O&G’s management of emergency delivery amounted to professional misconduct
Summary: Doctors need to ensure they have obtained appropriate handover. Even in an emergency a minimum handover is required, and doctors are expected to be able to follow emergency handover protocols. This is the responsibility of the most senior clinician present.
Sunday, 12 March 2023
Key messages from the case
Doctors need to ensure they have obtained appropriate handover. Even in an emergency a minimum handover is required, and doctors are expected to be able to follow emergency handover protocols. This is the responsibility of the most senior clinician present.
As this case illustrates, tribunals will be critical of doctors who make assumptions and don’t ask for further information if it is available.
Accepting handover of care also means doctors are responsible for examining and assessing the patient, and seeking consent for further treatment. Particularly where there are considerable and competing risks, it is important that patients are involved in decisions about an appropriate course of treatment.
Good communication in an emergency situation also means making or ensuring that adequate notes are made in the patient’s clinical record as soon as possible.
This case also discusses the role of professional guidelines.
Details of the decision
The Medical Board brought this case regarding the doctor’s management of a patient’s delivery. Dr B, a specialist O&G, was called in to assist in a difficult delivery. A GP obstetrician and midwives had been unable to deliver the foetus using assisted delivery techniques including multiple vacuum pulls and attempted forceps delivery.
After continued unsuccessful attempts at vacuum pulls and forceps delivery, the baby was eventually born by caesarean section. While it appears the baby did not suffer any ongoing adverse effects, the tribunal criticised many aspects of the doctor’s involvement – including failing to obtain an adequate handover and poor communication with the patient.
Handover of care
The tribunal was critical of Dr B for failing to obtain an appropriate handover, such that he was unaware of how many vacuum pulls had already been attempted.
Even in an emergency, a minimum handover is required and as an O&G, Dr B was trained and should have followed emergency handover protocols. This was his responsibility as the most senior clinician present.
If a colleague has not provided an adequate handover, doctors are responsible for seeking enough information to enable them to take over care.
Dr B’s failure to obtain adequate information to enable him to continue care of the patient was substantially below the standard reasonably expected.
Dr B did not make any handover notes, or request that any notes be made at the time he took over care. Nor did he record his diagnosis in the clinical notes.
Accepting that Dr B was occupied in an emergency situation, the tribunal noted he should still have appointed a scribe to make notes at the time or soon after handover.
Dr B’s failure to make adequate record of the handover fell substantially below the standard expected.
Standard of care and professional guidelines
Dr B was also criticised for failing to act consistently with relevant hospital and college guidelines (extracted at length in the judgment):
- Given the number of unsuccessful vacuum pulls (of which Dr B was not aware because of inadequate handover) Dr B should have stopped to clarify/reassess treatment. All relevant guidelines consider three pulls without evidence of imminent delivery an important indicator either that vacuum delivery should be abandoned, or at least that an alternative method of delivery should be considered.
- Equally, if Dr B’s diagnosis of prolonged foetal bradycardia had been correct, the professional guidelines state clearly what the appropriate management should be.
Though the experts disagreed on how much scope there was for varying procedures outlined in the guidelines based on professional judgement, the tribunal found there was no evidence Dr B even considered the guidelines.
In failing to give regard to professional and hospital guidelines about the number of vacuum pulls that should be attempted, or length of time the vacuum cup had been on the foetus’s head, Dr B’s conduct fell substantially below the standard reasonably expected.
After continued unsuccessful attempts at vacuum pulls and forceps delivery, the baby was eventually born by caesarean section and appears not to have suffered any ongoing adverse effects.
The tribunal found Dr B’s failures amounted to professional misconduct.
Dr B was reprimanded, his registration suspended for 2 months and he was fined $25,000 and ordered to pay the Medical Board’s legal costs.
When taking over care of a patient you are expected to ask questions or seek enough information to allow you to assume care. Obtaining appropriate handover is essential, even if it is necessarily brief in an emergency.
You are also expected to keep appropriate records. That means making notes contemporaneously or as soon as possible, or arranging for someone else to make notes if necessary.
Although the time taken for consent processes may be influenced by clinical urgency, you are expected to discuss management options and risks with a patient, and obtain consent to a course of management.
References and further reading
Scenarios in this publication are based on Avant claims experience to date. Certain information has been de-identified to preserve privacy and confidentiality. This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2022 MJN136 02/23 (DT-2924)