Reprimand after patient’s ‘catastrophic outcome’

A doctor has been fined $30,000 but avoided suspension after he made serious errors diagnosing a patient, and she later died

The Australian Health Practitioner Regulation Agency and the Medical Board of Australia have made a joint statement about Dr Vafa Naderi, after the State Administrative Tribunal of Western Australia released its orders in the matter.

Dr Naderi had prescribed benzodiazepine medication and analgesia for a woman he referred to as a “difficult patient to assess” and recorded “withdrawal from drugs” and “behavioural issue”.

She later died, with the cause of death established at a coronial inquest to have been staphylococcal septicaemia and pneumonia with osteomyelitis complicating a previous rib fracture.

The patient was the Yamatji woman Ms Dhu, who died in police custody in 2014.

While noting Dr Naderi’s remorse and the fact that he had made genuine attempts to assess her condition, Aphra and the Board noted that “Ms Dhu’s death demonstrates the serious and tragic consequences of racism in our health and justice system, with the wider events that led to Ms Dhu’s death having rightly been considered elsewhere including in a coronial inquest”.

Dr Naderi had been referred to the Tribunal for professional misconduct on 10 June 2019, after a coronial inquest into Ms Dhu’s death in police custody and an independent Ahpra investigation into the medical care she received.

On 2 August 2014, Ms Dhu, who was being held in police custody, was taken to an emergency department.

She had been complaining of pain in the lower right rib region, had a temperature of 36.6 degrees and a pulse of 72 beats a minute.

After she was seen by a medical practitioner, she was discharged back to police custody with a recorded diagnosis of “behaviour issues”.

The next day, she was taken back to Emergency, saying she had rib pain and shortness of breath.

At triage she was found to have be tachycardic, was dehydrated and was “warm” and “agitated” and also “grunting” and “moaning”.

She was allocated an Australian Triage Scale triage score of ATS 4, which meant that she needed to be seen within 60 minutes, but was not seen by Dr Naderi until about two hours after triage.

By this time she had been examined by a nurse who recorded an elevated heart rate of 126 beats a minute and later 113 beats a minute.

Dr Naderi performed an ultrasound which ruled out collapsed lung, bleeding in her chest and any abdominal pathology.

He made notes regarding her being difficult to assess and withdrawing from drugs, and behaviour issues were noted again: “c/o (illegible) thought to be behavioural” and “? anxiety/personality problems”.

After prescribing the benzodiazepine and analgesia, for which he did not record any clinical justification, he signed a “Fitness to Hold Form,” which meant that Ms Dhu had been found fit to be held in police custody, to which she was released.

The next day, Ms Dhu was again taken to Emergency. This time, she was unconscious, had no pulse and was not breathing.

Resuscitation was attempted but she died.

The Tribunal released findings that Dr Naderi’s examination and investigating of Ms Dhu was inadequate.

It fell substantially below the standard of care expected of someone with his training and experience, it found.

He failed to read the triage nurse notations recording Ms Dhu’s heart rate and failed to appreciate the increase in Ms Dhu’s recorded heart rate from 2 to 3 August 2014; failed to take Ms Dhu’s temperature in the presence of significant changes in her vital signs; failed to order a chest x-ray, and failed to maintain adequate clinical records.

“He also could have examined Ms Dhu in the area beyond the lower front ribs when she drew to his attention that the area was bruised and swollen,” Ahpra and the Board note.

Despite her tachycardia and with no sign that her condition was improving, he discharged her and declared her fit to be held in police custody – and he did not record his diagnosis or conclusions as to the explanation for her pain.

He also failed to advise her custodians as to circumstances under which she should be brought back to Emergency.

The Tribunal found that Dr Naderi’s conduct amounted to professional misconduct.

It noted that he had taken full responsibility for his action, and was still deeply affected by the events.

“He is remorseful about the catastrophic outcome for Ms Dhu and has insight into his management,” the Tribunal noted.

It also said that he had made genuine attempts to assess her condition, but made errors in his assessment and investigation of her presentation and condition, and that he had taken steps to avoid a similar situation arising again, including improvements in his note-taking practice and emergency department practice.

He had also made significant efforts to promote and advance sepsis care and education at the hospital among his colleagues and trainees.    

“The Board considered that given the genuine steps that Dr Naderi had taken to learn from these tragic events to improve both his own practice and the practice of his colleagues, a suspension was not required to prevent any potential future risk he may pose,” Ahpra and the Board said.

“However, due to the serious failure to meet accepted professional standards in his care for Ms Dhu, the Board considered that the most serious finding available under the National Law was warranted – namely a finding of professional misconduct and the maximum fine available ($30,000).”

The doctor was reprimanded, told to complete a reflective practice report and ordered to pay the Board’s costs.

Ahpra and the National Boards said they reaffirmed their commitment to the advancement of cultural safety in healthcare.

They said they welcome the proposed introduction into the National Law of a new guiding principle and objective that recognises the importance of cultural safety for Aboriginal and Torres Strait Islander Peoples, and their role in the development of a culturally safe and respectful health workforce that is inclusive and responsive to Aboriginal and Torres Strait Islander Peoples and helps eliminate racism.

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