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Psychiatrist’s registration cancelled over boundary breach with patient compounded by unsatisfactory prescribing and record-keeping

It is never acceptable to have a sexual relationship with a current patient, even if the relationship is consensual. Sexual relationships between psychiatrists and patients will always be regarded as unethical. Boundary violations will be seen as particularly egregious where the patients are vulnerable and where doctors are seen to cause further harm by attempting to deny or conceal the relationship.

Tuesday, 6 February 2024


Patient with hands clasped during consultation with doctor.
Key messages from the case

It is never acceptable to have a sexual relationship with a current patient, even if the relationship is consensual. Sexual relationships between psychiatrists and patients will always be regarded as unethical. Boundary violations will be seen as particularly egregious where the patients are vulnerable and where doctors are seen to cause further harm by attempting to deny or conceal the relationship.

Details of the decision

Psychiatrist, Dr M, had been treating Ms P over the course of several years. Over time their conduct during consultations became more intimate – Ms P would manicure Dr M’s hands, or sew buttons onto his shirt, or they would share food or drink alcohol that she had brought. They began to hug and kiss and then have sex during the consultations. They gave each other gifts and met outside the consultations– at restaurants and at Dr M’s home. 

Dr M began to give Ms P prescriptions for Cialis, which she would fill and give to Dr M.

Dr M prescribed Ritalin for Ms P in increasing dosages. There was no clinical indication for Ms P to be prescribed Ritalin. Ms P became addicted and began to suffer adverse effects including tremor, heart palpitations, insomnia, disinhibition and an elevated libido.

Eventually Ms P was admitted to an acute mental health facility where she had to be weaned from the Ritalin. At this time Ahpra was notified of concerns about Dr M’s conduct.

Boundary violation 

The tribunal concluded that Dr M had failed to maintain professional boundaries, had permitted the relationship to develop and had used his professional position to establish and pursue a sexual relationship with Ms P. In doing so he had placed her at risk of exacerbating her underlying mental health issues and put her at risk of developing additional mental health issues.

This behaviour constituted professional misconduct.

Prescribing

It was not established that there was any clinical indication for Ms P to be prescribed Ritalin. The prescribing was clinically unusual and resulted in Ms P suffering adverse effects and becoming addicted to Ritalin. 

The tribunal found that Dr M’s prescribing of Ritalin for Ms P amounted to professional misconduct.

Medical records

Dr M’s record-keeping was also criticised. 

The Board alleged that many of the ‘consultations’ were social rather than clinical. Notes for these were missing. The Board also alleged that notes of some consultations had been falsified in an attempt to support Dr M’s defence and discredit the patient.

The tribunal was unable to find on the evidence that Dr M had failed to keep or had falsified medical records. However, it did find that that the copies of handwritten notes provided by 

Dr M were mostly illegible and entirely unintelligible. He had failed to keep a record of his prescribing or of any diagnostic formulation or treatment plan. His notes were insufficient to facilitate continuity of patient care.

The tribunal concluded Dr M’s record-keeping was so inadequate and unsatisfactory as to constitute professional misconduct.

False and misleading statements

The tribunal found that Dr M had included misinformation about Ms P’s prescriptions and medications in a referral letter to another psychiatrist and that this compromised Ms P’s care and placed her at risk of harm. 

It also found that after Dr M became aware of the Ahpra investigation, met Ms P on several occasions and attempted to influence her not to give a witness statement and not to co-operate with the investigation. 

This conduct also constituted professional misconduct.

Outcome

Dr M’s registration was cancelled and he was disqualified from re-applying for registration for five years.

Dr M was ordered to pay the Board’s legal costs.

Key lessons

It is never acceptable to have a sexual relationship with a current patient, even if you believe the relationship is consensual.

The Royal Australian and New Zealand College of Psychiatrists will not countenance a sexual relationship with a current or former patient under any circumstance.

Blurring boundaries can also mean your professional judgment and objectivity is compromised. If you ever need to provide treatment to someone with whom you have a close personal relationship it should only be in an emergency context. If you are required to provide care in an emergency, you should document your treatment carefully and refer the person to their treating doctor or another practitioner as soon as possible.

If you are the subject of complaints or questions about your behaviour, always act with integrity and never attempt to conceal a breach or deceive regulatory authorities.

References and further reading

Avant factsheet – Boundary issues 

Medical Board of Australia Guidelines – Sexual boundaries in the doctor-patient relationship

Avant factsheet – Medical records: the essentials

Avant factsheet – Treating family members, friends or staff

Medical Council of NSW – Guideline for self-treatment and treating family members

Avant eLearning - Managing sexual boundaries

More information

For medico-legal advice, please contact us on nca@avant.org.au or call 1800 128 268, 24/7 in emergencies.

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Psychiatrist’s registration cancelled over boundary breach with patient compounded by unsatisfactory prescribing and record-keeping approvals

Disclaimers

The case discussed in this article is based on a real case. Certain information has been de-identified to preserve privacy and confidentiality.

IMPORTANT: 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.

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