When your reputation is on the line: mock inquest highlights key lessons for doctors

Sep 11, 2015

During coronial inquests doctors can face criticism which may lead to disciplinary, civil or criminal proceedings. Avant’s now-regular event, the Moot Court, this year gave attendees a vivid insight into how an everyday situation can unfold and threaten a doctor’s reputation and career if expert advice is not sought early.

This year’s spirited inquest into the death of Jane Joe was held on June 18 2015 at Sydney’s Westmead Hospital with 400 attendees and a cast that included Avant and external experts. Proceedings were overseen by barrister Cameron Jackson (as the NSW Coroner) and moderated by John Kamaras, Special Counsel – Coronial, Avant Law.

The case

On 11 July 2011, 76-year-old Ms Joe injured her leg after slipping at home, She presented to Westmead Hospital’s emergency department where an x-ray revealed she had a longitudinal fracture of her left tibia.

Ms Joe was treated by RMO Dr Michael Swannie (Michael Swan, Senior Solicitor, Avant Law). In accordance with the advice of the orthopaedic registrar on-call, Dr Swannie applied a non-weight-bearing splint and advised ice and elevation. He discharged her on analgesia and instructed her to see an orthopaedic surgeon in a week.

A week later, Ms Joe died suddenly from a pulmonary embolism due to a deep vein thrombosis (DVT).

Criticism of Dr Swannie’s history taking and treatment

Counsel Assisting the Coroner (barrister Stephen Barnes) told the court that Dr Swannie did not seek assistance from his medical indemnity organisation when police asked him in November 2012 for a statement regarding Ms Joe’s death.

Dr Swannie’s statement, which outlined that he had taken Ms Joe’s medical history, reviewed her medical records and examined her, was inconsistent with his contemporaneous notes.

Dr Swannie proved to be a rather unreliable witness after he confirmed that he had recorded that Ms Joe suffered from fibromyalgia, but omitted to record that she suffered from a number of conditions including systemic lupus erythematous (SLE), based on her medical records. He said it was a ‘complete shock’ when he discovered Ms Joe had suffered from SLE for 15 years.

The coroner also raised concerns about a note that Dr Swannie submitted as evidence, which he wrote a day after Ms Joe died to refresh his memory of the case. The coroner criticised Dr Swannie for not informing the police of the note when they had asked him for a statement for the coroner.

Dr Swannie’s treatment of Ms Joe also attracted scrutiny from the expert witness, Dr Peter, an eminent vascular surgeon. Dr Peter advised that Ms Joe should have been given low-molecular weight heparin due to her high risk of developing a DVT based on her age, obesity, immobility due to the fracture and the fact that she suffered SLE which can lead to a higher risk of spontaneous thrombosis.

Recommendation to change policy for prevention of DVT

In view of Dr Peter’s expert opinion, Mr Barnes highlighted the NSW Health policy directive ‘Prevention of Venous Thromboembolism’ which recommended that all in-patients in NSW public hospitals at risk of developing a DVT be considered for treatment with prophylaxis.

Unfortunately, Westmead Hospital’s protocols did not require prophylaxis to be given to patients such as Ms Joe who were treated in the emergency department. This was borne out by Dr Swannie’s statement which said: “DVT prophylaxis was not considered for Mrs Joe, full stop. She was already taking aspirin.”

Although Dr Peter’s credibility as an expert witness was also questioned during the inquest, he agreed with Mr Barnes’ recommendation that the NSW Health policy should be amended to enable all patients in out-patient settings in emergency departments to be considered for DVT prophylaxis.

Ultimately, Dr Swannie accepted that Ms Joe was at risk of developing a DVT and should have received prophylaxis.

Was Dr Swannie’s treatment appropriate?

Edson Pike represented Dr Swannie at the inquest and, while he conceded that his medical notes were inadequate, he said he should not be criticised for failing to elucidate Ms Joe’s history of SLE.

“…It’s a pretty long stretch to suggest that failure to get that information should somehow be sheeted home to the doctor. He asked the questions - he didn’t get the responses,” Mr Pike said.

Mr Pike also argued that the profession was divided on the issue of whether appropriate management mandated the administration of DVT prophylaxis and any criticism of Dr Swannie in relation to this issue was inappropriate.

The coroner’s recommendations

While the coroner said he had misgivings about all of the witnesses’ evidence during the inquest, there was “no evidence to suggest that any practitioner did anything other than the best with the information that they had the time.”

“My recommendation is to the Minister for NSW Health that consideration be given to the creation of a guideline or policy that addresses patients with a lower leg fracture treated in the emergency department of a hospital to be assessed, and if appropriately, be treated for the risk of venous thromboembolism (VTE),” the coroner said.

Outcomes and lessons learned

In fact, following similar real cases, the policy was amended in 2014. The amended policy now requires that:

  • all adult patients admitted to NSW public hospitals be assessed for the risk of VTE;
  • any adult patient who has significantly reduced mobility must be assessed for VTE before being discharged from the Emergency Department; and 
  • patients identified at risk of VTE should receive prophylaxis.

Key lessons

Seeing the case unfold in this case helps bring to life a number of key lessons:

  • Members should notify Avant early in the coronial process so that their interests can be protected.
  • Ensure you keep good records. 

Learn more

For more information on the process and issues involved in coronial investigations and inquests:
Read our Risk IQ factsheet: The coroner and you and Medical records: the essentials
View our new Risk IQ video: Preparing a statement for the coroner.
Visit our webpage: Understanding the legal process: Coronial inquiries.

Avant would like to thank our guest stars for the night:

  • NSW Coroner – Cameron Jackson, Barrister, Second Floor Selborne Chambers
  • Counsel Assisting the Coroner – Stephen Barnes, Barrister, 16 Wardell Chambers 
  • Counsel for Dr Swannie – Edson Pike, Barrister, Level 2 Wentworth Chambers
  • Moderator – John Kamaras, Special Counsel-Coronial, Avant Law
  • RMO, Dr Michael Swannie – Michael Swan, Senior Solicitor, Avant Law
  • Expert witness, Dr Peter – Associate Professer Peter Thursby, General Surgery - Vascular.

Share your view

We welcome your feedback on this article – email the Editor at: editor@avant.org.au