No management plan for complex patient


A doctor has been reprimanded, ordered to pay $30,000 and conditions placed on his registration after the death of a patient from multi-drug toxicity

The doctor, who worked at a medical centre in Sydney’s south-west, regularly saw a woman described in court proceedings as “Patient A” – a complex patient who was also seeing other medical practitioners.

In 2010, the woman was found dead at her home. A toxicology report identified a high level of morphine, toxic levels of pethidine and quetiapine, therapeutic/non-toxic levels of several benzodiazepine drugs and a high level of alcohol at post-mortem.

The coroner found that the cause of her death was misadventure.

A number of complaints were brought against the doctor, including unsatisfactory professional conduct regarding his administration of pethidine to patient A, his prescription and administration of diazepam to patient A, and prescribing diazepam to patient A in an inappropriate combination with pethidine on three occasions; and on failing to keep adequate medical records. A third complaint held him guilty of professional misconduct.

A schedule was presented at a hearing at the Civil and Administrative Tribunal NSW setting out 42 occasions on which the doctor had administered “pethidine” to Patient A, and another where he administered “pethidine IM”.

The doctor had made a statement outlining his “relevant treatment of patient A and his recognition of the deficiencies in what he did or did not do for this patient, whom he described as ‘a complex patient’ with a complex history of chronic pain, and a variety of mental health issues… Her mental health problems included bipolar affective disorder, major depression, anxiety and alcohol dependence,” the tribunal noted.

The court did not accept the doctor’s evidence that when Patient A presented with a severe migraine, he carried out a neurological examination before administering the pethidine; it found that on none of the 43 occasions did such an examination take place.

While he did write referrals to a number of specialists and allied health professionals, he did not follow up on these.

He also prescribed diazepam to Patient A on a number of occasions, without communicating with her primary treating practitioner or other practitioners about whether or in what quantity Valium was being prescribed to her. On one occasion he also dispensed diazepam to her and on three dates “Valium IM” was “administered”.

He did not formulate a pain management plan, effectively refer to specialists or make a proper assessment of whether Patient A was drug dependent or exhibiting drug-seeking behaviours.

Expert witnesses found his conduct fell “significantly below” the expected standard.

While the doctor was not Patient A’s only treating GP, and “other practitioners must take some responsibility for what occurred,” the Tribunal noted that if the doctor had comprehensively assessed the woman’s condition and provided appropriate treatment when she presented for administration of pethidine or when diazepam was prescribed or administered, her death could have been avoided.

The doctor expressed regret that he did not help wean Patient A off pethidine and did not liaise with the prescribing doctor to develop a consistent management plan.

The Tribunal noted that the doctor had met quality improvement and CPD requirements and that his current practice was appropriate.

However it was concerned that he had not undertaken further training in the treatment of patients with chronic pain and mental health issues, and recommended a number of courses, including some run by the RACP and Black Dog Institute.

The Tribunal concluded that it was not appropriate to suspend the doctor’s registration.

“We believe that the need for specific deterrence is less in the present case than in other cases where there was deliberate misconduct or where the practitioner displayed no remorse or insight,” it noted.

The doctor was reprimanded and a number of conditions imposed, including that he complete a number of courses pertaining to pain and mental health; that he practice under Level C suspension for six months; and that he submit to an audit of his medical practice within three months.

He was ordered to pay the Health Care Complaints Commission’s costs, a sum of $30,000.

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