre and performed an urgent L5/S1 discectomy on Ms B that day.

47. Dr C then wrote to Dr A stating:

"Thank you for referring urgently this young lady.

As you are aware you left a message on my phone on Friday evening but unfortunately I could not track [her] down. She did not come to the hospital at that stage nor over the weekend and I was on call and would have been notified if she had. …

I feel most uncomfortable, as I am sure you did on Friday, about her status with urinary incontinence and have admitted her urgently.

The CT organised prior to the appointment with me shows a central disc prolapse of L5/S1 with almost certainly a moderate degree, at least, of cauda equina compression."

48. Dr C said that Ms B improved to some extent after the initial surgery. However, when orthopaedic consultant Dr F reviewed her at the end of December 2009, he was concerned about her ongoing symptoms and clinical signs.

49. Ms B has had two subsequent surgeries, but has significant ongoing neurological symptoms indicative of cauda equina syndrome.[4] She has been referred […] for rehabilitation. Dr C stated: "She undoubtedly will have permanent disability as a consequence of her disc prolapse."
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#9 User is offline   hukildaspida 

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Posted 01 August 2012 - 08:40 PM

http://www.hdc.org.n...2012/10hdc00454

Additional information

Dr A

50. Dr A stated that after these events he had telephone conversations with an orthopaedic surgeon and the DHB's Chief Medical Officer to discuss the difficulties he encountered contacting the orthopaedic team on Friday 20 November. Dr A advised HDC that after the new ED opened in 2009 the GPs were told to contact medical specialists directly before sending patients to the ED. They were advised not to refer via the house surgeon or send the patient directly to the ED. Dr A said: "I thought I was following the correct protocol [on 20 November 2009]."

51. Dr A advised HDC that he had discussed with his the medical centre colleagues the difficulties being experienced by GPs when referring patients to the ED, and that he intends to change the manner in which he accesses specialist service in future.

The medical centre


52. The medical centre has not provided HDC with any policy or procedure regarding the referral of patients (either acute or non-acute) to the hospital. The medical centre's Practice Manager, Ms E, advised HDC that the system in place at the clinic for referring non-acute patients to the hospital is that all referral letters are sent to the hospital via internal mail. The letters are collected from the clinic twice a day. She said that the clinic had no written instruction from the hospital about changes to the system for acute referrals, and believes that any information about referral changes was disseminated verbally amongst the practice clinicians.

The DHB

53. The DHB's Chief Medical Advisor advised HDC that "[i]t appears that there is no consistent approach from senior medical staff working in specialties other than emergency medicine with respect to the processing of acute GP referrals for specialist assessment in the ED". The DHB later advised HDC that in 2009 the process for patients to be referred from primary care to a medical specialist was for the GP to call the relevant specialist to request an urgent assessment and to arrange for the patient to present to the ED to be seen, unless instructed otherwise by the specialist. ED staff then notified the specialist or his/her house surgeon when the patient arrived in the department and requested that he or she attend to conduct the medical assessment. GPs wanting specialist review of a patient also had the option of referring patients by telephone or sending the patient to the ED for a review by ED staff.

54. The Chief Medical Advisor advised HDC that in 2009 the DHB did not have a written protocol for primary care referrals to the hospital ED. There was an expectation that GPs would telephone the senior medical staff based in the ED (or a junior medical officer if the senior was unavailable) prior to sending a patient into the ED for assessment. The DHB advised HDC that the process of GP referrals to ED (as opposed to referring for specialist review) was updated in March 2012. A process document, "Procedure for Acute Admission - GP Referral" has been circulated to hospital staff, and a laminated copy of this document is displayed in ED.

55. Additionally, a protocol for the processing of "Primary Care Referrals to [the] ED on phone" was drafted. The protocol attempts to streamline referrals to ED through the establishment of a dedicated phone line for doctor-to-doctor referrals. The new line is intended to be answered by, or directed to, the ED Senior Medical Officer between 8am and 11.30pm. The protocol states that, in all cases, the ED expects a referral letter to be clearly addressed to the accepting doctor, which includes a summary of the acute problem, past history, current medications and allergies. The DHB advised HDC in March 2012 that this protocol is to be implemented as a priority once a dedicated "red telephone" (to be carried by the senior medical officer on duty) is available.

56. The DHB also advised HDC in March 2012 that the ED Charge Nurse Manager will liaise directly with the Primary Health Organisation, for broad distribution of this information.

Dr A


57. Dr A stated:

"With the benefit of hindsight, I have reflected on why I didn't just send [Ms B] to ED with a note or try to contact another specialist. Sending her direct to ED would probably have been the best way for [Ms B] to receive specialist assessment on the Friday. I did with all sincerity however, believe that [Dr C] would get my message (which it appears he did) and would contact [Ms B] or myself if he thought more urgent action was necessary. However, I accept that it was my responsibility to ensure that [Dr C] got my message and it was not good enough to just leave a message. I would not, faced with the same situation, do this again.

At the time I was also reassured by the fact that I had already contacted the orthopaedic department and spoken to a specialist [Dr F] and was partially reassured by the fact that her scan had been brought forward to the Monday morning. … However, again I totally accept that I should have sent her to ED in the absence of being able to speak to a specialist.

I have discussed [Ms B's] case with my colleagues as individuals and at our last peer review group meeting. My peers acknowledged the difficulty of contacting specialists and delays in accessing acute services at times and I intend following up this aspect of [Ms B's] case to ensure that GPs in our practice are clear about communication between primary and secondary care in [the town]."

58. HDC has not been advised about any further action that Dr A may have taken regarding his concerns about the difficulty GPs have contacting specialists and delays in accessing acute services at the hospital.


Responses to provisional opinion


59. The parties were offered an opportunity to respond to my provisional opinion. The following responses were received.

Dr A

60. In response to the provisional opinion, Dr A stated: "I would like to apologise sincerely for not having participated in the investigation as I should have, and responded as requested [sic]."

61. Dr A acknowledged that there was discrepancy in the information provided about his telephone message to Dr C. He commented that Dr C has provided conflicting information to HDC - on one hand in his follow-up letter, thanking Dr A for "referring urgently this young lady", he acknowledged that Dr A had left a message on Friday evening, but "unfortunately I could not track [Ms B] down". Dr A said that Dr C's later statement to HDC does not mention that he had been trying to contact Ms B prior to her appearing at his clinic on Monday morning, but that he was waiting to be advised when Ms B attended the hospital over the weekend that he was on call. Dr A stated:

"In my view [Ms B's] recollection and [Dr C's] letter immediately after her surgery are consistent with my recollection that I did leave her contact details and that [Dr C] did try to contact her knowing that the situation was serious, otherwise why would he have said he had tried to contact her?"

62. Dr A said he is certain that he clearly said in his telephone message for Dr C that Ms B was not going to the ED, and that Dr C was to contact her. Dr A said: "There does not seem to be any dispute that Dr C did get the message on Friday night. I did leave a name and I did leave clinical details for her."

63. Dr A said that when he saw Ms B on Friday 20 November, she had only intermittent bladder incontinence. He said that at this time he did not know that this was a chronic condition for her - that she had been admitted previously with this condition, but no cause had been found. Dr A said: "Obviously, if cauda equina had been evident I would have sent her straight up, but she had no obvious signs."

64. Dr A stated:

"My position was that having received the message that I was referring a patient to him with very serious symptoms and given [Dr C's] view that there was a limited window of opportunity to attend to [Ms B], if [Dr C] had any concerns regarding the message, or the information left in the message (or lack of information if he considered that to be the case), or if he could not get hold of [Ms B], as he said, then I would have thought it not unreasonable for [Dr C] to try to call me. …

I have accepted responsibility for not following up to ensure that [Dr C] had got the message or the fax at his rooms over the weekend when he was on call. I have said that in retrospect, ringing later on in the evening to ensure he had the message would have been the next step for me to check up on [Dr C's] action or lack of it and that this could possibly have achieved a better outcome for [Ms B]. I am sincerely regretful that in the circumstances I did not do that."

65. Dr A stated that the medical centre has made changes since these events, which include amending its Fax Policy. The medical centre achieved Cornerstone Accreditation Process in 2011, and is about to undergo its yearly review. Dr A arranges and mediates a monthly internal peer review meeting, and one of the subjects for discussion at an upcoming meeting is the outcome of this complaint and the HDC report. The medical centre staff meet regularly to discuss cases and system issues.

66. There have been changes in the interaction between the primary and secondary care services. Dr A stated that a new ED specialist has been employed at the hospital, and the philosophy of ED seeing all patients that attend rather than turning a number away has changed. This has improved the ability of sending patients through to the hospital. Since March 2012, GPs have had direct access to the "Primary Care Referral Line". A senior Medical Officer Special Scale in ED carries the phone around, and GPs can ring directly to it to speak to a doctor. Dr A stated that he has used this system and found that it has improved "the flow" of decision-making hugely. On 13 January 2012, in order to minimise the confusion around phone/fax numbers and assist with hospital and primary care communication, a combined fax number for all public outpatient departments at the hospital was established. Some on-call specialists are now putting on their answerphone messages: "Please send patient to ED or ring ED if I am not contactable."

67. Dr A stated that as a result of these events he has made a number of changes to his practice. He has discussed these events with his peer group, and is "going to make sure I write more full notes from now on". Dr A stated that he leaves fewer phone messages now and, if he does leave a message, he follows up serious or urgent cases to check whether the message has been received. He said that he also follows up any acute referral faxes, such as ED and specialist referrals and requests for X-ray or ultrasound, with a phone call, and checks that the fax number is correct. Dr A is reviewing the medical centres process for faxing consultation notes in Med Tech, which does not always generate the full patient details, and is arranging IT input to improve the system.

Dr C

68. In response to the provisional opinion, Dr C commented that the focus of the Commissioner's report - Ms B's referral to the hospital over the weekend of 20 to 22 November 2010 - overshadowed her three-week history of deteriorating symptoms and increasing lower limb neurology in her right leg. He considered that this focus is unreasonable, as he believes Ms B's predicament was irreversible by 20 to 22 November 2010. He also noted that Ms B did not choose to see another physician while she was waiting for an appointment, or present to the hospital.

69. Dr C said that the severe pain Ms B reported on 16 November and through the week to 20 November indicated an "ischaemic nerve root in real trouble". Dr C noted that orthopaedic surgeon Dr F offered Ms B a consultation at any stage from 16 November when Dr A discussed Ms B's condition with him. Dr C said:

"The correct pathway in such circumstances, in my opinion, would have been to take up [Dr F's] original offer and have the patient seen and assessed properly by a senior clinician, not as did eventually occur focussing on a CT scan which would have only been necessary to prove the diagnosis. An alternative pathway at the end of the week would have been immediate referral via the emergency department to the hospital."
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#10 User is offline   hukildaspida 

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Posted 01 August 2012 - 08:41 PM

http://www.hdc.org.n...2012/10hdc00454

The DHB

70. The DHB did not respond to the provisional opinion.


Opinion: Dr A

Assessment and diagnosis - No Breach

71. When Ms B consulted Dr A on 16 November 2009 reporting a four-day history of right-sided sciatic pain and tingling in her right foot, he examined her and considered that she had a spinal disc prolapse. He discussed her problems with Dr F, an orthopaedic surgeon at the hospital, organised for her to have a CT scan to confirm the diagnosis, and prescribed medication to treat the symptoms.

72. On 20 November, Dr A saw Ms B again when she reported ongoing pain and the new development of intermittent urinary incontinence. He realised that she needed an urgent specialist assessment and contacted the radiology department to bring forward her CT scan appointment. Dr A attempted to contact the on-call orthopaedic surgeon, Dr C, directly by telephone. When he was unable to reach Dr C, Dr A left Dr C a message describing the details of Ms B's situation, and then faxed a referral for her to what Dr A understood to be Dr C's private clinic's fax number. Dr A advised Ms B to seek further medical attention if her symptoms got worse over the weekend.

73. I am advised that there are few surgical emergencies in the treatment of back pain, but cauda equina syndrome is one that should be recognised by all GPs. The New Zealand Guidelines Group's "New Zealand Low Back Pain Guidelines 2003" states: "Cauda Equina Syndrome is a medical emergency and requires urgent hospital referral. … All patients with symptoms or signs of Cauda Equina Syndrome should be referred urgently to hospital for orthopaedic or neurological assessment." The symptoms include urinary retention, faecal incontinence, saddle numbness, and neurological symptoms such as gait abnormalities. I am also advised that it is common knowledge among medical practitioners that cauda equina syndrome is a serious complication of back pain, and one that should be recognised by all general practitioners.

74. HDC's clinical advisor, Dr Dave Maplesden, advised that Ms B's presentation was suspicious for cauda equina syndrome. Dr A also recognised this, and Ms B's need for an urgent specialist review. In my view, Dr A's clinical assessment and diagnosis of Ms B was competent, and his clinical documentation of his two consultations with her was consistent with expected standards.

Referral - Breach

75. Dr A appropriately recognised that Ms B's condition had worsened on 20 November and that she required a more urgent specialist review. Given the seriousness of Ms B's presenting condition, it is my view that Dr A had a duty to take all reasonable steps to ensure that Ms B received a specialist review on 20 November. For the reasons set out below, it is my opinion that Dr A did not adequately fulfil this duty.

76. When Dr A was unsuccessful in contacting Dr C he left a message on Dr C's mobile giving details about Ms B's symptoms and the actions taken. He then informed Ms B to seek further medical attention if her symptoms got worse over the weekend. While Dr A believes that he left his and Ms B's contact details for Dr C, neither Dr C's or Ms B's recollection of the telephone message confirms this. I accept, however, that Dr A did identify himself in the telephone message and that Dr C would have been able to obtain Dr A's contact details.

77. Dr A believes that when Ms B did not present at the ED, Dr C should have contacted him.

78. Dr A's duty to take all reasonable steps to ensure Ms B received a specialist review on 20 November required him to do more than leave a telephone message with the specialist and fax a referral to the specialist's private clinic. It was unwise for Dr A to assume that those actions alone would result in Ms B receiving the timely specialist care that she needed. Contrary to Dr A's submission, his responsibility for Ms B did not pass to the hospital orthopaedic department when he left a message with the specialist advising him of her condition and the need for specialist care. Dr A's duty was ongoing and, in this case, the duty required him to take a more proactive approach to Ms B's management. This requirement is supported by Medical Council of New Zealand guidelines (see below), and previous HDC opinions.

79. The Medical Council of New Zealand's Good Medical Practice: A Guide for Doctors (2009) (the Guidelines) provides that when a patient is referred, the referring doctor must "provide all relevant information about the patient's history and present condition". The guidelines further provide that, "when the transfer is for acute care, this information should be provided in a face-to-face or telephone discussion with the admitting doctor".[5] Furthermore, the guidelines provide:

"When a patient is being transferred between a doctor and another health care practitioner, he or she must remain under the care of one of the two at all times. Formal handover is essential. The higher the degree of activity, the more important it is to ensure appropriate communication at the point of transfer. The chain of responsibility must be clear throughout the transfer."[6]

80. Ms B required an urgent acute referral for specialist care, and Dr A recognised this. Seamless patient care requires that clinicians act to ensure their concerns are being appropriately actioned. Dr A did not take sufficient action to ensure his concerns about Ms B's condition were being appropriately addressed. He should have taken further steps to ensure he discussed Ms B's case and the referral directly with Dr C, and that there was a clear passing of responsibility for her care to Dr C.

81. As previously stated by this Office:[7]

"GPs have a key role to play in following up referrals to check that they are actioned promptly. For most patients, their GP is the health care provider who is best placed to keep an overview of their care. … An aspect of this duty is actively following up a referral for a patient who is still awaiting a further specialist assessment. … I consider that the GP retains a residual responsibility to monitor the progress of the patient through the system."

82. In another opinion,[8] where a GP assumed that putting a letter in the mail fulfilled her professional responsibility to a potentially life-threatening situation, this Office stated that GPs who refer patients to a specialist also need to take reasonable steps to follow up the referral, especially if the patient's need for specialist assessment becomes more urgent. In the District Court, on an appeal against an ACC Review Board decision to quash the ACC finding of Medical Error against a general practitioner, Judge Beattie stated:

"In all the circumstances I find that the acts and omissions of [the general practitioner] … when she failed to identify the degree of urgency that was required to have Mrs P seen by the appropriate specialists and therefore given over to the appropriate treatment without delay, was inexcusable and constitutes a failing below the standard of care expected in the circumstances."[9]

83. Judge Beattie held that in the above case "a degree of aggression" was called for in following up the referral. Although in this case Dr A did correctly identify the degree of urgency required to have Ms B assessed by a specialist, in my view he did not exercise the degree of aggression required in response to that need. Although Ms B's condition was not life threatening, it was a medical emergency, and Dr A was well aware that there was a risk she might develop a significant neurological impairment if her condition was not treated. There were other steps that Dr A could reasonably have taken to ensure that his referral was actioned promptly. For example, Dr A could have instructed Ms B to present to the ED if she did not hear from Dr C by the end of the day, and he could have contacted Dr C and/or Ms B later that day to confirm that the referral had been received and actioned. This was a potential orthopaedic emergency, and Dr A's actions were not adequate.

84. I have taken into account Dr A's submission to the provisional opinion, that given the serious concerns he outlined in his telephone message to Dr C, and that there was a limited window of opportunity to attend to Ms B, it would not have been unreasonable for Dr C to contact him when Ms B did not present to the hospital. I agree and have commented in a following section on Dr C's omission to follow up Dr A's telephone message. However, I remain of the view that Dr A's passive approach to Ms B's management and referral meant that Ms B fell through the cracks, and did not receive the seamless and timely service that she was entitled to.

Summary

85. Dr A had a duty to take all reasonable steps to ensure that Ms B received a specialist review on 20 November. He did not take all such steps, and therefore exposed Ms B to an unnecessary degree of risk. In my opinion, by not ensuring that Ms B was reviewed by a specialist in a timely manner, Dr A failed to minimise potential harm to Ms B, and breached Right 4(4) of the Code. Dr A also failed to ensure co-operation among providers to ensure quality and continuity of services to Ms B and, accordingly, breached Right 4(5) of the Code.


Opinion: No Breach ― The medical centre


Vicarious liability


86. Under section 72(3) of the Health and Disability Commissioner Act 1994, employing authorities are responsible for ensuring that their agents comply with the Code, and may be vicariously liable for an agent's failure to do so. Under section 72(5) it is a defence if an employing authority provides evidence that it took such steps as were reasonably practicable to prevent the breach of the Code.[10]

87. Dr A is one of the five medical practitioners working in partnership at the medical centre. He has been practising as a full-time GP for 15 years and has been working at the medical centre for five years.

88. The medical centre did not have any policies and procedures in place to guide staff on the system for referring acute patients to hospital for assessment. However, it is my view that Dr A's failure to appropriately refer Ms B to specialist care was an individual error. Dr A, as Ms B's GP, had a clear duty to adequately action his referral, and he failed to do so. The standard of care required of an individual practitioner in referring patients is clearly set out in the Medical Council's document Good Medical Practice: A Guide for Doctors. This standard of care applied irrespective of any policies or procedures that were or were not in place at the medical centre. Accordingly, I find that the medical centre is not vicariously liable for Dr A's breach of the Code. However, I do have concerns about the lack of a formalised process for the referral of patients between the DHB and primary care centres at that time, and this is discussed below in the section "additional comment".


Adverse comment - Dr A/The medical centre

89. I am concerned about the lack of co-operation that Dr A and the medical centre have displayed during this investigation.

90. The medical centre Practice Manager Ms E was advised on 14 May 2010 of Ms B's complaint about the care Dr A provided to her. On 3 June 2010, Ms E advised HDC that Dr A was "well aware" of the complaint and working on his response. HDC received Dr A's response on 23 June. On 15 September, after a review of the information gathered and the clinical review provided, it was decided that formal investigation of Ms B's complaint was warranted, and Dr A and the medical centre were advised and asked to respond to specific issues relating to the process at the clinic and follow-up of these matters.

91. Since that time, Dr A and the medical centre have been contacted by telephone, email and letter a total of 13 times in an attempt to obtain further information, including actions taken in relation to Dr A's statement that GPs in the region experience difficulties in contacting specialist and acute services for their patients; clarification of the procedures that the practice has relating to hospital referrals; and follow-up of complaints and significant issues.

92. Although Dr A has now responded and expressed his sorrow for the distress Ms B has suffered, I find his lack of co-operation, which has severely hindered the investigation and consequently resolution for Ms B, unacceptable. The Medical Council of New Zealand's publication Good Medical Practice: A Guide for Doctors (2009) sets out professional standards expected of doctors in respect of co-operating in formal proceedings:

"You must cooperate fully with any formal inquiry into the treatment of a patient and with any complaints procedure that applies to your work."

I acknowledge Dr A's subsequent apology for "not having participated in the investigation as [he] should have".


Adverse comment - Dr C


93. Dr C was the orthopaedic surgeon on call for the weekend of 21-22 November 2009. Between operating on patients on the afternoon of Friday 20 November 2009, he picked up Dr A's message about a patient with a deteriorating spinal condition and urinary incontinence. Dr C advised that he went to the ED and the ward to look for the patient referred to in Dr A's telephone message and, when he found that the patient had not presented, left instructions that he was to be notified if she should arrive.

94. Dr C acknowledged that he had been advised about a patient with a spinal problem who had developed urinary problems, and that he initially made an attempt to find this patient, but did nothing else to follow up Dr A's message. My independent orthopaedic surgical advisor, Dr Tregonning, advised that Dr C should have made attempts to track down Ms B on Friday evening, and certainly over the weekend. He said that this omission would be viewed by peers as a mild departure from the expected standard.

95. I agree with Dr Tregonning that Dr C also had a responsibility to Ms B in this case. The responsibility for managing the referral of patients between primary and secondary care does not fall solely on the shoulders of the primary care physician. While there is a clear division of responsibility in the management of patients following specialist referral, it is essential that general practitioners and specialists work together to ensure quality and continuity of care for patients. As previously stated by this Office:

"Handling care between primary and secondary care is a crucial step in ensuring safe/quality care. It is also a vulnerable step which, if not carefully managed, is an area that can cause misunderstanding and sub-standard care."[11]

96. In recognising the seriousness of the symptoms described in Dr A's telephone message, Dr C should have taken a more proactive approach to track down Dr A's patient. At the least, this would have included telephoning Dr A to enquire further about his patient. Dr C's failure to take a more proactive approach to track down Dr A's patient was an important link in the chain of events that led to Ms B not receiving the timely specialist care that she needed. Dr C should reflect on the part his omission to follow up on Dr A's telephone message had on the unfortunate outcome in this case, and I recommend that he review his practice in this regard.


Additional comment


97. HDC has been advised that changes were made to the way primary care referrals were made to the hospital ED after the new ED opened in 2009. The DHB Chief Medical Advisor advised HDC that there were no written protocols for primary health care referrals to the ED. However, senior ED medical staff expect GPs to contact them, or a junior medical staff member if the specialist is unavailable, before sending a patient to the ED.

98. It is clear that Dr A's understanding of the management of GP referrals to the hospital was not in accordance with the DHB's expectations. Dr A believed he was to contact the specialist directly, and that he was not to refer a patient directly to ED. The DHB advised that GPs wanting specialist review of a patient had the option of calling the relevant specialist to request an urgent assessment or referring patients to the ED.

99. In my view, it is concerning that there were no clear guidelines or policies for patient referrals between primary care providers and the hospital operating at the time. It would be helpful for primary care centres to have clear policies and procedures available to guide staff on the system for referring acute patients to hospital. However, these policies and procedures cannot be developed in isolation. Primary care centres and district health boards need to work together to develop clear, unambiguous systems for referring patients between primary and secondary services in their respective areas.

As this Office has previously stated:[12]

"It is not for HDC to prescribe the correct solution to these problems. But it is my job to state the obvious: whatever referral system is operating between district health boards, it has to work for patients, who should have justified confidence that referrals will lead to action in sufficient time to treat preventable problems that the public system undertakes to treat."

It is reassuring that the DHB has now developed a procedure for primary care referrals to the ED, although it is concerning that this did not occur until March 2012. I encourage the DHB to continue working with the primary care providers in its area to ensure that the new procedure is clearly and unambiguously understood, so as to ensure the seamless provision of services to future patients being transferred between primary and secondary care providers.
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#11 User is offline   hukildaspida 

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Posted 01 August 2012 - 08:47 PM

http://www.hdc.org.n...2012/10hdc00454

Recommendations

Dr A

I recommend that Dr A apologise to Ms B for his breach of the Code. A written apology should be sent to this Office by 13 July 2012, for forwarding to Ms B.

The DHB

I recommend that the DHB:

Report to HDC by 30 October 2012 on the operation and effectiveness of the referral guidelines introduced in March 2012.

Follow-up actions

A copy of this report, with details identifying the parties removed, except the experts who advised on the case, will be sent to the Medical Council of New Zealand, who will be advised of Dr A's name.
A copy of this report, with details identifying the parties removed, except the experts who advised on the case, will be sent to the DHB, who will be advised of the names of Dr A and the medical centre, and to the Royal New Zealand College of General Practitioners, who will be advised of Dr A's name.
A copy of this report with details identifying the parties removed, except the experts who advised on the case, will be placed on the Health and Disability Commissioner website, http://www.hdc.org.nz, for educational purposes.


Appendix A ― Independent clinical advice - Dr David Maplesden

"Thank you for the request that I provide clinical advice in relation to the complaint from [Ms B] about the care provided to her by [Dr A]. To my knowledge, I have no personal or professional conflicts of interest.

1. Documents reviewed

1.1 Complaint from [Ms B] received 16 April 2010

1.2 Response from [Dr G] received 24 May 2010

1.3 Response from [Dr A] received 28 June 2010

1.4 Response from [Dr C] received 15 June 2010

1.5 [The hospital] notes regarding current problem

1.6 GP notes including historical reports



2. Complaint

2.1 [Ms B] states that on 16 November 2009 she presented to [Dr A] with severe shooting pain starting in my right hip going down the back of my leg and behind my knee, I also had pins and needles in my leg and loss of feeling. [Dr A] diagnosed a prolapsed disc and organised an urgent CT scan. He also advised [Ms B] to rest and she was placed on ACC.

2.2 On 20 November 2009 [Ms B] saw [Dr G] and told her of her history and that she was awaiting a CT scan. She also told her she had lost bladder control since the previous day although her bowels were functioning as usual for her. [Dr G] recommended that [Ms B] see [Dr A] and she saw him a short time later. [Dr A] increased the urgency of the CT scan (to 23 November 2009) and left a message with orthopaedic surgeon, [Dr C], explaining [Ms B's] symptoms. He then sent [Ms B] home.


2.3 On Monday 23 November 2009 [Ms B] attended for her CT scan and shortly after she received a call from [Dr C's] secretary saying that he wanted to see [Ms B] urgently (he had been trying to contact her since Friday 20 November) and he had been waiting for me to turn up to the emergency department either Friday night or over the weekend as this was a medical emergency. [Dr C] examined [Ms B] and she underwent emergency disc surgery that afternoon.



2.4 A couple of weeks after the surgery [Ms B] had a relapse of her pain and MRI scan in [city] suggested a further prolapse. She was booked for surgery at the end of January 2010 but instructed to return immediately if she lost control of her bladder again. Unfortunately this did occur and she was undergoing surgery within a few hours of the symptom recurring. At the time of the complaint [Ms B] was undergoing rehabilitation at [a] spinal unit but had ongoing signs of cauda equina syndrome that may be permanent and significantly detract from her ability to function normally and to enjoy life. She wants someone held accountable for this situation.

3. Provider(s) response


3.1 [Dr G] was asked to see [Ms B] on 20 November 2009 as [Dr A] was running late. [Dr G] listened to [Ms B's] history and reviewed the notes and thought it preferable for [Dr A] to review [Ms B] given his previous contact with her and the fact he had recently spoken with specialist about her case. [Dr G] spoke with [Dr A] who agreed he needed to see her and did so a short time later.

3.2 [Dr A]

(i) [Dr A] apologises for any distress caused to [Ms B] through these events. He has seen her only once since her surgery and she voiced no concerns at his management of her at that visit. He is happy to meet with her to discuss any issues she may have.

(ii) [Dr A] describes [Ms B's] presentations and management by him on 16 and 20 November 2009 (see clinical note summary). Following the initial presentation he was suspicious of a right disc prolapse and contacted orthopaedic surgeon [Dr F] to get advice and endorsement to arrange an urgent CT scan which was done. [Dr A] recorded that [Dr C] would likely see [Ms B] as an outpatient in the public system once the scan was completed.

(iii) [Ms B] presented again on 20 November 2009 - [Dr A] was fully booked but saw [Ms B] after discussing her with his colleague, [Dr G], who had some concerns. After examining [Ms B], [Dr A] immediately recognised the new development of intermittent bladder loss of control as a further 'red flag' and signal that the situation was worsening. He rang [the] Hospital, established [Dr C] was on call, and was put through to him on two occasions with no answer from him. [Dr A] then contacted the radiology department and managed to expedite the CT scan for the following Monday.

(iv) [Dr A] states that he then rang [Dr C] again and left a message on the answer phone describing [Ms B's] symptoms especially the recent development of incontinence…that the CT scan had been brought forward and was booked for early Monday morning…[Ms B's] details if he wanted to call her in earlier than this to ED…informing him that I was faxing through [Ms B's] details as well…My details are available at the hospital if [Dr C] had wanted to get hold of me for more information…I then told [Ms B] to seek further medical assistance if her symptoms got worse over the weekend.

(v) [Dr A] notes, with the benefit of hindsight, that it was his responsibility to ensure [Dr C] received his message and would not use that method of communication in the future. However, he sincerely believed that he had done everything possible at the time to ensure the orthopaedic service was aware of [Ms B's] predicament and would manage her accordingly, and was following protocol in attempting to contact the specialist rather than just sending the patient in to ED. As a consequence of this event, the issue of communication between primary and secondary care in the district is being examined and will be followed up.

3.3 [Dr C]

(i) [Dr C] was operating on Friday 20 November 2009 and was on call for the weekend 21/22 November 2009. Some time after the conclusion of surgery (after 1700hrs) [Dr C] opened a voice-mail message on his phone from [Dr A]. It indicated [Dr A] was referring acutely a patient with a three week history of back pain and some abnormal neurological abnormalities who had presented today with new urinary symptoms. He had previously discussed her with [Dr F] (another orthopaedic surgeon) and she had been awaiting a CT scan.

(ii) Regarding the call, [Dr C] states No details were left regarding the name of the patient or any contact details, nor were any details left with regard to contacting the General Practitioner. [Dr C] assumed the patient would be presenting to ED for him to assess as would be normal practice. After completing his operating list about 1900hrs on 20 November 2009, [Dr C] called in to ED to see if the patient in question ([Ms B]) had presented. She had not so he left instructions for him to be called as soon as she presented. However, no call was received over the weekend.

(iii) On Monday 23 November 2009 [Ms B] presented to [Dr C's] private clinic stating she had been sent by her GP who had arranged a CT for this day the previous Friday. Staff managed to track down a fax[13] sent by [Dr A] the previous Friday but which had been sent to the wrong fax number and was not at [the private clinic] or the hospital orthopaedic clinics. [Dr C] subsequently assessed [Ms B] and undertook an L5/S1 discectomy that afternoon after which her symptoms initially improved. She required further surgery at a later date after her symptoms deteriorated but did not make a good recovery. She has ongoing neurological symptoms of significance indicative of Cauda Equina Syndrome and has been referred to [a] Spinal Injuries Unit for assistance. She undoubtedly will have permanent disability as a consequence of her disc prolapse.

4. Review of clinical records

4.1 There are a variety of historical specialist letters in the GP notes. … There is a letter from [Dr C] to [Dr A] dated 9 June 2005 after [Ms B] presents with persistent low back pain diagnosed as mechanical. [Dr C] notes Examination revealed some positive Wardell signs which are not typically related to the condition, of course, but do possibly reflect underlying health issues. Discharge summary from [the Spinal Unit] dated 21 April 2010 concludes, This lady has suffered from incomplete cauda equina syndrome, poorly correlated with the actual neurological compromise. Clinically there is a component of functional overlay and it was also identified that there is a significant psychological/social situation contributing to her stress…final follow-up there in six months is recommended.

4.2 GP notes for 16 November 2009 note [Ms B's] history of a fall three weeks previously with persistent right leg pain since then, sciatic distribution, [numbness] & tingling around foot, weakness & loss R AJ, also SLR 20 deg on R…L leg all OK Dx acute L5/S1 disc prolapse d/w Ortho…[Dr F] for CT and ref [Dr C]. A CT request is initiated and analgesics prescribed. On 17 November 2009 there is a nurse comment recorded T in excruciating pain and burning with back pain, does not feel that rx analgesia is cutting the mustard. d/w [Dr A]. On 20 November 2009 severe lumbar pain into R leg, sciatic, still nil AJ reflex. Lost control of urine, but no saddle anaesthesia/numbness. Rung and left message with [Dr C], rung CT scan, refaxed letter/copy consult. On 24 November 2009 [Dr A] records last evening I rung [Ms B's] hme no. after receiving CT report…her partner advised me she was having operation etc…today [orthopaedic surgeon] rung re contactability of ortho on Friday. I advised him of details of consult & my attempts to contact [Dr C]…I left detailed message on his answerphone etc…refaxed letter & arranged CT! & couldn't do any more.

4.3 There is a fax from [Dr A] dated 20 November 2009 1452hrs and addressed to [Dr C] Private. It contains a copy of the consultation note from 16 November 2009 with a handwritten addition: returned ++ pain, now loss of urinary control, no saddle anaesthesia, rung CT & ortho again, rung [Dr C] - left message. 9.15am CT Mon booked. [Ms B's] demographic details and address are noted but there is no typed contact phone number for her. There are however two handwritten telephone numbers across the top of the fax which may belong to [Ms B]. [Dr A] has placed his stamp to identify the sender - this is partially obscured but there is enough detail to recognise his surname.

4.4 Letter from [Dr C] to [Dr A] dated 23 November 2009 - Thank you for referring urgently this young lady. As you are aware you left a message on my phone on Friday but unfortunately I could not track [Ms B] down…I feel most uncomfortable, as I am sure you did on Friday, about her status with urinary incontinence and have admitted her urgently. The CT organised prior to the appointment with me shows a central disc prolapse of L5/S1 with almost certainly a moderate degree, at least, of cauda equina compression.

4.5 Imaging - 23 November 2009 CT: Significant L5-S1 disc protrusion centrally and a little to the right of centre. Impingement on S1 nerve root.

3 December 2009 CT: L5-S1 there was a prominent bulging disc annulus…there may well be some compression of the emerging right S1 nerve root.

14 December 2009 MRI: Probable recurrent/residual L5/S1 right paracentral disc extrusion.

12 January 2010 CT: Appearances have slightly improved from the post-operative MRI…residual right L5/S1 subarticular recess stenosis.

4.6 [The] Hospital discharge summary for admission of 23 November 2009 notes Examination in ED found there to be weakness in most ranges of movement in the right but not the left leg, altered sensation in the L5 and S1 dermatomes, absent ankle jerk on the right, normal perianal sensation and intact anal tone. Discectomy and decompression are performed that afternoon. Subsequent progress is as per the response, with evidence of recurrence of disc prolapse noted in a letter of 23 December 2009 and requirement for further surgery. Orthopaedic Clinic letters post operatively indicate [Ms B's] persisting symptoms of pain (requiring Oxycontin, Gabapentin and Voltaren), bowel and bladder symptoms and a right foot drop.

5. Comments

5.1 Background: The New Zealand acute low back pain guidelines[14] state: Features of Cauda Equina Syndrome include some or all of: urinary retention, faecal incontinence, widespread neurological symptoms and signs in the lower limb, including gait abnormality, saddle area numbness and a lax anal sphincter… Cauda Equina Syndrome is a medical emergency and requires urgent hospital referral...All patients with symptoms or signs of Cauda Equina Syndrome should be referred urgently to hospital for orthopaedic or neurosurgical assessment. There are few surgical emergencies in the treatment of back pain but this is one that, in my opinion, is common knowledge and should be recognised by all GPs. [Ms B's] presentation was sufficiently suspicious for Cauda Equina Syndrome for the diagnosis to be clear, although her past history of a variety of neurological symptoms with significant functional overlay could have influenced the diagnosis somewhat and appears to be an ongoing issue.

5.2 Management by [Dr A]: [Dr A] has documented a competent clinical assessment of [Ms B] on 16 November 2009. He suspected a significant disc prolapse and sought specialist advice and assistance with expediting a CT scan at that point. He provided analgesia for [Ms B]. His management of [Ms B] was very good and consistent with expected standards. On 20 November 2009 he again undertook a competent and appropriate assessment of [Ms B] and considered the diagnosis of Cauda Equina Syndrome (CES). He realised the need for urgent assessment with imaging in this situation and sought initially to make a direct referral to [Dr C] (which was unsuccessful), and then to expedite the CT scan. He left a message with [Dr C], the content of which is outlined in 3.2(iv) but disputed by [Dr C]. He faxed details to the orthopaedic service although the number was incorrect and the fax did not arrive at the correct destination. He was confident that, on receiving his message, if [Dr C] thought [Ms B] should be seen sooner than after the CT scan on Monday 23 November 2009 he would contact her to come in to ED. He advised [Ms B] to go to ED if her symptoms worsened in the weekend and she had not heard from [Dr C]. In my opinion, [Dr A's] duty of care was to ensure (rather than assume) that [Ms B] would receive an orthopaedic review and appropriate imaging on Friday 20 November 2009 after she presented with a clinical picture suggestive of CES. This was a potential orthopaedic emergency and it was inappropriate to suggest that leaving an assessment until Monday was reasonable. I am saying this without hindsight basis - orthopaedic emergency in any context means immediate assessment is indicated. If [Dr A] was reasonably confident that [Dr C] would act on the phone message left for him in a timely fashion i.e. see [Ms B] immediately, he should have told [Ms B] to present directly to ED if she had not heard from [Dr C] by the end of that working day. It was not sufficient to tell her to present to ED only if her symptoms worsened over the weekend. Ideally, she should have been referred immediately to ED once [Dr A] was unsuccessful in his attempts to contact [Dr C]. I acknowledge that [Dr A] was competent in his clinical assessment and diagnosis of [Ms B], and had a good standard of clinical documentation, and that he went to considerable effort to expedite [Ms B's] imaging and assessment. These are all mitigating factors but they do not cover the fact that it was [Dr A's] duty to ensure [Ms B] received a specialist review on 20 November 2009 and he failed to do this. His decision to assume a voice message and fax to the specialist would result in [Ms B] receiving timely care was an error of judgement that may have significant repercussions for [Ms B]. Under the circumstances, his management of [Ms B] departed from expected standards to a moderate degree. … [Dr A] has acknowledged he will change his practice when attempting to access urgent specialist services in the future. I do not feel that his clinical competency is an issue and I do not feel that any additional remedial actions are indicated.

5.3 Management by [Dr C]: [Dr C] received a voice message from [Dr A], the exact content of which is subject to debate, between operating on patients in the late afternoon of 20 November 2009. There was evidently enough detail in the message to lead [Dr C] to expect that the patient would be presenting to ED for an assessment. In my opinion, had [Dr A] adequately recognised that immediate assessment was warranted the message should have stated that the patient would be presenting to ED as an emergency with suspected CES. In my opinion, it was quite reasonable for [Dr C] to assume that if a practitioner suspected CES in a patient he would refer them directly to ED, having been courteous in informing the specialist of the patient's imminent arrival. In retrospect, when the patient had not arrived by perhaps the morning of 21 November 2009, it might have been reasonable for [Dr C] to have contacted [Dr A] to clarify the situation. However, there are several reasons why the patient may not have presented including decision to seek attention elsewhere and unexpected resolution of the symptoms. I do not think it was reasonable to expect [Dr C] to 'chase up' [Ms B] to see why she had not attended whether or not [Dr A] had left her contact details in the phone message. When [Ms B] did attend [Dr C] on 23 November 2009, the exact mechanism for her getting to his private rooms being somewhat unclear, he recognised the urgent nature of her predicament and subsequent management by him was appropriate. …

6. Opinion

6.1 On the basis of the records available to me, and referring to comments in section 5, I am of the opinion that the management of [Ms B] by [Dr A] departed from expected standards to a moderate degree.

Dr David Maplesden, Clinical Advisor, Health and Disability Commissioner"


Appendix B ― Independent orthopaedic advice - Dr Garnet Tregonning

"This report relates to the most unfortunate situation where a 29 year old lady developed a Cauda Equina symptom secondary to an L5/S1 disc herniation following a fall in the shower. She developed neurological symptoms some 4 days following the fall and in the 4 days after that developed symptoms of urinary incontinence.

It is clear to me that when she saw her General Practitioner [Dr A] on the Friday afternoon the 20th of November he correctly recognized that she had a major problem in that she had developed the new symptom of loss of bladder control. As you know, when she was seen on the 16th of November 4 days earlier she had symptoms consistent with significant Lumbar Disc Herniation with absence of ankle jerk and marked reduction of straight leg raising.

It is also apparent that [Dr A] certainly tried to contact [Dr C] the Orthopaedic Consultant on-call that day. It is noted that he had previously spoken to another Orthopaedic Surgeon [Dr F] after the initial presentation with the Sciatica.

It is also clear to me that [Dr A] did make significant attempts to contact [Dr C]. He claims that he left a message on [Dr C's] phone including the patient's contact details, (in case '[Dr C] wanted to see the patient in the Emergency Department'). He also faxed a referral through to [Dr C's] private clinic.

From [Dr C's] perspective, he did acknowledge that he received a message from the General Practitioner at about 5pm whilst he was operating. He acknowledges that he was aware that the patient had developed urinary symptoms. However, [Dr C] claims that there were no details of the name or contact details of the patient. He also stated that he had assumed the patient had been referred to the Emergency Department which he stated was standard practice.

After he completed his operating list that evening he attended the Emergency Department looking for the patient who had not attended. He discussed with the Medical Officer in the department the fact that he had expected to see the patient and informed the doctor to contact him as soon as the patient attended. He states that over the subsequent weekend he had received no response.

[Dr A], however, stated that he did identify the patient and felt that [Dr C] 'should have contacted him when the patient did not present at the Emergency Department'.

It is most unfortunate that the phone message was not retained so that we can get the full details.

Unfortunately I believe that this patient has 'fallen between the cracks' and that there are deficiencies on the part of both the General Practitioner and [Dr C] the Orthopaedic Surgeon. In saying this I do acknowledge that it is easier after the event to identify deficiencies. With respect to [Dr C], I believe he should have made attempts to track down the patient either that Friday evening and certainly over the subsequent weekend. I believe that his actions in relation to her care departed from the expected standard as a mild departure.

Garnet Tregonning F.R.A.C.S., F.R.C.S.© Orth.


ORTHOPAEDIC CONSULTANT"


Appendix C

[Please refer to scanned image in pdf version of this report]







[1] Right 4(4) of the Code states: "Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer."

[2] Right 4(5) of the Code states that every consumer has the right to co-operation among providers to ensure quality and continuity of services.

[3] The DHB advised that Dr F was working at the hospital as a locum in November 2009.

[4] A serious neurological condition in which there is acute loss of function of the lumbar plexus, neurological elements (nerve roots) and the spinal canal below the termination of the spinal cord.

[5] See paragraphs 51 and 52 of the Medical Council of New Zealand's Good Medical Practice: A Guide for Doctors (2009).

[6] See above, paragraph 44.

[7]Opinion 07HDC20199.

[8] Opinion 01HDC04864.

[9] P v ACC, District Court Palmerston North, No. 129/04, 27 April 2004.

[10] While the defence set out in section 72(5) refers to "employees", it is generally considered as also being available in respect of agents (see: Totalisator Agency Board v Gruschow [1998] NZAR 528).

[11] Opinion 05HDC14141.

[12] 07HDC19869 3 October 2008.

[13] Dr Maplesden made the comment about the retrieval of Dr A's fax and Ms B's presentation at Dr C's private clinic before the information provided by Ms D was obtained.

[14] NZGG. New Zealand Acute Low Back Pain Guidelines 2003

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#12 User is offline   hukildaspida 

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Posted 01 August 2012 - 08:53 PM

P v ACC, District Court Palmerston North, No. 129/04, 27 April 2004

http://www.hdc.org.n...alist-referrals

Publications > Other publications from HDC > Articles > 2004 > Follow-up of specialist referrals



Follow-up of specialist referrals


Download Follow-up of specialist referrals (PDF 62Kb)

The responsibility of general practitioners to follow up patient test results has been the subject of extensive debate, with HDC decisions and College consultation leading to interim guidelines on 'Minimising Error in Patient Test Results' (RNZCGP, 2003). Follow-up of specialist referrals raises similar issues. GPs who refer patients to a specialist also need to take reasonable steps to follow up the referral, especially if the patient's need for specialist assessment has become more urgent. A recent case, which progressed to HDC, ACC and the District Court, illustrates the problems that can ensue when a GP fails to follow up a specialist referral adequately.

Mrs P's progressive breast symptoms
In May 1999 Mrs P, aged 53 years, consulted her GP, Dr H, concerned about the 'changing' nature of a swelling under her left arm, which had begun to spread into the side of her left breast, creating a 'thickness'. Mrs P told Dr H that her sister had been diagnosed that week with breast cancer. Dr H ordered a mammogram, which showed no evidence of malignancy, but did not order a needle biopsy. Mrs P consulted Dr H again in May, and two months later, when the results of the mammogram were discussed. Dr H offered no further treatment and reassured Mrs P that there were no problems.

Referral
Mrs P consulted Dr H again in September as the swelling had become a lot worse and was restricting her left arm movements. The GP sent a letter of referral to Palmerston North Hospital requesting surgical review but, as there was nothing in the letter to denote urgency, the referral was accorded low priority, and Mrs P received an appointment for May 2000.

On 21 January 2000, Mrs P again consulted Dr H because her breast was greatly out of shape. On examination, Dr H found the breast irregular to the feel and moderately oedematous, and the left nipple had retracted. On 27 January Dr H wrote to Wanganui Hospital asking that the "appointment be expedited". On 8 March Mrs P consulted Dr H once more because of further changes in her breast and aching. She still did not have a hospital appointment. At the 8 March consultation, Dr H realised she had sent the letter of 27 January to Wanganui Hospital rather than Palmerston North. She sent a copy of the misdirected letter to Palmerston North Hospital, where it was received on 30 March. (Dr H claimed she faxed a copy on 8 March, but the hospital had no record of receiving the fax.)

Self-referral to private care
By this time, having become increasingly concerned and scared, Mrs P contacted a private general surgeon, Dr W, on 18 March. When requested by Dr W's nurse, Dr H provided a referral letter noting "clinical findings of advanced breast cancer". Dr W immediately took a core biopsy, which showed infiltrating lobular carcinoma. Mrs P underwent chemotherapy prior to a mastectomy and, subsequently, six weeks of radiotherapy treatment.

ACC claim and HDC complaint
In August 2000, Mrs P lodged a claim with ACC for personal injury caused by medical misadventure as a result of misdiagnosis and delayed diagnosis of left breast cancer. Dr Baird, ACC's independent general practice advisor, stated that Dr H "should have had a much higher level of suspicion" (given the family history) and "should have shown a greater degree of urgency in her management". In March 2001, ACC accepted Mrs P's claim, holding that Dr H's medical error had delayed diagnosis and treatment of her advanced breast cancer, and worsened her prognosis.


Dr H sought a review of ACC's decision. Soon after, in May 2001, Mrs P laid a complaint with HDC. During the course of the HDC investigation, the ACC review occurred. Dr H obtained supportive opinions from three specialists from the University of Otago: Professor Doyle (radiology), Professor Tilyard (general practice) and Associate Professor Reid (medicine). ACC sought further advice from Dr Baird, and Dr Dady, a specialist oncologist. The reviewer found that the weight of evidence did not support a finding of medical error and, in April 2002, ACC's decision in favour of Mrs P was quashed.

In December 2002, on the basis of my own independent advice from Dr St George (general practice), HDC concluded that Dr H had breached the Code of Consumers' Rights in her management of Mrs P, noting that Dr H "seems to have assumed that putting a letter in the mail was all that was required to fulfil her professional responsibility to respond to a potentially life-threatening situation". Meantime, Mrs P appealed against the ACC review decision to the District Court. The Court received a copy of the HDC report upholding Mrs P's complaint (01HDC04864, 19/12/02).

What the experts said
All the experts agreed that at least by 21 January 2000, the symptoms Dr H noted were highly suspicious of breast cancer, and a medical practitioner should be aware of the possibility of cancer with such symptoms. However, there were sharp variances of opinion regarding the extent of a doctor's duty to follow up a specialist referral. The doctors for the defence took a benign view of Dr H's actions. Professor Tilyard noted that Dr H had written a further referral asking that Mrs P's appointment be expedited, and considered that the GP "could not be faulted in her management of the case", which conformed to "currently accepted best practice in New Zealand" - even though the request was not made until six days later on 27 January, and was sent to the wrong address! Professor Doyle thought Dr H acted "entirely appropriately" and that it was "quite unreasonable to suggest that she was remiss in not trying to harass 'the system' over the phone". Associate Professor Reid thought that the "deaf ears" of the public hospital system had failed Mrs P.

The independent experts took a less charitable view. Dr Baird advised ACC: "I strongly maintain that any reasonable doctor who suspects an advanced breast cancer does not send out missives to hospitals without having an aggressive follow-up mechanism in place to assure both the patient and themselves that timely intervention will occur. To be uncertain of such an obvious diagnosis, to be uncertain of the destination of a crucial referral letter, to have no apparent concern over the continued delays in having Mrs P seen, and to not facilitate alternative referral would suggest failure to provide a standard of care and treatment to be expected."

Dr Dady advised ACC
: "In my opinion a telephone call by the surgeon requesting an appointment within a few days would have been more appropriate."

Dr St George advised HDC:
"By January [Dr H] must have been aware her patient had cancer, and she should have discussed it with her patient and made direct contact with the surgeon … In such a situation most general practitioners would phone the surgeon for an early appointment."

District Court Judge's decision
Judge Beattie was very critical of Dr H's failure to follow up the referral
. The Judge commented that Professor Tilyard's advice (that Dr H's advice could not be faulted) "defies belief" and rejected his advice entirely. He stated: "In all the circumstances I find that the acts and omissions of Dr H on 21 January and following, when she failed to identify the degree of urgency that was required to have [Mrs P] seen by the appropriate specialists and thereby given over to the appropriate treatment without delay, was inexcusable and constitutes a falling below the standard of care expected in the circumstances. I cannot emphasise too much that the circumstances of this case were that of a life-threatening disease and which any competent general practitioner ought to have identified and taken far more direct action and follow-up if necessary." (P v ACC, District Court Palmerston North, No. 129/04, 27 April 2004). Unlike Professor Doyle and Associate Professor Reid, Judge Beattie did not think it too onerous to expect a GP to telephone the hospital to speed up an appointment given the suspected malignancy and the fact that time was of the essence. "[A] degree of aggression" was called for in following up the referral.


Unhappy outcome for the doctor

It is obviously important that doctors are able to pursue their legal remedies, including appealing an ACC finding of fault. (Happily, ACC medical error findings will become a relic of history once the proposed medical misadventure reforms are enacted in 2005.) Yet by appealing the ACC decision, Dr H had to endure the stress of the claim for a further three years. Earlier resolution of the ACC claim may also have avoided the HDC investigation, which led to two years of stress (from notice of investigation to notice of decision by the Director of Proceedings not to prosecute), and the very duplication of process that doctors rail against. Unlike ACC and HDC processes, District Court judgments are publicly available (consistent with the principle of open justice), so Dr H's dogged fight resulted in her name being published in her local newspaper. She may have been better advised to accept responsibility for her mistakes, which so clearly had a significant impact on her patient. A simple written apology, and an assurance that her practice had instituted systems to ensure timely follow-up of specialist referrals, could have avoided the stress of protracted investigation and litigation, and the harmful publicity.

Ron Paterson
Health and Disability Commissioner

New Zealand Family Physician, 13 August 2004
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#13 User is offline   hukildaspida 

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Posted 01 August 2012 - 09:28 PM

This is the ACC Medical Misadventure case Purdie and another v Harper [2004] NZACC 129 (27 April 2004) that is referred to in the above http://www.hdc.org.nz cases

http://www.nzlii.org...C/2004/129.html

Purdie and another v Harper [2004] NZACC 129 (27 April 2004)

IN THE DISTRICT COURT

HELD AT PALMERSTON NORTH
Decision No. 129/2004

IN THE MATTER of the Accident Insurance Act 1998

AND

IN THE MATTER of an appeal pursuant to Section 152 of the Act

BETWEEN CATHERINE PURDIE

(AI 183/02 )


First Appellant

AND ACCIDENT COMPENSATION CORPORATION

(AI 188/02)

Second Appellant

AND KATRINA HARPER

Respondent

HEARD at PALMERSTON NORTH on 6 April 2004

APPEARANCES

Mr T Manktelow, Counsel for Mrs Purdie .
Mr B Corkill, Counsel for Second Appellant.
Miss G Phipps, Counsel for Respondent.


RESERVED JUDGMENT OF JUDGE M J BEATTIE

[1] The issue in this appeal is whether Mrs Purdie is entitled to cover for personal injury by medical misadventure being medical error alleged to have occurred on divers occasions between 15 September 1999 and 14 March 2000.

[2] This appeal arises from the Second Appellant's decision of 18 March 2001 whereby it granted cover to Mrs Purdie for personal injury by medical misadventure, it accepting that Mrs Purdie had suffered injury as a consequence of medical error by the Respondent, her then General Practitioner. That decision granting cover was reversed by Review Decision dated 10 April 2002 and it is from that decision that both the claimant and the Corporation have now appealed to this Court.


[3] The background facts, which are not in dispute, may be stated as follows:

At the material time Mrs Purdie was aged 53 years, married, and a schoolteacher by occupation.
At all material times Mrs Purdie's General Practitioner was
Dr Katrina Harper, who practised in partnership at the Stewart Street Surgery in Marton.
On 12 May 1999 Mrs Purdie attended on Dr Harper for several matters, including a swelling under her right armpit where she had a long-standing surgical scar.
Dr Harper arranged for a screening mammogram and on that referral document she noted:

"Breast check NAD" (NAD = no abnormality detected)
"FH - Breast Cancer" (FH = Family History)

The Mammogram Report from Palmerston North Hospital Radiology, dated 27 May 1999, stated ¾

"The breast tissue is dense throughout. No discrete mass, distortion or microcalcification is seen. There has been no significant change from the previous mammogram in 1990.

Impression: No evidence of malignancy."

Dr Harper advised Mrs Purdie of the result of the mammogram and no further action was taken.
On 15 September 1999, Mrs Purdie again consulted Dr Harper for an ear problem and for the swelling under her left armpit. It was noted that this had now progressed and was causing some restriction of arm movement.
Dr Harper arranged for Mrs Purdie to be assessed at the Surgical Outpatients Clinic at Palmerston North Hospital and wrote a letter to that effect dated 16 September 1999 as follows:

"Please could you review and assist this lady who has a large scar in her (L) axilla following an infected gland ?cyst some years ago. This is causing her problems with tethering and restriction of arm movements.

Previous medical history - nil, she has no allergies and is on no medication.

Many thanks for seeing Mrs Purdie."

That letter was received by Palmerston North Hospital on
20 September 1999 and it was accorded "routine" priority being the priority below "urgent" and "semi-urgent".
Mrs Purdie was contacted by Palmerston North Hospital and given an appointment date for 5 May 2000.
On 21 January 2000, Mrs Purdie again attended on Dr Harper because her left breast had changed considerably, it being noted that the left nipple was retracted and the breast irregular and moderately oedemataus.
By letter dated 27 January 2000, Dr Harper wrote to the Surgical Clinic at Good Health Wanganui as follows:

"Mrs Purdie is currently awaiting an appointment at Mr Booths surgical clinic for review of scarring in her left axilla.

Recently she has noticed gradual inverting of the left nipple and distortion of the left breast. This has been over the past one month. The scarring is several years old. Mammogram in 1999 is enclosed, normal.

On examination left breast oedematous looking with a inverted left nipple. No discrete lumps felt but irregular ++.

We wonder if this is secondary to scarring and tethering from left axilla, but are concerned about the rapid change in the left breast.

In view of these changes please could her appointment be expedited."

On 8 March 2000 Mrs Purdie again consulted Dr Harper because of further changes in her breast. At this time Dr Harper ascertained that her referral letter of 27 January 2000 had gone to Wanganui Hospital and not Palmerston North.
A copy of the letter of 27 January 2000 was thereupon sent to Palmerston North Hospital.
On 13 March 2000, Mrs Purdie, on her own initiative, contacted
Mr Colin Wilson, General Surgeon, for an appointment regarding the changes in her left breast.
Mr Wilson saw the appellant on 14 March and took a core biopsy and which biopsy confirmed breast cancer.
Mr Wilson thereupon referred Mrs Purdie to Dr Richard Isaacs, Medical Oncologist, for consideration of appropriate treatment.
On the advice of Dr Isaacs, Mrs Purdie underwent chemotherapy and then in May 2000 Mr Wilson carried out a mastectomy, including some axillary lymph nodes.
Subsequent to the mastectomy Mrs Purdie has undergone further chemotherapy treatment and her condition is under regular review.
In August 2000 Mrs Purdie lodged a claim for cover with the Corporation for personal injury caused by medical misadventure, being misdiagnosis and delay of diagnosis of left breast cancer.
The Corporation sought the opinion of a representative of the Royal New Zealand College of General Practitioners and it nominated
Dr Douglas Baird, one of its members, to give advice to the Corporation regarding the acts or omissions of Dr Harper.

Dr Baird gave his advice on 30 January 2001, his advice being that there had been medical error on the part of Dr Harper. The Corporation issued a decision to that effect on 18 March 2001.
Dr Harper sought a review of that decision and for the purposes of that review she obtained opinions from three specialists, Professor Terence Doyle, Professor of Radiology, Professor M W Tilyard, Professor of General Practice, University of Otago, and Dr J J Reid, Associate Professor of Medicine and Part-time General Practitioner.
For the Corporation a report was obtained from Dr Peter Dady, Specialist Oncologist, and a further report from Dr Baird.
The Review Hearing took place on 10 December 2001 at which the parties gave evidence as did Professor Tilyard. In his decision dated 10 April 2002 the Reviewer found, contrary to the advice of Dr Baird, that Dr Harper's referral of Mrs Purdie in September 1999 for a second opinion of a specialist, in the terms that she did, had followed accepted best practice and that the weight of evidence did not support a finding of medical error. The decision to grant cover to Mrs Purdie for personal injury by reason of medical misadventure was therefore quashed.
For the purposes of this appeal, the Court has received a copy of a letter from Mr Wilson to the Health and Disability Commissioner and also a copy of the Health and Disability Commissioner's Report dated 19 September 2002.

[4] The foregoing represents a chronology of the events but in crucial areas it is an outline only. I now propose to identify the facts as I find them to be in relation to the key events from 15 September 1999 onwards.

1. Mrs Purdie's attendance on Dr Harper on 15 September 1999.

Although problems with her left breast were not the only reason for this appointment it was, nevertheless, a major reason, and Dr Harper's medical notes made at the time state:
"Scar under (L) axilla increasingly pulling."

I have used the word 'increasingly' as the actual notation was an arrow pointing upwards which is shorthand for 'increasing' or 'increasingly'.

The letter that Dr Harper wrote to Palmerston North Hospital for a surgical review of Mrs Purdie's condition was afforded the lowest priority of "routine" by Palmerston North Hospital.

2. Mrs Purdie's consultation with Dr Harper on 21 January 2000.

Dr Harper's clinical notes record that her left nipple was retracted and that the breast was irregular to the feel and moderately oedematous.
The breast was also observed to have been dimpling over the nipple.
Dr Harper informed Mrs Purdie that she would endeavour to have the appointment at Palmerston North Hospital brought forward.
The letter seeking to bring the appointment forward was not sent until 27 January 2000 and then to the wrong hospital.

3. Mrs Purdie's consultation with Dr Harper on 8 March 2000.

Mrs Purdie had still not received notification of the bringing forward of her appointment and her breast had undergone further changes. At this appointment
Dr Harper discovered that her letter of request of 27 January had been incorrectly addressed to Wanganui Hospital. She thereupon re-addressed the same letter and forwarded it to Palmerston North Hospital. The precise date when the letter was actually received by Palmerston North Hospital, either by fax or post is unclear, but it is the case that by 14 March, when Mrs Purdie consulted Dr Wilson, she had not heard anything from Palmerston North Hospital about any change in her appointment date.

[5] The Medical Misadventure Unit obtained the opinion of Dr Douglas Baird, dated 30 January 2001. Dr Baird identified the essence of Mrs Purdie's complaint as being,

"that she feels that given her family history and the symptoms and signs that she had, Dr Harper should have had a much higher level of suspicion and should have shown a greater degree of urgency in her management. It is hard to dispute this view."

[6] Dr Baird notes that in the letter of 16 September 1999 Dr Harper used the word "tethering" but gave no indication that there was a progressive nature to the lesion.

[7] Dr Baird noted the signs which Mrs Purdie exhibited when she next consulted Dr Harper on 21 January 2000, and he advised that she exhibited two signs that were individually pathognomonic for breast cancer. He commented that although
Dr Harper made a note to say that she would attempt to speed up the appointment, she gave no indication to Mrs Purdie of the likely cause, nor did she put her suspicions in the notes. Dr Baird went on to state:

"It appears this letter was either sent to the wrong place or went astray after being correctly addressed. Either way, despite the extremely serious nature of the likely diagnosis, and the need for rapid intervention, it appears that there was no follow-up from Dr Harper to ascertain that Mrs Purdie was correctly seen and managed, even though Mrs Purdie was doing her best to pressure Dr Harper into action."

[8] It was Dr Baird's opinion that medical error had occurred in Dr Harper's treatment of the Mrs Purdie and he stated as follows:

"I base my opinion on the belief that Mrs Purdie had clear symptoms of breast tissue changes in September 1999 and that with her changes and her family history of breast cancer she required a more clearly worded and urgent referral. From this point on Dr Harper failed to appreciate the gravity of the condition she was faced with and, despite being reminded by Mrs Purdie, did not adequately explore the options and opportunities available to her as Mrs Purdie's GP. Reliance on the result of a mammogram when there are clear clinical signs and when it is well-known by GPs that 10% of cancers are not detected by this test is not acceptable. Six months delay is a significant amount of time in such a rapidly transforming lesion.

Given this I believe there is an issue of Medical Error as defined by the Act."

[9] Dr Harper sought the opinion of Professor Murray Tilyard, a Professor of General Practice at Otago University, but who also carried on a general practice as well. Of the referral letter of 16 September, Professor Tilyard advised as follows:

"The copy of that referral letter appears to correctly portray the situation as of that time, i.e. the scar was present and there was some tethering and restriction of arm movements and could the patient please be reviewed. At that stage there was not any reason to consider either from the patient history and physical examination, nor the previous mammograms that this patient could or was necessarily suffering from a malignancy within the breast tissue. I therefore believe that this was an appropriately worded referral letter and process at that time."

Professor Tilyard then went on to consider the circumstances surrounding
Mrs Purdie's consultation with Dr Harper on 21 January 2000 and the subsequent letter of 27 January.

"The patient next presented on 21 January 2000 again with multiple problems as stated in the notes. One of these problems was the change in the breast and the records state that there was a history of changes affecting the nipple and the breast tissue. The examination found that the left nipple was retracted, and the breast was moderately oedematous. It was also noted that the patient's hospital appointment as previously requested was not until May of that year, and the practitioner wrote a further referral asking that the appointment be expedited. Not only did she request a degree of urgency for the patient to be seen, but she also included all of the relevant findings which should have alerted the surgical services in the public hospital, that this patient needed to be seen with a degree of urgency. The letter specifically states that the breast was oedematous with an inverted left nipple, but no discreet lumps were felt, but the tissue was irregular. The practitioner commented whether this could be secondary to scarring, but specifically stated her concerns about the rapid change in the left breast. This was an appropriate referral made by Dr Harper given the circumstances and knowledge as at the 21 January 2000."

Professor Tilyard then considers the third consultation of 8 March 2000 where he states as follows:

"The patient was then seen on 8 March with further changes in the left breast and aching, especially worse at the end of the day. The notes record that it seemed to decrease somewhat at night. There was obviously quite marked concern from Mrs Purdie in regards to the changes of her breast, and this appears to have been shared by Dr Harper. Dr Harper therefore resent a copy of the letter that she had sent on 21 May again pointing out the changes in the breast and asking for the appointment to be expedited. It is accepted in the medical profession that if a doctor asks for an appointment to be expedited, that they are expressing concern in regards to a patients welfare, and again no action appears to have been taken by the public health system."

[10] Professor Tilyard further advised that the fact of a doctor asking for an appointment to be expedited was an accepted means of communicating a degree of urgency to medical colleagues and, in his view, Dr Harper could not be faulted in her management of the case at this time, i.e. 21 January 2000.

[11] It was also Professor Tilyard's opinion that the symptoms which Dr Harper noted on 21 January 2000 were, as Dr Baird had stated, symptoms highly suspicious of breast cancer, and that a medical practitioner should be aware of the possibilities of cancer with those symptoms.

[12] Professor Tilyard also commented on the opinion of Dr Baird, as I have set it out above, and he noted as follows:

"Dr Baird is somewhat critical of the letter that Dr Harper sent to surgical outpatients on 16 September 1999. In particular he uses the word tethering and states it gives no indication that there is a progressive nature to the lesion. If Dr Baird had had access to the clinical records, which as stated previously, are exemplary, he would have seen that there was no evidence available to Dr Harper at the time that there actually was any progression or that tethering had actually worsened. Dr Baird then states that the priority assigned by the hospital was routine. I don't believe one could necessarily argue against that given the history and findings at that time, it was not necessarily inappropriate for this referral to be seen as routine."

[13] In addition to providing his own opinion, Professor Tilyard sought a second opinion from Dr Terence Doyle, Professor of Radiology, University of Otago. Dr Doyle was asked whether the carcinoma as reported in March 2000 could have grown since the mammogram of May 1999. His advice was that it was well recognised that carcinomas can grow quickly, and more importantly, that they can go from mammographically invisible to being apparent in a matter of a few months. His answer was therefore "yes".

[14] Professor Tilyard also asked Dr Doyle his opinion as to whether Dr Harper had acted appropriately. His answer to that was as follows:

"In answering this there seem to me to be several pertinent observations. The patient had a large scar in the axilla where the carcinoma later appeared. This must have made clinical evaluation very difficult indeed. The referral form for the mammogram of 1990 nine years previously, gives as the clinical indication 'thickening in the tail of L breast.' The doctor may reasonably have had a mindset that there was a similar longstanding problem in the axillary tail of the breast now as then. The doctor had a 1999 mammogram report indicating that the area was unchanged and normal - and furthermore that it was an opinion given by two radiologists. In view of the above the doctor seems to have had no evidence that the lesion was clearly or even probably malignant.

In spite of this, the doctor is concerned that the character of the scarring has changed and has written several letters referring the patient for a surgical opinion - unsuccessfully. Should the doctor have rung the hospital to expedite a referral? I think that is unreasonable. It is the usual practice for a doctor referring patients to the outpatient services of public hospitals, for radiology, pathology or clinical opinions, to do this by mail, fax or email. This happens several times a day for all GPs and provides a record for all concerned. If the expectation were that every request had to be followed up by a telephone call to hurry 'the system' along, or to achieve any action at all, the situation would be chaotic and unmanageable. Moreover, it seems to me that the doctor was not dealing with a situation that was clearly malignant, but being properly concerned for the patient's welfare asked for a further opinion through the proper channels and in the usual and proper manner using the facilities provided by the NZ health system. My answer to this question is therefore that the practitioner acted entirely appropriately and that it is quite unreasonable to suggest that she was remiss in not ringing up to harass 'the system' over the phone."

[15] Counsel for Dr Harper also sought the opinion of Dr James Reid of the Faculty of Medicine at Otago University. Dr Reid devotes three-tenths of his time to private general practice. Dr Reid's opinion was as follows:

"In a nutshell, in May 1999 Mrs Purdie had a normal screening Mammogram. This was reported as "normal". In September of that year she presented with the scar in the breast from a previously infected lesion giving a sensation of "pulling". This is the first reference I can see in the notes of the scar, which had been present for some years, being symptomatic. On that occasion Dr Harper made a referral for surgical opinion. There therefore can be no criticism of delay in on the occasion of initial referral. Some three months later an appointment arrived for an appointment at Palmerston North Hospital for May 2000. On this occasion the appointment would have been regarded as "non urgent" and under the existing circumstances I feel that this is appropriate."

Dr Reid then considered the events of January 2000 and stated as follows:

"In January 2000 Mrs Purdie presented again with further changes in the breast and Dr Harper wrote a further referral letter expressing concern about the breast changes and requesting expedition of the appointment. This obviously fell on deaf ears and was not acted upon within the hospital system. The patient was eventually seen within the private system and a carcinoma of the breast was distressingly subsequently diagnosed in the unfortunate woman."

In conclusion, Dr Reid stated as follows:

"There has undoubtedly been unnecessary delay and error in this case. Mrs Purdie has been failed by the Public Hospital system - it is my considered opinion that the error lies fairly and squarely in this arena and not on the shoulders of Dr Harper. Her actions do not constitute Medical Error, those of the Public Hospital system do."

[16] The Corporation's Medical Misadventure Unit sought the opinion of Dr Peter Dady, Oncologist, and he had access to Dr Harper's notes and the reports which had been obtained to that date by the Unit. Dr Dady advised, inter alia, as follows:

"I find it difficult to decide if a general practitioner whose patient has a longstanding lesion in the left axilla should have been able to deduce from the tethering and restriction of arm movement that there was a high probability of malignancy. I do however agree with Dr Baird that by 21 January 2000 there were changes in the breast that were definitely a cause for concern. As stated by Mrs Purdie, the breast was greatly out of shape and the nipple was inverted and I agree with Mr Wilson that Dr Harper's letter of 27 January 2000 indicated locally advanced breast cancer that should have alerted the addressee to the urgency of the referral. I note that Dr Harper believed that the urgent waiting list in Palmerston North was 2 weeks. However, the letter was sent to Wanganui.

Six weeks later, on 8 March 2000, according to Dr Harper's note the swelling in the breast had increased and the breast was aching and it is clear from Mr Wilson's examination (1 week later) that the abnormalities in the breast were very obvious. The mistaken address on the 27 January letter was discovered. Dr Harper's response was to fax this letter to Palmerston North Hospital but it does not seem to have reached there. I do not understand why. In my opinion a telephone call to a surgeon requesting an appointment within a few days would have been more appropriate."

Dr Dady went on to advise that in his opinion the injury suffered by Mrs Purdie was a worse prognosis or decreased life expectancy and that this was causally linked to the delayed diagnosis.

[17] The reports from Dr Tilyard, Dr Doyle and Dr Dady were referred by the Corporation to Dr Baird for his comment and he commented as follows:

"The further material provided does not significantly alter my concerns held at the time of my writing my original opinion. The notes of 15 September 1999, the consultation from which the first hospital referral was generated, do not record that Dr Harper palpated the breast to ascertain the nature of the underlying tissue. It was her assumption that it was the scar pulling, rather than an underlying mass. I do not think that this reflects "currently accepted best practice". There is no clear evidence she palpated the breast on 21 January 2000 either. Though she does describe nipple retraction and peau d'orange skin changes that are pathognomonic of breast cancer, and should be acted on with urgency.

I strongly maintain that any reasonable doctor who suspects an advanced breast cancer does not send out missives to hospitals without having an aggressive follow-up mechanism in place to assure both the patient and themselves that timely intervention will occur. To be uncertain of such an obvious diagnosis, to be uncertain of the destination of a crucial referral letter, to have no apparent concern over the continued delays in having Mrs Purdie seen, and to not facilitate alternative referral would suggest failure to provide a standard of care and treatment to be expected.

Dr Tilyard states several times that Dr Harper conformed to "currently accepted best practice in New Zealand" and that "Dr Harper cannot be faulted in her management of the case". However the peer group to which I belong is stridently of the opinion that any suspicion of cancer requires the GP to aggressively follow-up referral to ascertain planned and acceptable management. This group accepted that for the routine referral of non-life-threatening disorders Dr Doyle was right in his statement: "if the expectation were that every request had to be followed up by a telephone call to hurry 'the system' along, or to achieve any action at all, the situation would be chaotic and unmanageable". However they scoffed at the suggestion that this applied to suspected malignancies."

[18] The final evidence to which the Court has had reference was that provided to the Health and Disability Commissioner arising from a complaint made to that body by Mrs Purdie against Dr Harper. In particular the opinion of Dr St George is relevant.

[19] Dr St George's advice on matters relevant to the issue in this appeal was as follows:

"In May 99 Dr Harper did not make a diagnosis but assumed a negative mammogram was all that was needed - I think she should have ordered needle biopsy then. On 15 September Dr Harper noted the lesion was 'causing problems with tethering and restricting arm movements'; this would be most unusual for axillary scarring, and indeed should have alerted her and the recipient of the referral letter at Palmerston North Hospital to the possibility of cancer. In January she knew the situation was urgent ('speed up appt') but failed to ensure her referral was successful. In such a situation most general practitioners would phone the surgeon for an early appointment. The same is true of 8 March."

Dr St George did not believe that Dr Harper's failure to detect the cancer earlier was reasonable and gave as his reason as follows:

"By September 1999 (only 4 months after the May consultation) there was increased pulling (casenotes) and tethering and restriction of arm movements (referral letter). That signifies a quite rapid change in the lesion - after an interval of nine years of apparent quiescence - and should have alerted her in September to the likelihood of cancer. I believe she should have ordered needle biopsy in May, and certainly by September."

Dr St George then considered whether Dr Harper's referrals of 15 September 1999 and 21 January 2000, could or should have been expedited. It was his belief that they should have been and he stated as follows:

"In January her letter indicating urgency went to the wrong hospital - that is a mistake but mistakes do happen - nonetheless it did cause further delay. A copy faxed to Palmerston North Hospital also went astray - and that caused further delay again. Certainly by January she must have been aware her patient had cancer, and she should have discussed it with her patient and made direct contact with a surgeon."

DECISION

[20] In this appeal the onus is on Mrs Purdie, the First Appellant, to establish on the balance of probabilities that the actions of Dr Harper in relation to her treatment of Mrs Purdie fell below the standard of care and skill reasonably to be expected in the circumstances. That is the test required by Section 36 of the Act which defines medical error.

[21] As a starting point, I note two basic facts which bear on the issue to be determined. Firstly, Dr Harper was aware of a history of breast cancer in
Mrs Purdie's family. She was aware of that at least from the time of the May 1999 mammogram. Secondly, she was aware that in cases of urgency the appropriate clinic at Palmerston North Hospital would give an appointment within 14 days of request.

[22] I turn now to the circumstances. The evidence is clear that what was initially a small lump in May 1999, and sufficient for Dr Harper to direct a mammogram, had further progressed when she next saw Mrs Purdie on 15 September 1999.

[23] Dr Harper clearly identified that the condition which Mrs Purdie then displayed required specialist investigation and I find that in view of the fact that a change had occurred and the fact of the family history, that the possibility of a malignancy ought to have been considered at that time.

[24] I note that the opinions of the specialists are divided on this point. Professor Tilyard and Dr Doyle were of the view that there was nothing which would invite a view that the lesion was possibly malignant; whereas Dr Baird and Dr St George take the opposite view and Dr Dady cannot decide whether the situation ought to have identified a probability of malignancy.

[25] In those circumstances, I find that it cannot be established to the necessary degree of probability that Dr Harper ought to have identified that the condition of
Mrs Purdie's left axilla, when seen by her on 15 September 1999, was of such a state that she ought to have identified it as being highly likely as indicating malignancy and taken urgent steps to clarify diagnosis by requesting urgency in her request of
16 September to Palmerston North Hospital.

[26] Turning now to the events of 21 January 2000 and subsequent, I find on the evidence, that the symptoms which Mrs Purdie presented to Dr Harper on that date were clear signs of breast cancer and which indicated that the condition had changed rapidly since she had last examined her. I find that Dr Harper must be taken to have known from what Mrs Purdie told her that the change had accelerated in the previous month.

[27] I also find as a fact that there can be no question that on 21 January 2000
Mrs Purdie presented to Dr Harper as having breast cancer and that urgency was therefore required. From Dr Harper's perspective she had knowledge by that date that the appellant had an appointment with Palmerston North Hospital for 5 May and she must be taken to have known that that was an appointment given in response to her letter of 16 September 1999 and that therefore from the Hospital's perspective her request was not regarded as 'urgent' or even 'semi-urgent'.

[28] With Dr Harper then taken as having that knowledge and also being aware that an urgent request to the hospital would give an appointment within 14 days of request, I find that Dr Harper's subsequent actions fell well below the standard required of her in the circumstances that pertained at that time.

[29] Whilst it may be that it was pressure of work or slackness of her support staff, the fact of the matter is that it is her responsibility and duty to her patient to ensure that the necessary degree of urgency is communicated to the right place, in this case the clinic at Palmerston North Hospital, where Mrs Purdie was already booked in for the 5 May.

[30] The facts are that the letter that requested that the appointment be "expedited" was sent out dated six days later, incorrectly addressed, yet signed by Dr Harper herself.

[31] It seems that Professor Tilyard has overlooked the fact that the request for expedition was not made on 21 January but 27 January, and was sent to the wrong address. On that basis I cannot give weight to either his or Dr Doyle's opinion on events from 21 January onwards. To suggest as he does that Dr Harper cannot be faulted in her management of the case at that time defies belief and I reject it entirely.

[32] I adopt the criticism of Dr Tilyard and Dr Doyle as made by Dr Baird, that any suspicion of cancer requires the GP to aggressively follow-up referral to ascertain planned and acceptable management.

[33] The fact of the matter is that Dr Harper did not take any action, be it aggressive or otherwise, after signing a letter on 27 January and not hearing anything until 8 March. I find this both surprising, and unacceptable that there was no follow-up by her to see whether her communication, supposedly with Palmerston North Hospital, had met with a response which dealt with the matter with the urgency which she somewhat mutedly asked for by her request for "expedition."

[34] The Court has not heard nor received any evidence of any follow-up systems which Dr Harper may have had in place within her practice regarding referrals to specialists and one can only infer that they were non-existent. Certainly any that were in place were not implemented and it was not until a rather distraught Mrs Purdie saw her on 8 March that she discovered that matters had in fact not progressed one jot since Mrs Purdie's consultation with her on 21 January.

[35] It is at this point that the facts get somewhat confused because it is the case that Dr Harper says that she faxed the same referral letter, now addressed to Palmerston North Hospital, on 8 March. Dr Wilson, when he was called upon to make a report to the Health and Disability Commissioner, advised that his investigations indicate that no fax of a letter could be found and that the hard copy of the letter did not show up until about 30 March.

[36] I find that this somewhat uncertain state of affairs post 8 March 2000 is not pivotal to the central issue in this appeal as I find that by 8 March the damage had been done and the opportunity of Mrs Purdie being seen and then treated within a few days of 21 January were long gone.

[37] I have given consideration to the comments made by Professor Tilyard,
Dr Doyle, and Dr Reid regarding the fact that Dr Harper did not seek to contact the hospital by telephone to follow-up or accelerate her request for an examination of her patient. Dr Doyle seems to suggest that at the stage that had been reached after
21 January Dr Harper was not dealing with a situation of breast cancer. That may well be his view, but I find that it is not the view which I have ruled the evidence clearly discloses.

[38] Professor Tilyard's opinion is that the wording of Dr Harper's letter that she wished the appointment to be expedited was sufficient to communicate a degree of urgency to her medical colleagues. That I find is debatable, but in any event, it is the case that the letter was tardy and sent to the wrong address and that is where the first error lay.

[39] Dr Reid simply gives the opinion that it is not practical for doctors to telephone to expedite appointments. This view is not shared by Dr Baird or Dr St George who both indicated that the appropriate practice would be for the doctor to telephone the hospital or the surgeon for an early appointment.

[40] This matter must be viewed against the fact that the circumstances were not one of a non life-threatening condition where it may be that phone calls to a hospital may be considered unwarranted, and for the recipient, annoying. Breast cancer is life- threatening and I can find no basis for concluding that a degree of aggression should not be used when there seems to be silence and inaction on the part of the body to whom the referral has been made, and where time is of the essence.

[41] In all the circumstances I find that the acts and omissions of Dr Harper on
21 January and following, when she failed to identify the degree of urgency that was required to have the appellant seen by the appropriate specialists and thereby given over to the appropriate treatment without delay, was inexcusable and constitutes a falling below the standard of care expected in the circumstances. I cannot emphasise too much that the circumstances of this case were that of a life-threatening disease and which any competent general practitioner ought to have identified and taken far more direct action and follow-up if necessary.

[42] For the foregoing reasons I therefore find that Mrs Purdie is entitled to cover under the Act for personal injury by medical misadventure, being medical error committed by Dr Harper between 21 January and 8 March 2000. The Reviewer's decision to the contrary is hereby quashed.

[43] Mrs Purdie is entitled to costs which I find in this instance are payable by the respondent and which I fix at $2000.

DATED at AUCKLAND this 27th day of April 2004


M J Beattie
District Court Judge

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#14 User is offline   hukildaspida 

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Posted 19 October 2012 - 08:34 PM

http://www.biomedsea...n/22920451.html

Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation.

MedLine Citation:
PMID: 22920451 Owner: NLM Status: In-Data-Review
Abstract/OtherAbstract:
OBJECTIVE: To model the progression of 3 functional outcome measures from patients with incomplete spinal cord injury (SCI) receiving standardized locomotor training.
DESIGN: Observational cohort.
SETTING: The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for SCI patients.
PARTICIPANTS: Patients (N=337) with incomplete SCI (grade C or D on the International Standards for Neurological Classification of Spinal Cord Injury scale) who were enrolled in the NRN between February 2008 and March 2011.
INTERVENTION: All enrolled patients received standardized locomotor training sessions, as established by NRN protocol, and were evaluated monthly for progress.
MAIN OUTCOME MEASURES: Berg Balance Scale, 6-minute walk test, and 10-meter walk test. Progression over time was analyzed via the fitting of linear mixed effects models.
RESULTS: There was significant improvement on each outcome measure and significant attenuation of improvement over time. Patients varied significantly across groups defined by recovery status and American Spinal Injury Association Impairment Scale (AIS) grade at enrollment with respect to baseline performance and rates of change over time. Time since SCI was a significant determinant of the rate of recovery for all measures.
CONCLUSIONS: Locomotor training, as implemented in the NRN, results in significant improvement in functional outcome measures as treatment sessions accumulate. Variability in patterns of recovery over time suggest that time since SCI and patient functional status at enrollment, as measured by the Neuromuscular Recovery Scale, are important predictors of performance and recovery as measured by the targeted outcome measures.

http://www.archives-...0286-9/abstract
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#15 User is offline   hukildaspida 

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Posted 09 January 2013 - 04:48 PM

In addition to post #13, this was reported in 2004 by Judge Martin Beattie

http://www.nzherald....bjectid=3565544

Judge criticises GP over breast cancer treatment
5:00 AM Tuesday May 11, 2004

A judge has lambasted a Marton doctor for substandard care of a Horowhenua schoolteacher's breast cancer.

Catherine Purdie, of Sanson, subsequently underwent surgery to have her left breast removed.

In a written judgment, District Court Judge Martin Beattie said GP Katrina Harper committed acts and omissions between January 21 and March 2000 that were inexcusable, and constituted a substandard level of care.


Judge Beattie overturned an ACC review decision, ruling that Mrs Purdie was entitled to compensation for medical misadventure. Dr Harper was ordered to pay costs of $2000.

In 1999, Mrs Purdie saw Dr Harper about swelling under her armpit. A mammogram showed no malignancy.

In September, the swelling had grown, and Dr Harper referred Mrs Purdie, then 53, for a routine assessment at Palmerston North Hospital. Her appointment was for May 5, 2000.

By January 21, 2000, Mrs Purdie's breast was showing clear signs of cancer, indicating the need for urgency.

On January 27, Dr Harper wrote seeking an earlier appointment, but sent the letter to Good Health Wanganui instead of the hospital.

Mrs Purdie saw Dr Harper again on March 8, reporting more changes, but by then, Judge Beattie said, the damage had been done.

- NZPA
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#16 User is offline   INTER 

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Posted 14 October 2014 - 08:15 PM

Im hoping to get cover for Cauda Equina Syndrome

Original Back Injury acc 1977 (herniated disk )
another recorded back injury 1984 & 1988
Well from 1977 untill this present time 2014 i have suffered with constant severe _ chronic back & leg pain, and severe back related problems, inc bowel, bladder, sexual, etc. tripping up, dropping things, Etc.
Some of the suffered back related problems are recorded in my acc reports from Dr. taine ( Dr. p g h summers Mr Whitehouse report Dr. atkinson
Right up to last report (2014)
All my life I have Suffered with Severe Back Pain and Back Problems Along With what i was told by ( family gp at the time ) it Must Be Irritable Bowel Syndrome And Clinical Tests over the Years Showed a Nil Result as to why i was suffering with ibs symptoms. so MY doctor at the time just put it down to ibs & severe back related spasms etc.

NOW 2014
( But in the last few weeks Everything I Found Pointed Towards Cauda Equina Syndrome )
it all became clear and made sense.

WELL The big Link of the missing chain is the NOT noted or Recorded bit, Unless there is still medical notes from the 1980's from my Family Doctor of the time
Back in the 80s when i had a bad back attack and couldn't move as back was locked up and had lost my legs etc. My doctor was called and he came over to se me, and from what i can recall said i was having a bad back day and he gave me an injection in the back, to help releive the back pressure which took some of the pain away but i still couldn't move off the bed, so he left me and said he will se me again the next day to see if the injection had worked, think i went to hell and back that day & night. he came back the next day and found i wasn't much better so gave me another injection and said i have to force myself to get mobile and go to the toilet etc. think he gave me a few diazepam tablets to take as well and said try to get mobile as soon as you can . Any how over the nxt few days and weeks , i had worked out a way to get mobile i would roll out of bed. had got my wife to hook a rope over the bedroom door onto 1 side of the door handle this way i could pull myself up in screaming pain. and use the door to lower myself back onto the bed so i could sit up. And used the same setup to pull myself upright and lower myself in a position to use the toilet & bath etc.
AS all i had to do was roll or get pushed out of bed onto the floor, and once on the floor i could use my arms & elbows to drag myself in reach of the rope i used for pulling myself around the house untill my bad back cleared up. think it must have been 3 - 4 weeks, before i could struggle up with out the rope, as by then i had been able to drag my self up to be able use a chair or stool as a support and a walking aid.
My doctor must have been over at least twice to see how i was doing and give me an injection and enough diazepam to help releive the back pressure so i could get better soon. so weeks turned into months before i was semi ablebodied again. and from then on its a 37 HISTORY of Back, bowel ,and everything inbetween your legs related problems. and still Years to come i Hope as would rather have living problems than be long time dead :

Any one else have anything like this and end up been confirmed with Cauda Equina Syndrome CES ?
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#17 User is offline   unit1of2 

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Posted 14 October 2014 - 09:20 PM

View PostINTER, on 14 October 2014 - 08:15 PM, said:

Im hoping to get cover for Cauda Equina Syndrome

Original Back Injury acc 1977 (herniated disk )
another recorded back injury 1984 & 1988
Well from 1977 untill this present time 2014 i have suffered with constant severe _ chronic back & leg pain, and severe back related problems, inc bowel, bladder, sexual, etc. tripping up, dropping things, Etc.
Some of the suffered back related problems are recorded in my acc reports from Dr. taine ( Dr. p g h summers Mr Whitehouse report Dr. atkinson
Right up to last report (2014)
All my life I have Suffered with Severe Back Pain and Back Problems Along With what i was told by ( family gp at the time ) it Must Be Irritable Bowel Syndrome And Clinical Tests over the Years Showed a Nil Result as to why i was suffering with ibs symptoms. so MY doctor at the time just put it down to ibs & severe back related spasms etc.

NOW 2014
( But in the last few weeks Everything I Found Pointed Towards Cauda Equina Syndrome )
it all became clear and made sense.

WELL The big Link of the missing chain is the NOT noted or Recorded bit, Unless there is still medical notes from the 1980's from my Family Doctor of the time
Back in the 80s when i had a bad back attack and couldn't move as back was locked up and had lost my legs etc. My doctor was called and he came over to se me, and from what i can recall said i was having a bad back day and he gave me an injection in the back, to help releive the back pressure which took some of the pain away but i still couldn't move off the bed, so he left me and said he will se me again the next day to see if the injection had worked, think i went to hell and back that day & night. he came back the next day and found i wasn't much better so gave me another injection and said i have to force myself to get mobile and go to the toilet etc. think he gave me a few diazepam tablets to take as well and said try to get mobile as soon as you can . Any how over the nxt few days and weeks , i had worked out a way to get mobile i would roll out of bed. had got my wife to hook a rope over the bedroom door onto 1 side of the door handle this way i could pull myself up in screaming pain. and use the door to lower myself back onto the bed so i could sit up. And used the same setup to pull myself upright and lower myself in a position to use the toilet & bath etc.
AS all i had to do was roll or get pushed out of bed onto the floor, and once on the floor i could use my arms & elbows to drag myself in reach of the rope i used for pulling myself around the house untill my bad back cleared up. think it must have been 3 - 4 weeks, before i could struggle up with out the rope, as by then i had been able to drag my self up to be able use a chair or stool as a support and a walking aid.
My doctor must have been over at least twice to see how i was doing and give me an injection and enough diazepam to help releive the back pressure so i could get better soon. so weeks turned into months before i was semi ablebodied again. and from then on its a 37 HISTORY of Back, bowel ,and everything inbetween your legs related problems. and still Years to come i Hope as would rather have living problems than be long time dead :

Any one else have anything like this and end up been confirmed with Cauda Equina Syndrome CES ?



Alacrity (spelling?) a member in the Forum does.... look up on the Members listing for this member and give them a message maybe..... All the best going forward. I can sympathise with suffering for years to. I had two serious painful conditions that needed surgery and I was ignored for 20 and basically 30 years with my issues. Being treated basically as a hypercondriac !!! The Specialist surgeons were gob smacked that I had been left so long. And understood I would have been in terrible pain with both my conditions. Because I was able to pay for my situation to be resolved finally, I was able to get them sorted. Fingers up to the doctors whom ignored me and treated me as they did as a hypercondriac...One doctor told me to go join a church group!! yup very true..

I was so blessed to have had the means to have gotten my much needed surgeries done.

However I am down with another load of issues since my accident.. so it's another load of crap battles to get the medical assistance going forward, ACC being the pack of A Holes that they are, driven and paid to be.

Sorry a wee rant...

But good luck going forward honestly......I hope you do get your issues sorted. Life is to short to be forced to live it like that.


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#18 User is offline   hukildaspida 

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Posted 16 October 2014 - 01:42 PM

This case may be of interest to some.

Note the Doctors names etc in it that are mentioned and use Google to find further information using them


Orthopaedic Surgeon, Dr B
Consultant Physician, Dr C
A District Health Board


A Report by the Health and Disability Commissioner

http://www.hdc.org.n...0951surgeon.pdf

(Case 04HDC20951)


Recommendation

I recommend that Dr C:

Apologise in writing to Mr A for his breach of the Code. The apology is to be sent
to the Commissioner’s Office and will be forwarded to Mr A.

Follow-up actions


A copy of this report will be sent to the Medical Council of New Zealand, the
Royal Australasian College of Physicians, and the Royal Australasian College of
Surgeons.

A copy of this report, with identifying features removed, will be placed on the
Health and Disability Commissioner website,
www.hdc.org.nz, for educational purposes.
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#19 User is offline   hukildaspida 

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Posted 21 August 2015 - 05:12 PM

Please click on the link to watch the video.

I'll never wear high heels again... This is permanent - says woman after botched surgery

BLANTON SMITH

Last updated 07:59, July 29 2015


http://www.stuff.co....botched-surgery

Lynley Fox will never wear high heels again.

She has cauda equina syndrome which has left her with numbness in her left leg and toes - the result of a quad bike injury in January.


And while she accepts she'll never get better, Fox is frustrated it's taken two months for the Taranaki District Health Board to respond to a complaint she laid about treatment she received while in hospital.
Lynley Fox is frustrated it's taken the Taranaki District Health Board two months to respond to a complaint she made about her treatment while in hospital.

Charlotte Curd/Fairfax NZ

Lynley Fox is frustrated it's taken the Taranaki District Health Board two months to respond to a complaint she made about her treatment while in hospital.

It all started on New Year's Day when Fox was riding a quad bike, hit a bump and came down hard on her seat compressing her spine.

Fox visited her GP about the pain, then on January 20 while in the bathroom noticed a numbness in her "saddle area" and spasms down her left leg. She went straight to Taranaki Base Hospital's emergency department and was quickly passed on to the orthopedic team.

However, there was no urgency shown and the team waited until the following day to give Fox an MRI. In the end they decided to "manage" the numbness and pain rather than sending her to surgery.

But the following day, a senior orthopedic surgeon saw the MRI results and instantly recommended emergency surgery to decompress the disc in her spine.

After the surgery Fox was left to lie flat for 72 hours, before being sent home. Then while reading through her discharge notes she found out there had been damage to the spinal cord during surgery.

"But they never said anything. It's a complication and I understand that but I should have been informed," she said.

Fox, who worked as a receptionist in the emergency department, said this should have been raised with ACC by hospital staff but it wasn't and she was left to file her own claim.


Then in February, Fox developed a prolapsed uterus and again visited her GP who sent a referral off on February 17. After two weeks Fox had heard nothing and rang up to ask about it.

"It was never printed out. But they found it and started to action it," Fox said.

Her case was classed as non-urgent and little was done. But ACC put Fox on to neuro-surgeons in Wellington, where she found out the numbness would never go away.

"I'll never wear high heels again. This is permanent," she said.

Her injuries affect her bowel and bladder and have also affected Fox's sex life.

On May 29, Fox complained to the DHB and asked eight questions about what happened during her treatment - particularly why she wasn't rushed into surgery straight away, why she wasn't told about the spinal cord tear and why she was left lying around for 72 hours.

Fox said she was disgusted by how long the fact it had taken two months, and a call to the media, to get a response.

"I'm dumbfounded. I don't know what the answers will be or if they will help. I just want to move on."

On Tuesday the DHB quality risk manager Anne Kemp apologised on behalf of the board for the delay in responding to Fox's questions.

"All patient complaints are taken very seriously and are investigated fully to ensure patients receive a full and considered response. The complaint from Mrs Fox was complex and covered a number of services and specialties, therefore it took longer than anticipated to complete the investigation," Kemp said.

Under complaints guidelines the DHB is required to acknowledge receiving complaints and respond within 20 working days and when an extension is needed, patients are updated accordingly.

Kemp confirmed Fox was sent a response by post and email on Tuesday, "which also includes an offer to meet should she have any further questions."

"Taranaki DHB recognises Mrs Fox's health issues and apologise for any undue stress she has experienced due to the delay in receiving a response to her complaint. It is the responsibility of Taranaki DHB to clearly communicate the reasons for any delay in response."

- Stuff
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