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Patient’s death after consult raises telehealth risks

Avant media

Sunday, 16 April 2023

Lady on the phone

An inquest has examined the health and safety issues associated with telehealth after a 70-year-old patient with a past history of bowel obstruction died a day after a telehealth consultation with a GP.

While the court acknowledged regular use of telehealth was new for many doctors at the time due to the pandemic, the coroner considered a physical examination was necessary at the time of the consultation, and that this would likely have prevented the patient’s death.

The inquest was held after the patient died at home, after calling an ambulance. A chronic smoker with several co-morbidities, the patient had two benign polyps removed during a colonoscopy. Five days later, she had surgery for an incarcerated femoral hernia that had caused a bowel obstruction.

Gastroenteritis diagnosed

During her recovery from the colonoscopy and hernia procedures, the patient consulted regularly with her usual GP. Approximately three months after her surgery, the patient organised a telehealth consultation with the doctor. She reported vomiting overnight, feeling sweaty, abdominal pain for two days and constipation. However, she denied having difficulty breathing or experiencing any diarrhoea. The patient believed she had gastroenteritis and requested medication for vomiting.

Given her history of a previous bowel obstruction, the doctor guided her through an abdominal self-examination, asking if she could feel any lumps in her groin. He documented “no abdominal mass” after the patient answered “no.” After diagnosing gastroenteritis, the doctor prescribed metoclopramide and provided general advice.

The doctor said he encouraged the patient to come in for a physical examination, but she declined, insisting she was all right and just wanted medication for vomiting. However, he did not document this request.

Tragically, although the patient called an ambulance the following evening, she died before it arrived as a result of an acute aspiration complicating bowel obstruction.

Telehealth consult comes under scrutiny

While the coroner accepted the doctor was “highly competent and caring,” and that COVID restrictions were in place, expert evidence obtained by the coroner highlighted the following concerns with the consultation:

  • The diagnosis of gastroenteritis was made based on a history of vomiting but not diarrhoea. Gastroenteritis, by definition, involves diarrhoea.
  • Abdominal pain is not usually a feature of gastroenteritis unless coupled with diarrhoea.
  • A previous incarcerated femoral hernia should have alerted the doctor to the risk of further bowel obstruction.
  • The questioning of the patient concerning her self-examination was “…a clearly flawed method.”
  • Given the patient’s recent bowel obstruction and comorbidities, her history of vomiting mandated a direct physical examination and assessment of whether intravenous re-hydration was needed.

An expert report concluded that if a direct physical examination had been performed at the time, this would have identified a degree of dehydration and led the doctor to either diagnose bowel obstruction or perform x-rays to exclude it.

Guidelines favour physical examination

The court accepted evidence from the RACGP’s 2020 telehealth guidelines which provided guidance on when, and when not, to use telehealth. The patient’s risk of contracting COVID based on her age and co-morbidities, supported the use of telehealth. However, telehealth was not recommended for assessing patients for serious, high-risk conditions requiring a physical examination and when a direct examination was required to support clinical decision-making.

The coroner noted the patient had not raised COVID as a concern during the consultation and concluded she, “needed a physical examination therefore, placing doubt on the utility of a telehealth on that day.”

Undue reliance on patient’s self-diagnosis

The coroner found the doctor had “unduly relied on her self-diagnosis of gastroenteritis” and a physical examination was required given the patient’s medical history and age.

Had the doctor seen the patient face-to-face, the coroner was confident he would have conducted further investigations and likely referred her immediately to the hospital.

The coroner said, “[the patient] needed help from [the doctor] who unfortunately on this occasion, on the background of COVID-19 restrictions, failed to provide adequate care.”

Coroner finds death was preventable

Ultimately, the coroner found the patient’s death was preventable and made a series of recommendations. These included that the RACGP provide the telehealth guidelines to GPs across the state and remind doctors of their importance.

Key lessons

Although this tragedy occurred when the use of telehealth was evolving, it serves as a reminder that the provision of telehealth is subject to the same standards of care as providing face-to-face consultations.

Therefore, it’s important to assess whether telehealth is appropriate based on the patient’s age, medical history, symptoms and significant conditions in a differential diagnosis. Doctors should continue to assess whether a physical examination is necessary throughout the consultation, in line with the Medical Board’s draft telehealth guidelines referred to below.

There are obvious limitations to telehealth, particularly in relation to physical examinations, so keep these tips in mind:

  • Assess if the mode of telehealth being used is reasonable.
  • Remember, documentation standards do not change for telehealth consultations. However, there are extra documentation requirements:
    1. What technology was used for the consultation (phone or video) and the rationale.
    2. Whether the patient has given financial consent, and whether the patient has consented to a telehealth consultation.
    3. Whether anyone else was present.
    4. Whether there were any limitations to your assessment. 
  • Put clear arrangements in place to transfer care to a face-to-face consultation, if you believe a physical examination is required.

Finally, remember the MBS item numbers define telehealth consultations as involving an audio and/or video link, not online chat consultations.

Medical Board’s draft telehealth guidelines

Recently, the board developed draft revised Guidelines: telehealth consultations with patients for public consultation.

The draft guidelines emphasise that doctors should continuously assess the appropriateness of the telehealth consultation and whether a direct physical examination of the patient is necessary. The guidelines also provide new guidance on prescribing for patients the doctor has not previously consulted.

Avant’s submission

Avant has made a submission to the consultation supporting the update to the guidelines.

Our submission supports the broad concept that, “The standard of care provided in a telehealth consultation must be safe and as far as possible meet the same standards of care provided in a face-to-face consultation.”

The submission voiced our support for doctors to convert from telehealth to face-to-face consultations if clinically indicated. We also called for enhanced guidance around the requirements for doctors when an in-person examination is needed.

Avant does not support the provision of services where consultations are not performed and there is no spoken contact with a patient. These services involve patients completing online questionnaires as essentially the sole basis to determine their clinical management (including providing prescriptions, referrals, investigation requests and medical certificates) without the patient speaking with their doctor. Instead, we recommend that doctors conduct a face-to-face, phone or video consult with a patient to determine if the prescription, referral, request or certificate is appropriate. That doctor can act as a contact for non-GP specialists for ongoing management, reducing the risk of fragmented care.

We anticipate the revised telehealth guidelines will be released within the next few months.

Changes to your telehealth cover

Avant’s indemnity cover for telehealth* that does not involve video or telephone consultations with patients has changed.

As of 1 January 2023, cover excludes telehealth services based on online questionnaires and/or text-based chat, unless the practitioner has access to the patient’s medical records associated with a previous in-person consultation. Check the notice of change for more information.

Useful resources

Telehealth - what you need to know.

Factsheet: Conducting a telehealth consultation

Podcast: Tips when seeing a new patient via telehealth

RACGP’s Guide to providing telephone and video consultations in general practice.

This article was originally published on 13 February 2023 and updated on 17 April 2023.

IMPORTANT: *Cover is subject to the terms, conditions and exclusions of the policy. Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. Please read the relevant Product Disclosure Statement or policy wording, available at www.avant.org.au before deciding whether to acquire, or continue to hold the product. 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.

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