In a reported case, a cardiologist has been found guilty of professional misconduct after the death of a patient. The doctor (not an Avant member) was accused of making false representations to the hospital’s Medical Advisory Committee (MAC) on more than one occasion, in a bid to obtain accreditation to perform coronary angioplasty.
The state’s tribunal found the doctor had not only misled the MAC but attempted to treat a patient for complex multi-vessel coronary artery disease when their training in this area was limited. The doctor also failed to inform the patient of the risks of the procedure or offer the option of a referral to a cardiothoracic surgeon. Financial gain was also a factor in this case.
While the facts of this case are unusual, it highlights the importance for doctors not to act beyond their scope of practice, and to inform patients of any material risks inherent with a procedure and alternative treatment options.
In October 2005 the doctor sought accreditation from the hospital’s MAC to perform angioplasty procedures and was granted this temporarily.
A few months later, he performed an unsupervised angioplasty to place stents in a number of a patient’s heart vessels, including the left anterior descending artery, during which the patient died. The cause of death was occlusion of the patient’s left main coronary artery, due to trauma induced by the guidewire. The inadequate anticoagulation with thrombus formation was found to have contributed to the patient’s death.
The doctor administered 5,000 units of heparin to the patient, and a further 5,000 units half an hour later. The amount administered on both occasions, was insufficient to ensure adequate anticoagulation in the patient throughout the procedure.
An angiogram carried out a month before the angioplasty, showed the patient had a lesion in the left anterior descending artery. The lesion was complicated because it was angulated, calcified, greater than 20 millimetres in length, had an irregular contour and was ulcerated and tortuous.
It became apparent during the tribunal hearing that due to the complexity of the lesion, it would have made it difficult to pass the guidewire without damaging or dissecting a coronary artery.
Expert witnesses agreed the procedure was complicated and high-risk and should have only been undertaken by an experienced interventional cardiologist.
The hospital’s MAC is ultimately responsible for granting accreditation to perform angioplasty procedures, under the direction of the current Cardiac Society’s guidelines.
When the doctor requested accreditation in 2005, he deliberately referred to the 2001 guidelines to support his application because he knew there were additional requirements under the 2005 guidelines.
Specifically, he claimed to have completed the below requirements from the 2001 guidelines:
- At least 200 procedures, with significant contribution to the pre-procedure assessment, the interventional procedure and post-operative patient care.
- At least 75 cases as primary operator.
- Logbook of cases: detailing clinical indications including assessment of procedural risk, interventional procedure, outcome and complications. This logbook must be certified by the director of the training unit.
The doctor was unable to substantiate his claims and made false representations on the number of procedures he had performed. He also intentionally misled the MAC on the number of times he had been the primary operator.
Furthermore, he deliberately misled the patient, failed to inform them of the high risks associated with the procedure due to the lesion, and did not discuss the option of a referral to a cardiothoracic surgeon for a coronary artery bypass.
Subsequently, he knowingly provided inaccurate details on the cause of death to the patient’s family.
Another factor was the lack of evidence he had obtained the appropriate consent to perform the angioplasty. In addition, the standard consent form used suggested coronary bypass surgery was an option to be considered after an unsuccessful angioplasty, not as an alternative treatment.
The doctor had been disciplined twice previously by the Medical Board of Australia for carelessness and incompetency. In this case his registration was suspended for five years and he was ordered to pay the Medical Board’s legal costs.
The false representations continued when the doctor failed to disclose a joint venture, where he was financially rewarded for the number of procedures he performed in the catheterisation laboratories using the stents.
The existence of the joint venture illustrates the significant financial advantage he stood to gain from being permitted to perform angioplasty procedures and demonstrates a strong motive on his part to do everything possible to gain full accreditation.
As outlined in the Medical Board of Australia’s Good Medical Practice Code of Conduct, doctors have a moral, ethical, professional and legal duty to ensure their patient’s care is their paramount concern, and to practise medicine safely and effectively.
While the doctor in this case was found to have acted unethically, it reinforces the importance for doctors not to act beyond their scope of practice and to refer to another specialist if they don’t possess the necessary expertise.
Doctors should also have a robust consent process in place. This means ensuring patients are fully aware of any material risks and benefits associated with the proposed treatment or procedure and any alternative treatment options, to allow them to make an informed decision. Information should be provided both in written form and by detailed pre-operative discussion.
It is vital to keep accurate, contemporaneous medical records of the discussion and any written information provided to the patient.
Be conscious of any possible conflicts of interest. You must fully disclose details of any ventures, where you stand to receive a financial incentive.
Finally, if you are involved in an adverse event, you have a responsibility to be open and honest with the patient and their family. Follow the open disclosure process as per the Australian Open Disclosure Framework.
Download our factsheet on ‘Open disclosure: how to say sorry’ or access further guidance on open disclosure through ACSQHC’s range of resources.
Download our factsheet Consent: the essentials for more information on consent.
If you experience an adverse event or would like more information or advice on the open disclosure process, call our Medico-legal Advisory Service on 1800 128 268 for expert advice, available 24/7 in emergencies.