ROYAL COLLEGE OF VETERINARY SURGEONS DR DUNCAN DAVIDSON MRCVS FINDINGS OF FACT AND ON DISGRACEFUL CONDUCT IN A PROFESSIONAL RESPECT

Transcription

1 ROYAL COLLEGE OF VETERINARY SURGEONS V DR DUNCAN DAVIDSON MRCVS FINDINGS OF FACT AND ON DISGRACEFUL CONDUCT IN A PROFESSIONAL RESPECT 1. Dr Davidson faces two heads of charge relating to his treatment of an Egyptian Mau cat, Ameira, in November and December 2013 belonging to Ms Hayat. Dr Davidson was a sole practitioner and owner of the Mitcham Veterinary Clinic, Mitcham, Surrey. Ms Hayat, who was a long standing client of Dr Davidson took her cat, Ameira, to him on 8 November 2013, after the cat became unwell. Dr Davidson qualified in 1975 and worked for various small animal practices in the south east of England before setting up his own practice. He retired from clinical practice in November 2014 but continues to act as an expert witness, primarily in dangerous dog cases. 2. At the outset of the hearing Dr Davidson did not admit any of the heads of charge and denied that any conduct, found proved, amounted to disgraceful conduct in a professional respect. The central features of this case are divided into two parts, first, allegations relating to Dr Davidson s clinical competence and second, allegations relating to clinical records. 3. The College alleges that Dr Davidson (i) between 7 November and 13 December 2013, incorrectly administered corticosteroids when they were either not indicated or contra indicated, (ii) between 21 and 23 November 2013, failed to administer adequate fluid therapy, (iii) on 23 November 2013, discharged Ameira to Ms Hayat's care, suggesting a referral on Monday 25 November 2013, when he should have suggested and/or arranged for an urgent same-day referral and/or transfer to another veterinary practice; and (iv) between 25 November 2013 and 13 December 2013 failed to communicate adequately to Ms Hayat the urgency of the need for further investigation of Ameira's condition and/or referral for the same. 1

2 4. The College also alleges that Dr Davidson, in relation to clinical records, (i) dishonestly made retrospective alterations to those clinical records; (ii) failed to keep clear, accurate and detailed clinical records, more particularly in that: (a) his handwritten records for Ameira were insufficiently legible; and/or (b) there were a number of different versions of his clinical records for Ameira; and/or (c) made retrospective alterations to his clinical records for Ameira without dating the amendments or otherwise making it clear that they had been made retrospectively. 5. The Committee has given detailed consideration to all the evidence in this case, the submissions of Counsel, and the advice of the Legal Assessor. It has applied the law on the burden and standard of proof, namely that the burden of proof is on the College to prove the facts alleged and that the standard of proof required is that the Committee has to be sure before it finds any allegation of fact contained in the charge proven. 6. The circumstances of this case are that Ms Hayat took Ameira to see Dr Davidson on 8 November 2013 because Ameira was not eating and Ms Hayat had seen thread in the cat's mouth. A follow up appointment was made for 12 November 2013 and then cancelled by Ms Hayat as Ameira was a little better. She was seen by a locum veterinary surgeon on 14 November 2013 when nothing abnormal was detected. Dr Davidson administered Dexadreson (a cortiscosteroid) and AmoxyLA (an antibiotic). Dexadreson was administered by Dr Davidson at subsequent appointments on 22 November 2013, 27 November 2013 and 30 November A further steroid (Voren) was administered on 5 December 2013 and 12 December Ms Hayat returned to the practice on 21 November 2013 and saw Dr Davidson. Ameira was reported to be anorexic and appeared dehydrated. Her condition had deteriorated significantly. Dr Davidson administered 50ml Hartmanns solution subcutaneously on 21 November 2013 and 23 November He has said that he gave another 50ml subcutaneously whilst Ameira was an inpatient at the surgery on 22 November There is no record of Dr Davidson administering 50ml on this occasion in the clinical records. It is common ground that Dr Davidson did not provide intravenous re-hydration, nor did he make arrangements for Ameira to be transferred to a practice which would be able to establish intravenous re-hydration. Blood samples and four radiographs were taken during Ameira's stay at the practice. Dr Davidson recommended that Ms Hayat take Ameira home on Friday 22 November Ms Hayat asked for Ameira to remain at the practice for a further night. 8. Ms Hayat collected Ameira on the morning of Saturday 23 November 2013 at Dr Davidson's request after he said that he would not be able to care for Ameira over the weekend. Ms Jennifer Dobson, Certified Clinical Animal Behaviourist, was present at the consultation. There is a conflict of evidence between Dr Davidson and Ms Hayat as to when Ms Hayat first mentioned that Ameira had been retching. Dr Davidson said that it was at this appointment and in conversation with Ms Dobson. Ms Hayat said that she 2

3 had mentioned retching previously. Dr Davidson said that the need for an endoscopy was discussed and recommended the Elands Veterinary Clinic, Sevenoaks. Ms Hayat said that she agreed to a referral in principle which was to be arranged by Dr Davidson on Monday, 25 November Again there is a conflict of evidence as to whether she was advised that Ameira's condition was critical or that a referral was required urgently. Ms Hayat does not accept that she refused an urgent referral. Dr Davidson sent Ameira home with Ms Hayat on the basis that the cat was sufficiently stable to return home temporarily in an effort to encourage her to eat and agreed to enquire about a possible referral on 25 November Dr Davidson and Ms Hayat discussed the blood test results by telephone on the afternoon of 23 November 2013 and the intention remained that enquiries would be made after the weekend, on 25 November 2013, about a referral. Dr Davidson accepts that he made no enquiries himself of the Elands Veterinary Clinic before 25 November 2015, when he telephoned the practice to inquire about availability for a referral. 9. On Monday 25 November 2013 Ms Hayat was seen by another veterinary surgeon, Mr Holden, at the Mitcham Veterinary Clinic. On examination he identified, cut and removed a piece of thread caught on Ameira's tongue. Ms Hayat was advised by Mr Holden that Ameira needed to be checked and may need an enterotomy if there was no improvement in 24 to 48 hours. He explained that Kydd & Kydd in Wimbledon, which was closer than Dr Davidson's suggestion of Elands Veterinary Clinic, Sevenoaks would be able to accept a referral. No referral was made on 25 November 2013 and Mr Holden spoke to Dr Davidson about the outcome of the appointment. Ms Hayat returned to see Dr Davidson, with Ameira, on 27 November 2013 and 30 November No referral was made and further cortiscosteroid injections were given. Ms Hayat's friend, Ms Isobel Toquero described how Ms Hayat expressed concerns on 27 November 2013 that the thread was being overlooked as an explanation for Ameira's condition by Dr Davidson and that he appeared to be looking for other reasons. 10. Ms Hayat described how on 5 December 2013 Dr Davidson suggested that it may take months for the inflammation of the throat to settle down and offered long term steroids. It is alleged that he did not explain that Ameira's condition was critical, nor did he suggest that the need for referral was urgent. At a final appointment on 12 December 2013 Ms Hayat described how Dr Davidson appeared to focus on the likely damage to the throat done by the thread. She said that he made no mention of ultrasound. Dr Davidson said that he told her there was a strong likelihood that Ameira would not survive, and gave her further corticosteroids at her request and against his advice. 11. Ms Hayat sought a second opinion. She contacted the Kydd & Kydd Veterinary Health Centre, Wimbledon on 12 December A request for records from the Mitcham Veterinary Centre was made on 12 December 2013, prompting Dr Davidson to telephone Kydd & Kydd that day to give Ms Donaldson MRCVS an oral account of Ameira's treatment. Ms Donaldson, also spoke to Ms Hayat by telephone on 12 3

4 December Ms Donaldson saw Ameira on the morning of 13 December 2013 when Ameira was dehydrated and looked very sick. Ms Donaldson therefore recommended a referral to the Royal Veterinary College, London as soon as possible. Ms Hayat accepted that advice and a referral was made that morning. 12. Ms Hayat arrived at the Royal Veterinary College shortly after lunchtime on 13 December 2013 where Ameira was seen by Ms Doolin MRCVS. A linear foreign body in the intestine was confirmed by ultrasound and Ms Hayat consented to the required surgery. The surgery was carried out on 13 December 2013 by Ms Lee MRCVS who stressed that Ameira had a guarded prognosis. Nevertheless, Ms Hayat asked her to proceed with the surgery. Ameira suffered two cardiac arrests after surgery and died on 14 December Ms Hayat requested copies of Ameira's records from the Mitcham Veterinary Clinic as part of her grieving process. She was provided with handwritten and typed records by the Mitcham Veterinary Clinic on 16 January She became concerned about the contents of the records and requested a copy of the records from Kydd & Kydd by way of comparison. The copy handwritten records were sent by Kydd & Kydd to Ms Hayat on 10 February Dr Davidson accepts that after he sent his copy handwritten records to Kydd & Kydd on 12 December 2013 he made a number of additions to them before they were provided to Ms Hayat by the Mitcham Veterinary Clinic on 16 January This has resulted in two different versions. It should be noted that four of the five additions relate to the offer of further investigations. Dr Davidson said that he made the alterations on 12 December 2013 to provide a more complete record of what had taken place. There is nothing to make it clear that they were subsequently altered. The records are made with the same coloured pen and are not dated. 14. When Kydd & Kydd requested the records on 12 December 2013, Dr Davidson also provided typed notes. Further additions or changes were made. Dr Davidson stated that the first version of the typed notes was made later on 12 December 2013 to assist Ms Donaldson reading the records. He says that he modified the typed notes on 15 December 2013 and made further corrections on 16 January 2014 before they were provided to Ms Hayat. Accordingly there are two sets of handwritten records and three versions of the typed notes for Ameira's care. It is also the College s case that the handwritten records are insufficiently legible. Ms Donaldson recalled that she was unable to read the handwritten records and did not find them helpful. 15. The Committee is satisfied that both Ms Hayat and Dr Davidson sought to assist it with their recollection of events. Where there are differences between their respective recollections, the Committee has concluded that they largely reflect the interpretation each has placed on the events. The Committee has found it difficult to reach a conclusion as to which account is correct. It accepts Ms Hayat s evidence that she genuinely believed, certainly after Ameira had died, that Dr Davidson did not make it 4

5 sufficiently clear to her before 12 December 2013 that Ameira s condition was critical and that she required a referral urgently. The Committee has concluded that Dr Davidson probably did raise at least some of the issues he contends he raised, regarding Ameira s treatment plan, with Ms Hayat at consultations after 21 November It is uncertain as to the extent that he did so. The Committee has concluded that it is not satisfied that the College has proved its case to the requisite standard as to what took place at the various consultations. The Committee also heard evidence from Ms Toquero and Ms Dobson as well as character evidence from four witnesses. Ms Toquero and Ms Dobson s evidence was of assistance but was also not conclusive as to what took place at the consultations. 16. The Committee also heard expert evidence from Mr Hurst MRCVS, on behalf of the College, and Mr Robinson MRCVS, on behalf of Dr Davidson. These experts gave evidence both as to whether Dr Davidson s treatment of Ameira, and the preparation of his clinical records, fell below an acceptable standard, and whether it was disgraceful conduct in a professional respect. The Committee is satisfied that both experts were doing their best to assist with explanations of the standard that is applied by first opinion veterinary surgeons in small animal practice. In some respects the Committee preferred the evidence of Mr Hurst and in others that of Mr Robinson for the reasons set out below. 17. The Committee finds the following facts: Heads of Charge [1] (i). The Committee accepts Mr Hurst s evidence that a reasonable minority of veterinary surgeons would have prescribed corticosteroids initially on 8 November 2013, albeit that Mr Hurst said that he would not personally have done so. It is satisfied that the position had altered by 25 November 2013, when Mr Holden removed part of the thread from Ameira s mouth. It accepts Mr Hurst s evidence that the corticosteroids would not be appropriate once the diagnosis of a linear foreign body had been made, at which time a veterinary surgeon should have treated the cause of the inflammation. This conclusion is supported by an extract from Mr Robinson s report where he said that Given the poor response to conservative management, and of a foreign body being present, the continued use of corticosteroids, even in the intermittent doses given, after 25 November 2013 would be considered contra-indicated. Mr Robinson s opinion was repeated in oral evidence. It does not consider that the circumstances described by Dr Davidson permit the Committee to come to the conclusion that he had no other choice, for instance, he could have continued to prescribe antibiotics without corticosteroids. The Committee finds head of charge 1 (i) proved. 5

6 [1] (ii) The Committee does not accept Mr Hurst s evidence that, in the particular circumstances of this case, no reasonably competent veterinary surgeon would not have fluids administered subcutaneously to Ameira on 21 November 2013 and on the subsequent two days. It generally prefers Mr Robinson s evidence on this issue. The Committee is not satisfied that on 21 November 2013 Ameira was so dehydrated that administration of fluids intravenously was essential. Dr Davidson s original handwritten note state feels dehydrated. This conclusion is supported by the blood test results from 22 November 2013, which indicated mild dehydration. The figures advanced by the experts on the quantity of fluid required are compromised by an absence of information regarding the weight of Ameira at that time, the amount of voluntary oral fluid intake and the ability to assess accurately the degree of hydration clinically. The Committee also considers that it is relevant that Ameira did not require parenteral hydration on 25 November 2013, or indeed subsequently. It noted that Ms Doolin at the Royal Veterinary College recorded on 13 December 2013 that Ameira was moderately dehydrated. Finally, the Committee cannot be sure that Dr Davidson did not administer 50 mls Hartmanns solution on 22 November The Committee finds head of charge 1 (ii) not proved. [1] (iii). The Committee is not satisfied that Ameira was sufficiently unwell on 23 November 2013 that she required an urgent referral to another veterinary practice. Dr Davidson accepts that he did not seek to arrange an urgent referral on 23 November He explained in oral evidence that he had concerns as to whether he could make satisfactory arrangements over the weekend. Mr Hurst s evidence was that not offering immediate referral on the Saturday when discussing the blood results, knowing how ill Ameira was, or at least offering it, instead saying it would be arranged on Monday was below the standard of a reasonably competent veterinary surgeon, not appreciating the urgency of a potential foreign body. Mr Robinson takes a contrary review, relying upon a number of factors: the blood test results, the absence of a definitive diagnosis, the difficulties making a referral over the weekend, the potential cost to the client, Ameira s stable condition, and Ms Hayat s ability to attend the South London Emergency Clinic, if required. The Committee prefers the evidence of Mr Robinson to Mr Hurst that the apparent clinical condition of Ameira did not make urgent referral essential on 23 November The Committee finds head of charge 1 (iii) not proved. [1] (iv). The Committee is not satisfied that Dr Davidson did not communicate adequately the urgency of the need for further investigation to Ms Hayat in the period between 25 November 2013 and 13 December Dr Davidson said that he contacted the Sevenoaks practice on 25 November 2013 regarding referral for further imaging. The Committee has concluded that Ms Hayat had probably lost confidence in Dr Davidson s competence following her consultation 6

7 with Mr Holden on 25 November 2013, when he removed part of the thread from Ameira s mouth. Mr Holden made a definitive diagnosis of a linear foreign body. Dr Davidson said that he explained on 27 November 2013 that there was a risk of damage to the oesophageal or gastrointestinal tract, and that further radiography was offered. He described a difficult meeting at which he did not believe that Ms Hayat was prepared to incur further expenditure, and he reduced the invoice to remove the cost of the blood tests. Ms Hayat probably did not want to pay because she believed that Dr Davidson should have found the thread. When Ameira began to deteriorate again by 5 December 2013, Dr Davidson s amended handwritten note refers to still advise endoscopy to examine oesophagus. Given options owner would prefer to continue with medication. Dr Davidson s evidence is strongly contested by Ms Hayat, however, the documentary evidence raises doubts in the Committee s mind as to what occurred. Whilst it is conscious that the additions to the handwritten records made by Dr Davidson on 12 December 2013 are mainly concerned with the issue of further investigation, it cannot be sure that he failed to communicate to Ms Hayat the urgency of further investigation or referral. The Committee finds head of charge 1 (iv) not proved. [2] (i). The Committee has concluded that the only documents that can properly be classified as clinical records are the handwritten records and the first typed version of the amended handwritten records. It is accepted that Dr Davidson made retrospective alterations to the clinical records. Dr Davidson said that he was concerned that he would be subject to civil litigation from Ms Hayat, which the Committee believes may have led to the production of the other documents. The Committee does not consider that, in circumstances where the original handwritten records had already been sent to Kydd & Kydd on 12 December 2013, it can be sure that Dr Davidson s motivation in making the alterations was dishonest. Although there are some troubling aspects about this case, particularly the attendance note of the telephone conversation with the RCVS Complaints Department, that no alterations had subsequently been made to the records, it cannot be sure as to Dr Davidson s motivation. In reaching this conclusion it has taken into account Dr Davidson s good character and his unblemished professional record over the past 40 years. The Committee has heard from four character witnesses, who have known Dr Davidson, in a number of different capacities, including two solicitors, a veterinary surgeon and the chair of the British Horse Society. The Committee finds head of charge 2 (i) not proved. [2] (ii). The Committee is satisfied that the records were insufficiently legible. Dr Davidson recognised the poor quality of his own handwriting. He accepted that where there were referrals he provided typed copies. Both experts were critical of Dr Davidson s handwriting. It is notable that neither Ms Donaldson nor Ms Doolin 7

8 were able to read his handwritten records. The Committee considers that where records are handwritten they should be sufficiently legible. It finds head of charge 2 (ii) (a) proved. The Committee accepts that Dr Davidson produced different versions of the clinical records. It does not consider that where they were made sequentially that, in itself, was outside acceptable practice. It finds head of charge 2 (ii) (b) not proved. The Committee is satisfied that the retrospective alterations were not dated nor that the making of the alterations was clear. The Committee finds head of charge 2 (ii) (c) proved. 18. The Committee has gone onto consider whether heads of charge 1(i), 2(a) and (c) found proved amount to disgraceful conduct in a professional respect. It does not consider that individually or cumulatively the facts found proved fall far short of the conduct to be expected of a reasonably competent veterinary surgeon. The Committee has already found that Dr Davidson was wrong to administer corticosteroids after 25 November It does not consider that on the facts of this case the administration of corticosteroids amounted to disgraceful misconduct. It has observed that the corticosteroids were being given in the context of ongoing antibiotic treatment. It prefers the evidence of Mr Robinson to Mr Hurst on this issue. The Committee has already emphasised the importance of making legible handwritten records but it does not consider that the failure to do so in this case amounts to disgraceful misconduct. Typed copies were provided to Ms Donaldson. The Committee has found that Dr Davidson was wrong to make retrospective entries in this case without making it clear when such alterations were made. The Committee does not consider that in this case the making of those alterations was capable of being disgraceful misconduct. The case is dismissed. DISCIPLINARY COMMITTEE DATED 22 January