FINAL DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE

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1 FINAL DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE Dr B CAC (Complaint laid by Ms A C) Ms A Dr B C D Dr E F Dr G Dr H Ms I Dr J Complainant Veterinarian complained against Name of pet Veterinary clinic where Dr B, Dr G, Dr H and Dr J work Veterinarian who took over treatment of C from Dr B Veterinary clinic where Dr E works Veterinarian who works at D Veterinarian who worked at D Ms A s friend Veterinarian who works at D Names and locations have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person s actual name. Summary 1. A Complaints Assessment Committee (CAC) of the Veterinary Council of New Zealand (VCNZ) has investigated the above complaint. Pursuant to section 43 of the Veterinarians Act 2005, the CAC has reached a final decision as set out below. Background 2. This complaint relates to the treatment of Ms A s 4 year old Shire X Gelding horse, C, by Dr B of D between January and March C had been in the care of Dr B until he was let go by Ms A in favour of Dr E of F on 30 March The investigation 4. The CAC considered the following information. formal complaint letter from Ms A received by VCNZ on 7 August 2012, including: - an extract from her diary - s to equine specialist at the University of Liverpool - s to Dr G of D - Vodafone statement - invoices from F - invoices from D - information on Sarcoid Treatment Protocol and advice for equine sarcoid treatment from the University of Liverpool - images of C, Ms A s horse, pre and post treatment. response from Dr B of 19 September 2012, including: 1

2 - C s clinical history from D - file note of conversation with Ms A of 30 March his phone records from March an sent to Ms A with the University of Liverpool information on Sarcoid Treatment attached - s to and from the equine specialist - screenshots of Facebook pages - copies of C s laboratory results sent to F. response from Dr B of 12 November 2012 in response to questions from the CAC response from Ms A of 14 November 2012 in response to questions from the CAC and her comments on Dr B s response of 19 September 2012 response from Dr E of 29 November 2012 clinical notes and laboratory results for C from F, provided by Dr E on 12 December 2012 response from Dr H, former employee of D of 12 December 2012 expert opinion of 10 February 2013 response from Dr B s legal counsel of 24 May 2013 in person interviews conducted by the CAC on 28 May 2013 with: - Ms A - Dr B - Dr E response from Ms A of 9 June 2013 in response to Dr B s legal counsel s letter, including photos of C clarification from Ms A of 12 June 2013 of the photos she provided in the response mentioned in the above bullet point recollection of events from Ms I of 16 June 2013 response from Dr J received 18 June 2013 response from Ms A to the provisional decision of 18 September Issues raised in the complaint 5. Ms A stated that her complaint and her concerns about Dr B were that he: did not offer or undertake pre-treatment screening to ensure C was in good health before treatment commenced continued to ignore or under respond to the concerns that Ms A was raising in regards to C s deteriorating health did not use diagnostic tools that were available to him that would have indicated C s deteriorating condition was fixed in his diagnosis of hoof abscesses as the only cause of C s illness, even in the face of C s continuing deterioration 2

3 distanced himself from C s care as it became more obvious to him that his diagnosis had been incorrect did not describe any potential risks, side effects, complications or contraindications of any medication apart from the potential for temporary lameness due to an inflammation response at the treated sarcoid site did not ensure that the veterinarian covering his practice was correctly informed about the application of the sarcoid treatment, causing it to be applied incorrectly did not commence an appropriate antibiotic treatment because he did not appropriately assess C s illness which meant that by the time C did receive antibiotics he was overwhelmed and on the point of collapse. Preliminary comment 6. The CAC would like to thank Ms A and Dr B for their patience during the course of the investigation. It has been a complex case that has required detailed consideration and thorough investigation. This has extended the timeframe, which the CAC appreciates will have been stressful for both parties. Brief case summary 7. On 25 February 2012, Dr B was asked by Ms A to examine C and confirm whether some skin lesions on C s belly and left hind fetlock were indeed sarcoids and to suggest options for treatment. 8. Sarcoids were confirmed by Dr B and treatment was agreed involving a series of topical cytotoxic applications (from the equine specialist) and was initiated. This treatment finished on 2 March Dr B initiated the sarcoid treatment, visiting C (21, 22 and 23 February) to apply the cream for the first three applications. Treatment was completed by two other veterinarians in the practice, Dr J on 25 February and Dr H on 28 February and 2 March Dr B was out of the country between 25 February and 13 March Following the sarcoid treatment C developed progressively worsening lameness involving initially one and then both back legs. 12. The first symptoms of lameness started on 8 March and involved the left hind leg, the leg which had received the sarcoid application. Initially this was thought to be a response to the sarcoid cream application. The lameness was poorly responsive to analgesic medication and progressed to the right hind leg with a hoof abscess that burst above the coronet on 16 March. Following a phone consultation with Ms A on the morning of 16 March about the ongoing lameness issues and lack of response to pain medication, Dr B prescribed morphine. After a further report from Ms A of pus draining from the right hind abscess, Dr B attended C at midday on 16 March On 20 March Dr B attended C again as he was now lame on both back legs. No cause for the right hind lameness was found. Pain medication (Phenylbutazone paste and Fentanyl patches) was re-instated. 3

4 14. On 22 March an abscess broke above the left hind fetlock. Dr H attended C on 23 March and initiated antibiotic therapy. Dr H revisited C on 28 March and repeated the antibiotic. 15. Dr B was not at work between 22 and 26 March C s condition deteriorated and Ms A sought a second opinion from Dr E on 30 March and placed C under his care. Despite intensive treatment C continued to deteriorate and was euthanised on 20 April CAC considerations 17. The CAC believes that the following aspects of Dr B s clinical decision making and professional judgement in this case are of concern. He did not insist on examining C on 14 March when he was told that the horse was non weight-bearing on the right hind leg, but instead he dispensed the analgesic medications Phenylbutazone and Fentanyl patches. The CAC accepts that it was reasonable to consider that C s initial lameness (first reported on 8 March) might be associated with the sarcoid treatment. However, progressive worsening to non weight-bearing and poor/no response to Phenylbutazone should have alerted Dr B to the possibility that there might have been another cause, and that the horse should be assessed. This was even more important considering the horse was non weight-bearing on the limb, raising the possibility of infection or fracture. Considering that Dr B had not seen the horse since 23 February the CAC does not consider that he had sufficient information about the case to justify dispensing more, and different, analgesics at this time without first assessing the horse. The CAC does not accept that any objections which might have been made by Ms A regarding Dr B visiting, as described by him, justified the decision not to insist on examining C. Ms A maintains that she was never offered that opportunity. The CAC considers that in these circumstances, including the potential animal welfare issues, Dr B should have insisted on examining C, and that further treatment had to be conditional on that reassessment. He did not insist on examining C during his discussion with Ms A in the morning on 16 March when he was told that C was no better (still non weight-bearing), and instead he dispensed more Fentanyl patches and Morphine injections. The CAC considers that at the time of the telephone conversation between Dr B and Ms A on the morning of 16 March, it was even more imperative that he examine C. It was now 3 weeks since he had seen the horse. The horse s condition had not improved since he dispensed analgesics two days prior. If he did not have sufficient information to justify dispensing restricted veterinary medicines on 14 March, he certainly did not at this time. He did not change his approach to managing the right hind hoof abscess when there was no real improvement after 4 days of standard treatment. The CAC accepts that Dr B s approach when he did visit C in the afternoon on 16 March was reasonable. The horse appeared to have a hoof abscess. This appeared to explain why the initial lameness did not resolve, and provided a rationale for ongoing management. 4

5 Dr B s management of the hoof abscess was standard, and the CAC has no criticism of the treatment plan or of his decisions not to treat with antibiotics, or to undertake further diagnostic tests (e.g. blood tests at that time). However, it would be reasonable to expect that if this was simply a hoof abscess that it would have shown signs of resolving after a few days, once it had started draining and was receiving standard treatment. C s symptoms did not improve and by the time Dr B visited him again on 20 March, his right hind hoof abscess was essentially the same as when it was seen on 16 March. Despite that, Dr B appeared to give no further consideration to how this hoof abscess might be managed differently. Re-initiating analgesic medication was inadequate in the circumstances. He took insufficient steps to investigate C s problems on 20 March at the point when C was now lame on both back legs, and the horse s clinical signs could not be properly explained from the examination and diagnostic procedures (nerve blocks) carried out at that visit. The CAC commends Dr B for taking diagnostic steps to localise the source of the pain causing lameness in both of the rear limbs. While a contralateral overloading injury to the left hind might be one explanation, the CAC considers that Dr B should have been alert to the possibility that C s problems were more complex. The horse had been showing progressively deteriorating symptoms for 12 days. It would appear that none of the treatments instituted by Dr B at any time were helping or influencing the course of the symptoms. The CAC is of the view that more should have been done at this point to investigate C s worsening condition. Dr B should have been looking for other underlying factors that would help to explain what was happening. Diagnostic tools such as blood tests, radiographs, etc should have been considered as well as considering/offering referral or the opportunity to seek a second opinion. Dr B told the CAC at the interview that he did discuss diagnostic options and referral with Ms A on 20 March but he says she refused on the basis of the costs of doing the investigations. However Ms A disagrees that she was offered any other options. His discussions with her on this topic are not recorded in the medical record. A vague reference to discussion about further diagnostics is made in Dr B s letter in response to the complaint dated 19 September This is further mentioned in his later letter dated 12 November In light of C s worsening condition, the CAC considers that Dr B should have been much more insistent about the need for further investigations/referral, these discussions should have been recorded, and if in fact these options were declined by Ms A it was critical that her decision should have been recorded by him at the time. 18. Dr B has explained to the CAC that a major factor affecting his clinical decision making in this case related to Ms A s insistence on treating C herself, and the restrictive economic constraints she applied limited his treatment options. The CAC notes: The medical records for C record on: - 14 March o wanting to save money March been in contact with o regarding this wanting time to treat herself while getting pain relief.. 5

6 - 20 March O still keen to save money where possible.. Dr J wrote about Dr B s visit to C on 20 March in his statement to the CAC: He again stated that he thought the horse needed further diagnostics in the form of ultrasound/radiography but Ms A did not want to spend any more money on diagnostics for C. The CAC considers that Dr J s statement may well be an accurate reflection of Dr B s perceptions, but also notes that Dr J did not have any direct personal experience of Ms A applying financial constraints. Ms A refutes that she applied any financial constraints. While she acknowledges that she may have asked what the likely costs of treatments would be, she considered this was only prudent behaviour on her part in order to know beforehand what she would have been committing herself to. Ms A undertook to treat C s sarcoids knowing that this would cost nearly $2000. This does not fit with someone who was reluctant to spend money on her horse. Ms A spent significant money with Dr E when she sought his services to investigate and treat C. Dr E told the CAC that Ms A was reluctant to spend money. But when questioned further by the CAC he said that he had that view because of what he had been told by Dr B, and as it turned out, it did not reflect his actual experience with her. Dr H treated C a number of times. She does not identify, either in her correspondence with the CAC, or her clinical notes, any reluctance on Ms A s part to accept veterinary attention for C or to spend money to treat him. 19. The CAC accepts that Dr B might have been under the impression that Ms A was reluctant to spend money on C s veterinary care, and that this consequently limited his approach to treating C. However this is not the impression conveyed by Ms A to the CAC. Based on the information before the CAC, including the face to face meetings, the CAC is of the opinion that it seems very unlikely that Ms A did apply any real financial constraints in relation to C s veterinary care. Unfortunately, this misunderstanding may have potentially compromised the care that C received from Dr B. The CAC is of the view that despite his perception of the financial constraints being placed on him, Dr B s primary obligation was to his patient, and he needed to have had a more effective discussion with Ms A about his concerns at the times when he believed that further intervention (including diagnostic investigations or referral) was necessary, and then at the time to record those discussions and Ms A s response. 20. While the CAC is critical of aspects of Dr B s involvement with C, these criticisms need to be balanced against a number of factors: On the basis of the clinical information provided it is reasonably likely that sepsis played a part in C s progression, but it is not clear when this started. The blood tests and clinical examinations carried out by Dr E on 30 March certainly suggest it was present then. However, when Dr H examined C on 23 and 28 March she found his vital parameters to be normal at both times, suggesting that systemic sepsis was not present at those times, and her findings were conveyed to Dr B. One of Ms A s concerns related to the apparent lack of clinical assessment by Dr B when he did visit C. She did not recall him properly examining the horse, including taking his temperature. The medical records support this assertion as no vital parameters are recorded for any of Dr B s visits to C. Dr B explained to the CAC that he: - did assess C including taking his temperature. He said that on a number of the occasions he examined C without Ms A being in close proximity. He said that 6

7 sometimes he was tied up and Ms A would be attending to other things like getting food and water for C, and he thought it was possible that she did not witness his examinations. The CAC considers this could possibly have happened. The CAC refers to the statement by Dr J who also described treating C with Ms A in the background attending to other matters when he visited C on 25 February: I arrived at Ms A s property and C was tied up in the barn. Ms A was also in the barn cleaning out her freezer. She said hello and went back to her work. - only records abnormal parameters in the medical notes, and that the absence of these assessments in the records does not mean he did not measure them. Dr B was not the only veterinarian to examine and treat C. Dr H, who is experienced in equine practice, attended C on 23 March and 28 March. She found both times that his vital parameters were within normal limits, and could not explain the persistence of symptoms. Dr B was not working between 22 and 26 March, which is why Dr H visited on 23 March. This period away from the practice related to days off in lieu of after hours work, and may have been unfortunate timing in that it created some loss of continuity of care for him in terms of being able to review C clinically. Dr B did not see C after 20 March. However, he accepted his responsibility for C s case at that time and communicated appropriately with Dr H both before and after her visits. The CAC is reassured that Dr B in treating C was not practising in isolation. Dr H was involved in C s treatment, and it is clear from the CAC s meeting with Dr B, and from Dr J s statement, that the situation was discussed between the veterinarians in the practice. Dr B provided phone records showing that he did try on a number of occasions between 27 and 29 March to contact Ms A, albeit unsuccessfully, to discuss C s condition. 21. Ms A questioned whether C s deterioration could be related to the cytotoxic Sarcoid treatment, and whether C should have been better assessed prior to initiating this treatment. There is no evidence to suggest that this treatment would or could have had a negative impact on C s immune system, and the CAC considers that this is very unlikely. The CAC does not consider that Dr B was remiss in not performing diagnostic evaluations (blood tests etc) prior to instituting the sarcoid treatment. 22. Dr B works in a supportive practice with plenty of scope to discuss cases. This case has been the subject of discussion within the practice and there have been learnings for all of the veterinarians including: better attention to recording details in the clinical notes being more proactive in making recommendations to clients about treatments and procedures when a case is not going as expected to maintain better communication with the client providing records to clients on request. 7

8 23. The CAC has reviewed Dr B's care of C against the determinants that have been listed for a competence assessment in the Veterinary Council s policy. It decided that a competence assessment is not required for the following reasons. There is no history of previous complaints or concerns brought to the Veterinary Council, so there is no pattern of poor standards of care over a period of time. Dr B is not considered to be working in professional isolation. There is not sufficient evidence of a significant knowledge or skill deficit that would warrant a competence assessment based on this one case. 24. The CAC can understand why Ms A feels let down by Dr B. The apparent misunderstanding by Dr B over costs resulted in missed opportunities at key times to intervene with appropriate diagnostic tests and possible treatments. The CAC acknowledges the distress caused to Ms A as a result of C s illness and subsequent death. The CAC does not consider Dr B s failings in this complaint reach the threshold to take disciplinary action against him, nor to recommend a competence assessment. In its discussions with him, the CAC considers that Dr B has learnt some important lessons from this case which will impact positively on his future practice. Provisional Decision 25. Both Dr B and Ms A were provided with this decision in provisional form and provided with the opportunity to comment. 26. Dr B chose not to comment. 27. Ms A responded, raising a number of issues. 28. The CAC discussed Ms A s comments and resolved that: no new issues were raised with regard to the complaint that had not been taken into account when drafting the provisional decision; and minor clarifications should be made to the description of the CAC s considerations to better reflect that some statements were Dr B s views, not the CAC s. Final Decision 29. The CAC has given careful consideration to all the information received including Ms A s response to the provisional decision. The CAC has found no evidence that Dr B has acted unethically or dishonestly and does not believe there are grounds for disciplinary action. 30. The CAC also does not recommend that he should be referred to the Veterinary Council for a competence assessment for the reasons set out in clause The CAC recommends to Dr B that he: Reviews the criteria he uses when making decisions to prescribe restricted veterinary medicines in situations when he has not seen the patient recently enough to have sufficient information to justify his treatment decision. Ensures in future that he keeps complete medical records for his patients that accurately reflect his clinical findings, and record critical communications with his clients. 8

9 Carefully reflects on this case and in particular considers: - The impact of his assumptions and interpretations about clients willingness to invest in treatment and diagnostic options for their animals. - The importance of reassessment of his clinical cases when patients are not responding to treatments as he might have expected. - The importance of being pro-active in recommending diagnostic tests at appropriate times, and recording those recommendations and the client s response in his clinical notes. - The importance of ensuring effective client communication especially when cases are not going smoothly, and giving appropriate consideration to offering a second opinion or referral where appropriate. 32. The CAC recommends that no further action needs to be taken in respect to Dr B. 9