Roman Hasil and the Whanganui DHB - Health and Disability ...

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Health and Disability Commissioner — Record-keeping A fundamental element of good medical practice is good record-keeping. Cole’s Medical Practice in New Zealand states: 37 “[Record-keeping] is a tool for management, for communicating with other doctors and health professionals, and has become the primary tool for continuity of care in many practices as well as in hospitals. To fulfil these tasks, the record must be comprehensive and accurate.” It is a doctor’s responsibility when making a record of a consultation with a patient (particularly a handwritten record) to do so in accordance with professional and ethical standards — which include writing legibly, recording the date and time, and signing the notes legibly. Dr Hasil did not complete the “Gynaecological record sheet” for his consultation with Patient A on 1 March 2006, but briefly recorded the consultation as follows: “G 4 P 3 NVD [normal vaginal delivery] unwanted fertility gynae examination NAD [no abnormality detected] PAP taken for sterilisation”. His letter to Patient A’s general practitioner reiterated his findings and plan. My advisor stated that Dr Hasil’s record of the initial outpatient assessment was inadequate, with minimal clinical history and no details of examination. Although a general consent form was signed at the assessment visit, there is no evidence on the form related to specific complications, including failure of sterilisation. Dr B subsequently recorded that a discussion of the risks of surgery and the giving of an information pamphlet were “not documented but done” by Dr Hasil. Dr Brown advised that Dr Hasil’s record-keeping was inadequate and the standard clinical record sheet for gynaecology patients was not utilised properly. I accept that Dr Hasil did provide some information regarding risks of sterilisation to Patient A. However, he failed to document his discussion. I note Dr Hasil’s submission that in an inadequately resourced department, it is likely that standards for record-keeping will be the first failing for any health practitioner. However, I am satisfied that the adequacy of his record-keeping has been considered in context. In my view Dr Hasil should have made more detailed note of his consultation with Patient A. I consider that his standard of record-keeping was inadequate and that he breached Right 4(2) of the Code. 37 Ian St George (ed), Cole’s Medical Practice in New Zealand (Medical Council of New Zealand, 2004) p 68. 68 February 2008
Opinion 07HDC03504 Patient B — Clinical care On 22 September 2005, Patient B consulted Dr Hasil about tubal ligation. He recorded his findings on gynaecological examination and his plan for laparoscopic sterilisation. They signed a “Request and agreement to treat consent form” for laparoscopic sterilisation. Although Dr Hasil did not document that the risks of surgery had been discussed at the preoperative assessment, it was noted that Patient B had a good understanding of the procedure and had been given brochures on anaesthesia and laparoscopic sterilisation. On 20 January 2006, Dr Hasil performed laparoscopic sterilisation under general anaesthesia. The Filshie clips were applied on both sides. Dr Brown commented that the operation was not straightforward as the right Filshie clip was partly on the meso-salpinx and not positioned correctly. The clip was removed and this was associated with some bleeding. The bleeding was stopped and a second clip was placed on the tube. Patient B remained in hospital overnight as she had mild discomfort and wound ooze. Dr Brown advised that Patient B’s postoperative care was appropriate. Dr Hasil did not take photographs of the Filshie clips during the surgery so no photographs were available for review. I accept Dr Brown’s advice that the second Filshie clip was also not applied correctly, as was clear when the second procedure was undertaken on 26 February 2007. Dr Brown advised that the first laparoscopic sterilisation procedure by Dr Hasil was not undertaken with reasonable care and skill. In my opinion, Dr Hasil failed to provide Patient B with laparoscopic sterilisation surgery with reasonable care and skill, and therefore breached Right 4(1) of the Code. — Record-keeping Dr Hasil’s initial outpatient assessment of Patient B was very poorly documented. It appears that he explained the risks of sterilisation to Patient B, but failed to document the discussion. I accept Dr Brown’s advice that Dr Hasil’s record-keeping was inadequate and the standard clinical record sheet for gynaecology patients was not utilised properly. Dr Hasil should have made more detailed notes of his consultation with Patient B. In my opinion, Dr Hasil’s standard of record-keeping was inadequate and he therefore breached Right 4(2) of the Code. Patient C — Informed consent On August 2005, Patient C presented to Dr Hasil with abdominal pain and an earlier CT scan showing left ovarian pathology of a cystic nature. He arranged for further investigations to be done. On review on 21 September 2005, Dr Hasil noted the ultrasound findings of cystic lesions on the ovaries, for which a malignant process could not be excluded on the left ovary, and negative tumour markers. He then booked Patient C for a diagnostic laparotomy and possible bilateral oophorectomy. On 30 September February 2008 69
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