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Underneath the surfaceWebinar, 23 July 2014
Tony KofkinDirector of InvestigationsNSW Health Care Complaints Commission
Focus of the webinar
• The following case highlights the importance of sufficient examination and monitoring of patients, as well as proper handover of care and treatment.
• The case also alerts to the importance of ‘secondary’ or peripheral aspects of the care and treatment of patients that may be missed without thorough reviews.
Case study
What happened?• A patient, aged 46, with a bipolar disorder that was diagnosed 13
years earlier, was involuntarily admitted under the Mental Health Act to a mental health unit at a public hospital for three weeks under Dr A.
• Presented at the ED first, and policy at the mental health unit at the time was that physical examination at ED was treated as adequate and no further initial physical assessment required.
• The patient had been treated for an autoimmune disorder with high doses of prednisolone.
• Due to the erratic behaviour of the patient, the prednisolone was stopped as a suspected trigger for the patient’s behaviour.
Case study
What happened?• The erratic behaviour continued amid the bipolar disorder. • The patient experienced catatonic features which resulted in
decreased mobility• After three weeks, the patient died of pulmonary emboli secondary
to DVT (deep vein thrombosis).
Case study - chronology
2-5 Jan *Dr A fully or jointly responsible for patient
6-13 JanDr B fully or jointly responsible for the patient
14-22 JanDr A returned from leave - fully or jointly responsible for the patient
Case study - continuedWhat the Commission did:• The Commission investigated and ultimately prosecuted both Dr A,
the consultant psychiatrist under whose care the patient was admitted. Dr A was considered to be responsible or jointly responsible for the care and treatment of the patient at the relevant times.
• Dr B, a colleague who was responsible for the patient while Dr A was on leave, was also investigated and prosecuted.
Case study - continuedIn relation to Dr A, the Commission alleged that he:• failed to examine or arrange for the patient to be examined
physically or psychiatrically within three days of admission and after his return from leave
• relied on a pre ECT anaesthetic review (14 Jan) carried out in preparation for the Mental Health Tribunal Review on 15 Jan which was insufficient for the purpose of the physical or medical examination which should have been arranged
• did not document or give orders for monitoring and managing the patient’s mobility given his catatonic features
• did not properly handover the care to Dr B or ensure proper handover on 14 Jan was received
• failed to give or document in the patient’s progress notes the patient’s management plan including the risks associated with the patient’s catatonic features, including thromboembolism
• did not undertake a full psychiatric examination of the patient
Case study - continuedWhat the Professional Standards Committee found:• Practice at the mental health unit was that on-duty psychiatrist
(registrar or CMO) takes over patient care when consultant away or on leave. Patient admitted under Dr A’s name, though no records show call made to Dr A. No unsatisfactory professional conduct proven for care and treatment between 2-5 Jan.
• Dr A should have read the patient’s file when returning from leave and should have reviewed the patient (Departure, but not significant)
• Dr A had not made himself sufficiently familiar with the case when he resumed his care for the patient when he returned from leave (Significant departure). If Dr A had seen the patient personally after he returned from leave, the acuteness of the patients condition would have been clear. The PSC found it was insufficient to rely on pre ECT anaesthetic assessment which is not a suitable replacement for a physical assessment.
Case study - continuedWhat the Professional Standards Committee found:• Dr A did not give orders regarding the mobility of the patient until 3
days before the patient died, because he relied on what others had told him about the patient (Significant departure)
• Dr A should have realised that the patient required a high level of monitoring and did not instruct or document such orders (Significant departure)
• Dr A’s failure to conduct a psychiatric assessment of the patient until three days before the patient’s death a amounted to a significant departure from accepted standards.
-> unsatisfactory professional conduct was found, the practitioner was reprimanded and ordered to accept mentoring
Case study - continuedWhat the Professional Standards Committee found:• Dr B was responsible for the care of the patient while Dr A was on
leave• Despite the patient being acutely unwell in the high dependency
unit, he was not seen by a psychiatrist consultant for 6 days• Dr B did not adequately supervise junior staff, had not recorded a
management plan and had not reviewed the patient sufficiently enough given the patient’s state while under his responsibility.
• Physical assessment had been requested by Dr B on 12 Jan due to a change in symptoms ( mild sweating, mild tachycardia, blood test abnormalities, such as rise in ferritin levels).Intern requested verbally to Medical Registrar, who said medical consultation not warranted. No subsequent follow up
-> the Committee found unsatisfactory professional conduct in relation to some aspects of Dr B’s care and cautioned the practitioner.
Summary
• The case highlights the need for proper and holistic patient assessment, review and monitoring to base decision-making upon.
• This case suggests that over reliance or acceptance of previous medical assessments without direct patient contact and appropriate investigation can lead to adverse patient outcomes.
• Consequence of MHRT meeting on 15 January was for further neurological investigations and for assessment by patients own neurologist. After this, the intern was no longer trying to arrange a physical examination and there was no follow up by Dr B. Change in symptoms not investigated further, no one identified the deterioration of the patient, policy at time vital signs only checked at discretion of nurse, but usually once a day.
• Systemic issues played a part, which have since been rectified on a state wide basis.
More information www.hccc.nsw.gov.au
