Practitioner's registration cancelled after multiple complaints over prescribing and lack of consent

Key messages from the case  

When obtaining patients’ informed consent for prescribing medications, doctors need to advise the patient of material risks or contraindications of the medication/s, and discuss alternative treatment options.  

Doctors are responsible for ensuring any medication they prescribe continues to be safe, appropriate and clinically indicated over time. Consent is a process and requires an ongoing discussion between doctor and patient as treatment progresses, circumstances change, or new issues arise. 

Details of the decision 

Dr W was in solo practice as a general practitioner.  

This was Dr W’s third case before the tribunal and one of multiple complaints of inappropriate prescribing of medications including anabolic steroids and drugs of dependence. Dr W had previously made a voluntary undertaking, been reprimanded, had their registration suspended and been subject to practice conditions. 

Inappropriate prescribing 

The patient was 53 when she first consulted Dr W. Dr W prescribed compounded hormone replacement therapy (HRT) with varying formulations of progesterone, testosterone, androstenolone (DHEA) and oestrogen. Dr W also prescribed thyroid hormones T3 and T4.  

About 2 years later, the patient advised Dr W she had discovered a mass in her right breast. Dr W increased the quantities of progesterone and oestrogen. They continued to prescribe the HRT for another 7 years until the patient was diagnosed with right breast carcinoma and she ceased taking the medications. 

Dr W accepted that they had breached their duty of care to the patient in failing to: 

• take an adequate history from the patient before prescribing – including obtaining details of a previous hysterectomy which may have been due to endometrial cancer and thus a contraindication for the hormone treatment 
• assess the underlying cause of her symptoms and whether they were associated with menopause or other conditions 
• identify or document any clinical indication for prescribing T3 
• conduct ongoing examinations or investigations or obtain the results of any tests conducted by other practitioners, even after the appearance of the breast mass 
• cease prescribing oestrogen and progesterone after a breast mass was identified, where continuing with these medications increased the risk of stimulating the growth of cancer cells. 

Informed consent 

Dr W agreed that they had prescribed medications for the patient on multiple occasions without reviewing the patient. 

Even on the occasions where they prescribed following a medical consultation, they accepted that they had never obtained effective informed consent for the prescriptions since they had not: 

• advised the patient of the risks of adverse side effects of the hormone medications  
• advised the patient that the hormone treatment was contraindicated after a mass was discovered in her breast, or 
• discussed any alternative treatment options. 

Medical records 

Dr W also accepted they had breached their professional obligation to make adequate clinical notes to ensure the safe and appropriate ongoing care of their patients. 

Since they had failed to obtain relevant details of the patient’s history, they were unable to appropriately record these. Nor had they documented their findings or observations, any working or differential diagnoses, their advice or management plan or any warnings or instructions they had provided to the patient about her medication. If there were clinical indications for some of the prescribing, the indications were not documented. 

Outcome 

Dr W agreed to settle the matter on the basis that their conduct constituted professional misconduct.  Dr W was reprimanded and disqualified from applying for registration for three years (they were not registered at the time the matter concluded). 

Key lessons 

Before prescribing always ensure you have enough information to assess the appropriateness of the medication for the patient. This includes taking an appropriate history and conducting any relevant examinations or tests. 

Make sure any medication you prescribe is, and continues to be, safe, appropriate, and in response to an identified therapeutic need. 

Obtaining informed consent for treatment includes discussing, at the time of each treatment, material risks and benefits, including potential adverse effects, contraindications for treatment and alternative treatments. 

As circumstances change or new issues arise, continue to discuss the appropriateness of the treatment and ensure that the patient continues to understand the risks involved and treatment options available as their circumstances evolve. 

Providing good patient care includes formulating a suitable management plan for the patient’s treatment that covers ongoing monitoring of the effectiveness of the treatment and for any adverse effects of the medication. 

Make sure your records include appropriate details of your assessment and reasons for prescribing; consent discussion including risks discussed, warnings or advice provided; monitoring plans and ongoing assessment where appropriate; and any authorities required to prescribe. 

References and further reading 

Avant factsheet – Consent: the essentials 

Avant factsheet – Medical records: the essentials