Surgeon suspended over surgical errors, missed diagnoses and inadequate patient care

Key messages from the case

Risk is inherent in healthcare. Practising professionally means taking appropriate steps to minimise risk, and to manage adverse events. Doctors may face more severe sanctions if they fail to respond appropriately when something goes wrong, or to provide ongoing monitoring, management and care.

Details of the decision

Dr S was a general surgeon practising in regional Australia. Their performance came into question after multiple adverse events, including a patient death.

Surgical error and delayed diagnosis

Patient X died in hospital and a coronial investigation determined the cause of death was complications of peritonitis, due in part to surgical error and a delayed diagnosis of mechanical bowel obstruction.

Dr S admitted having made an error while performing an urgent Hartmann’s procedure after X was diagnosed with bowel perforation. They brought out the wrong end of the bowel to create a temporary stoma, inadvertently creating a mechanical bowel obstruction. This was not a usual or anticipated risk of the procedure and was described as an avoidable error.

Dr S had only performed the procedure once before. Expert medical evidence indicated the procedure was within the expected skills of an on-call emergency surgeon and described it as a routine operation.

Of greater concern was Dr S’s lack of post-operative care. The coroner concluded Dr S had not visited X until 6 days after the surgery and had failed even to review his symptoms with the surgical team. This was a lost opportunity to identify and address the surgical error. 

Open disclosure

The coroner also concluded that when Dr S was eventually alerted to the surgical error, they failed to provide appropriate open disclosure. The evidence indicated Dr S advised X and his family he needed revision surgery but never disclosed their surgical error, and it was left to another surgeon to have the open disclosure discussion.

Patient care

Dr S’s care was also criticised after they failed to review or arrange appropriate care for another patient, Y, who had been admitted with a herniation of the large bowel into the left chest through a previous surgical incision.

Dr S was consulted about Y’s admission and agreed Y should be admitted, with a planned transfer to a tertiary hospital. Dr S did not attend or arrange for Y’s transfer. Three days later the intensive care team arranged for Y to be transferred by ambulance to a tertiary hospital for surgery, by which time the patient’s condition had deteriorated.

Missed diagnosis and standard of care

A further patient, Z, was a regular patient on whom Dr S had performed multiple colonoscopies over a 5-year period. Z was diagnosed with a 55mm adenocarcinoma of the caecum three months after the most recent colonoscopy and gastroscopy. Experts agreed this type of tumour could not have grown to this size in such a short period. Records indicated the procedure had been performed quickly and there was no evidence the colonoscopy had reached the caecum.

Expert medical opinion concluded Dr S had failed to perform an adequate colonoscopy and had missed the tumour.

Following these incidents, the hospital audited a sample of Dr S’s colonoscopy records. This concluded the procedures had been performed more quickly than would usually be expected. Expert evidence noted that conducting colonoscopies in rapid time would lead to lesions being missed. Almost 2,000 of Dr S’s colonoscopy patients were recalled and 1,000 underwent a repeat colonoscopy. Seven were subsequently diagnosed with cancer.

The tribunal noted it was not possible to conclude these diagnoses were due to a failure to identify a problem with the initial colonoscopies. However, the tribunal noted its concerns, particularly in relation to Dr S’s lack of insight about their own conduct and its implications for patients. 

Medical records

The tribunal found that Dr S’s clinical records were deficient and did not comply with professional or legal obligations to maintain appropriate documentation.

The audit of colonoscopies found the photographic record was poor and did not include adequate images. Images of the caecum were frequently missing, so it was not possible to be confident the entire large bowel had been examined.

Dr S’s surgical records for patient X were limited, they failed to include adequate details of the surgical error or plans for ongoing patient management.

Patient notes for multiple patients did not include appropriate details of consultations with patients, reports to referring doctors, progress notes, patient risk issues or clinical opinions.

Outcome

The tribunal was concerned Dr S had failed to take steps to reduce risk, such as asking for help or using cues or additional checks to ensure procedures were performed correctly. The most egregious aspect of Dr S’s conduct was their failure to monitor patients or to provide appropriate oversight, management and care.

The tribunal concluded Dr S’s performance had been significantly below the expected standard in each case.

Dr S admitted the conduct outlined by the regulator. The tribunal concluded it constituted professional misconduct.

The tribunal suspended Dr S’s registration for 6 months and imposed conditions for their return to practice including:

• supervision
• completion of Recertification in Colonoscopy program
• a requirement to submit records of colonoscopies each month until they satisfactorily completed recertification.

Dr S was ordered to pay the regulator’s costs.

Key lessons

Your professional obligations include taking steps to minimise risks to patients, including working to reduce error and improve patient safety and seeking help or advice if you have concerns.

The chance of error can increase when there are compounding mistakes. Strategies to mitigate or minimise risk of errors include checklists, second opinions and considering differential diagnoses.

Effective communication with colleagues and patients is an essential aspect of good patient care.

If something does go wrong, you have a duty to disclose an adverse event to patients.

Make sure you understand and can follow the open disclosure process – being prepared before something goes wrong can help make the process more effective.

After an open disclosure discussion, keep clear notes of the process and the discussion, including any incident reports, patient records or reviews of the adverse event.

You are also expected to review and reflect on any adverse events and implement changes to reduce risk of recurrence.

Your medical records need to be accurate, clear and contemporaneous, and include enough information to allow another medical practitioner to continue management of the patient’s care.

You may need to rely on your notes in future, so avoid very general notes that do not help you recall exactly what occurred or what was discussed.

References and further reading

Avant factsheet – Missed or delayed diagnosis

Avant factsheet – Reducing diagnostic error

Avant factsheet – Open disclosure: responding when things go wrong

Avant eLearning – Medical records: part one - documentation