Critical of care: defending your reputation

Jun 19, 2018

Most doctors will have a patient die while under their care at some point in their career. For any doctor, a patient’s death can have a significant emotional toll and provoke strong feelings of loss. The stress of such an event can become even more protracted in situations where the patient’s death leads to a coroner questioning the doctor’s treatment.

Even good doctors can be criticised during what can become a complex and lengthy coronial inquest. Doctors who find themselves in these situations, like the doctor in the following coronial inquest, without good representation, can find their reputation and registration under threat.

Patient death brings care under scrutiny

Dr Grey*, a psychiatrist with over 30 years’ experience, assumed the care of Ms Smith* as an on-call psychiatrist for an acute psychiatry unit. Dr Grey had no prior contact with Ms Smith who had recently moved to the area.

Ms Smith was in her mid-40s and had a history of depression and bipolar disorder, and a dependence on alcohol and prescription drugs. She had also been diagnosed with neurocardiogenic syncope.

In early 2014, Ms Smith overdosed on alprazolam and was admitted to the emergency department but claimed she wasn’t suicidal. However, on returning home, her partner reported that she had tried to hang herself and threatened to gas herself in the car.

After being reassessed, Ms Smith was involuntarily admitted to the low dependency unit of an acute psychiatry unit under Dr Grey. Ms Smith’s outpatient medication regime of quetiapine and an antidepressant was continued and augmented with benzodiazepines.

Evidence provided at the coronial inquest reported that Ms Smith’s behaviour deteriorated and she became increasingly aggressive, disinhibited and uncooperative. Ms Smith was admitted to the high dependency unit (HDU) seclusion room but became increasingly disturbed. She was given a total of two 2 mg intramuscular clonazepam injections as she refused oral medication, and placed on 15- minute observations.

That evening, she was found unconscious in her HDU bedroom in a sitting position against the door with clothing around her neck. CPR was commenced and she was transferred to an intensive care unit. Tragically, Ms Smith died later that evening. Her ‘last will and testament’ was found on her bed.

Doctor’s care criticised

Dr Grey was understandably shocked and distressed over Ms Smith’s death. He was asked to provide a coronial statement to police and a coronial inquest into her death ensued. Nearly three years later, on the eve of the inquest, expert opinion evidence served on behalf of the coroner was critical of Dr Grey’s care for Ms Smith.

While the coroner’s expert, a psychiatrist, agreed that considering Ms Smith’s agitated and suicidal state, Dr Grey’s decision to provide mental healthcare was reasonable and necessary, he criticised his medication regime. The expert said Ms Smith’s underlying mania was not treated earlier with mood stabilisers and this had resulted in ongoing behavioural disturbance. He also believed that antidepressant medication was not indicated and criticised the use of sedative benzodiazepines as a first line of sedation. He also questioned the use of 4 mg clonazepam intramuscular injections in a three-and-a-half-hour window, describing it as a very high dose.

Response to criticism

Dr Grey rejected the coroner’s expert’s criticism and remained confident that his treatment of Ms Smith was appropriate.

Our defence team had to quickly mobilise a strategic response to challenge the criticism of Dr Grey’s care. On behalf of Dr Grey, Avant Law obtained the expert opinion of a nationally respected psychiatrist, Dr White*, who had experience in managing patients with acute mental health problems and suicidality.

Dr White penned his report which was not critical of Dr Grey’s treatment in any way, including the delay in commencing mood stabilising medication. Nor did Dr White believe this resulted in ongoing behavioural disturbance. Dr White also pointed out that mood stabilisers take at least a week to work. In summary, he acknowledged that his own approach to the diagnosis and treatment of Ms Smith would have been similar. Dr Grey was able to rely on the supportive opinion of Dr White and Avant was able to serve Dr White’s report on the coroner’s court.

During the two-day inquest, we briefed a barrister specialising in coronial law who successfully challenged the coroner’s expert’s experience and qualifications. The coroner’s expert, who had worked primarily in private practice, conceded that Dr Grey had far greater and more recent experience in the public sector than he. Our barrister was also able to elicit from the expert that he had not treated an inpatient with mania for over 30 years.

Ultimately, the coroner’s expert conceded that Dr Grey was correct in exercising caution before ceasing antidepressant treatment, the 4 mg of clonazepam was within the therapeutic range and some of his suggested treatments were not available at the hospital.

Coroner’s findings

In handing down his findings three months later, the coroner was not critical of the care provided by Dr Grey or the hospital staff to Ms Smith. Furthermore, the coroner concluded that the expertise and experience of Dr Grey and Dr White should be preferred over the court’s own expert.

The coroner found that Ms Smith died of hypoxic brain damage caused by cardiac arrest due to neurocardiogenic syncope.

While admitting that the coronial inquest had been more stressful than he had anticipated, Dr Grey was very grateful for Avant’s support and relieved that his personal and professional reputation remained intact.

Case comment

John Kamaras, LLB, BSc (Hons), Practice Manager ­– Legal, Avant Law, NSW

This case serves as a reminder that any doctor’s care can be questioned during a coronial inquest, causing considerable distress for the doctor involved. While the coroner ultimately vindicated the doctor’s treatment, coronial proceedings can be drawn out and stressful. They can also result in civil and disciplinary action or even criminal proceedings if criticisms or concerns are raised by the coroner.

Coronial investigations often require a strategic approach to effectively support doctors as they can turn into complex and lengthy affairs. Our support aims to relieve the pressure by becoming the point of contact for the police and the coroner’s office, helping members draft coronial statements, advising and assisting members through the investigation and representing them at the inquest. This is orchestrated by assembling the best and most appropriate team of experts for the case and briefing barristers.

In this case, our defence team was able to protect our member’s interests by employing an immediate response to the coroner’s expert’s criticism. We represented the member at the inquest and quickly obtained supporting evidence, including relevant expert opinion, which supported the member’s care of Ms Smith.

*Names have been changed.

More information

Download our factsheet: The coroner and you, or view our video: Preparing a statement for the coroner.

You can also read our articles: Protecting your interests when your coronial statement is used against you and Patient suicide: dealing with the aftermath.

For more medico-legal information and support, call our Medico-legal Advisory Service (MLAS) on 1800 128 268 for expert advice, 24-7 in emergencies.

This article was previously published in Connect issue no. 9.

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