Key messages from the case

Ensuring that treatment and clinical results are documented in clinical records is not a substitute for effective communication between members of a patient’s care team. This is illustrated by a case where treatment was delayed due to failures of communication.

Details of the decision

During a laparotomy and adhesiolysis at a private hospital, a small perforation to patient VW’s duodenum was overlooked. The patient appeared to have developed peritonitis. At the family’s urging, surgeon, Dr F, consulted a physician, Dr D, for an opinion to assist with post-operative care.

Dr D saw VW twice over 2 days and ordered blood tests which showed a rising white cell count, monocytosis and elevated C-reactive protein. He documented these results in VW’s clinical record and asked nurses to bring these to Dr F’s attention, but did not communicate with Dr F himself.

That night, nursing staff called Dr D when VW developed rapid atrial fibrillation. He did not attend, but prescribed an anti-arrhythmic drug. The patient reverted to normal rhythm.

The next day the patient developed life-threatening peritonitis and was transferred to the regional base hospital for emergency surgery.

Communication

The Medical Board agreed that the primary care of the patient was Dr F’s responsibility.

Experts did not consider that Dr D had acted inappropriately. VW was Dr F’s patient and it was reasonable for Dr D to assume Dr F would attend the patient and see the results. Dr F had not formally handed over care to Dr D or advised he would be unavailable.

However the Board argued, and Dr D accepted, that his failure to communicate directly with Dr F about the patient led to a delay in treatment. He accepted this was unsatisfactory professional conduct.

In separate proceedings, Dr F admitted his conduct in failing to monitor and review VW’s test results or seek information from the hospital or Dr D was unsatisfactory and that it was inappropriate to put Dr D in the position of having primary responsibility for care of VW.

Outcome

Dr D was cautioned and was required to provide an undertaking to complete a course in professional communication.

Key lessons

Even if patient care is primarily the responsibility of another practitioner, good practice involves taking proactive steps to communicate with professional colleagues on patient care, particularly when you become aware of significant findings.

For more information or immediate medico-legal advice, call us on 1800 128 268, 24/7 in emergencies.