FINAL DECISION OF THE COMPLAINTS ASSESSMENT COMMITTEE. Dr B and Dr C CAC (Complaint by A Re D)

Transcription

1 FINAL DECISION OF THE COMPLAINTS ASSESSMENT COMMITTEE Dr B and Dr C CAC (Complaint by A Re D) Ms A Dr B Dr C D E F Dr G H Dr I Complainant First veterinarian complained against Second veterinarian complained against Name of pet Dr B s and C s place of employment Second clinic to treat D Veterinarian from second clinic who examined D D s usual veterinary clinic Veterinarian who worked at E 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. The Complaints Assessment Committee ("CAC") of the Veterinary Council of New Zealand has investigated the above complaint. Pursuant to section 43, the CAC is of the view that this complaint does not require further action. The investigation 2. The CAC considered information from the following sources: a. Ms A s initial letter of complaint dated 11 March 2012 b. Ms A s to the Veterinary Council dated 16 March naming the veterinarians she considered relevant to her complaint c. clinical records from E and F for D supplied by Ms A d. Dr G s response for further information requested by the CAC dated 20 April 2012 e. Dr B s response to the initial complaint dated 17 May 2012 with attached clinical records f. Dr C s response to the initial complaint dated 17 May Background based on Ms A s complaint dated 11 March D is a 4 year old female Yorkshire Terrier. In March 2011 Ms A noticed that she was limping and pulling up her left hind leg. D was taken to her usual vet (H) and was diagnosed as having a luxating patella (grade 2-3). 4. The vet at H recommended surgical correction and quoted a price. 5. Ms A decided to seek a second opinion and called the SPCA who suggested (not recommended) E.

2 6. Ms A called E and spoke to Dr I and explained D s situation. Dr I said that the vet who performs such operations is experienced and had performed, conservatively speaking, around 50 of these operations. She was quoted a lower price for the surgery compared to the H quote. 7. Ms A s brought D in for a consultation at E on 28 March She was told both D s knees were affected, but the left was worse (grade 3-4). 8. Surgery was performed on the left leg on 30 March On collection post-surgery Ms A was advised to not allow D to jump or run for 6 weeks and a course of cartrophen injections was prescribed. 10. Ms A returned to the clinic to have D's stitches removed on 11 April 2011 which is when she started 4 weekly cartophen injections followed by 5 monthly injections. 11. On 31 October 2011 Ms A noticed D s left leg was not improving. Her temperature was elevated and she was given her cartrophen injection. She was told to wait a further 2 weeks to see if there was any improvement. 12. On 21 November 2011 Ms A called the clinic to advise that there was still no improvement. The dog was re examined and given a course of antiinflammatories and she improved a little. 13. On the 30 November 2011 Ms A reported the leg was getting worse and D had a high temperature. D was booked in for x-rays but Ms A was unable to make the appointment. 14. D was returned to the clinic on 5 December and 30 December 2011 as she was so miserable and not eating. Her temperature was reported as high. 15. On 17 January 2012 x-rays were performed at the clinic and Ms A was told that they can find nothing wrong. Nothing was suggested to help resolve D s suffering. 16. As D was not using her leg at all she was hospitalised overnight on 20 February 2012 at the clinic for blood tests, x-rays and for a sample of fluid to be taken from the affected joint. The diagnosis for the lameness was that the pin that was put in at surgery had become loose and the ligament was torn. The joint fluid came back with no significant findings and the blood results had no significant changes. 17. Ms A states that she was advised by Dr I that apart from a minor matter relating to D s liver the blood tests were clear. Dr I advised they (the clinic) were not really sure what to do and suggested that the pin should be removed. Ms A agreed to this and was quoted approximately $1,100 for the surgery. Ms A felt this was unfair as she had been back to the clinic on a regular basis raising concerns about D s leg. 18. Dr I explained that the Senior Practitioner (Dr B) was away and they had

3 no authority to make a decision regarding charges without him. Ms A requested they contact Dr B. 19. When Ms A collected D on the afternoon of 21 February, she was told by another vet that D s pin was too long, that she had now gone and broken her ligament and that they had over-corrected her knee. Ms A felt she got mixed messages regarding the pin length and pin loosening and noted that no one had mentioned previously that the knee was over corrected. 20. The second surgery was performed on Friday 24 February. Ms A paid a deposit towards the surgery. 21. On collecting D after the surgery a different antibiotic and pain killer was prescribed. This confused Ms A as she believed the joint was not infected from the previous fluid results. 22. On 26 February 2012 Ms A took D back to the clinic as she was not eating. Dr I thought this was due to the anaesthetic and treated her with antinausea and antibiotic medication. 23. On 29 February 2012 D was taken back to the clinic and given laxatives as she had been constipated for several days. 24. Ms A did not pay when she left but the receptionist followed her and asked her to pay for the last two visits. A second person came up to Ms A and demanded payment immediately. Ms A explained she had been told the bill would be sorted out on Dr B's return. 25. By the time D s stitches were due to be removed Ms A had lost confidence in the E and felt that they would not now remove D s stitches unless she made a full payment. 26. Ms A made an appointment with Dr G at F on 6 March D s medical records were sent to F and Dr G s examination revealed a high temperature and breakdown of the second operation (11 days after surgery). 28. On 9 March 2012 Dr G left a message to say D s knee fluid was normal but the lab was doing further work on it and he was in communication with E. The Complaint 29. Ms A was very unhappy that the initial surgery performed by Dr B on D s left luxating patella was unsuccessful. 30. Ms A complained that D s deteriorating condition had continued for many months before any action was taken. 31. Ms A was unhappy that the second surgery performed by Dr C was not

4 successful. 32. Ms A was distressed about the excessive financial demands that were put upon her as she believed D s complications were due to the surgical complications / failures of the clinic. Dr B s Response 33. Dr B responded to the initial complaint on 17 May Dr B summarised the clinical history in his response as follows: On 28 March 2011 D presented with bilateral medial luxation of the patella. The left hind leg was worse than the right. The initial surgery to correct the left medial luxation of the patella was performed on 30 March by Dr B. There were no immediate postoperative problems. On 31 October, 7 months post surgery, D presented lame and there was confusion as to which leg she was lame on indicating that the lameness was subtle. On 21 November D presented with definite left leg lameness and nonsteroidal anti-inflammatories were prescribed. On 30 November D was presented with left hind lameness again and was seen by Dr C. She was booked in for x-rays the following day but the owner did not make the appointment. On 5 December D was presented again this time with a history of not eating, off colour, intermittent lameness and a very high temperature of 40 degrees. On 30 December Dr C prescribed more non-steroidal antiinflammatories as the owner felt cartrophen was not helping. On 7 January 2012 both stifles were x-rayed and no abnormalities detected. There was confusion as to what was causing the lameness. On 31 January the owner presented a video showing D's left hind lameness. A high temperature was also identified. On 21 February D presented again with a high temperature and worsening left hind lameness. A full workup was performed. Blood tests and joint fluid were taken. The lab results of the joint cytology showed no abnormalities, except a suggestion of chronic inflammation in the joint. Clinical examination revealed a cranial draw of the left stifle indicating a rupture of the cranial cruciate ligament. And the patella was now luxating laterally (indicating over correction). It was suggested that the pin may be contributing to the lameness and it was recommended that it be surgically removed. On 24 February D was admitted for the second surgery of the left stifle joint. Dr C was the attending surgeon and he removed the pin, deepened the trochlear groove and placed a lateral suture. On 26 February D presented not eating and was treated accordingly.

5 On 29 February D was again presented with a problem of constipation and was again symptomatically treated. D was not seen at E after this date as the owners elected to take their pet to F. Dr B indicated that at the time of writing his response there has been no further communication regarding this case and they were not aware of the outcome for D. In summary Dr B: o reported that he performed a routine surgery to correct a luxating patella on the left stifle, which initially healed as expected. Seven months after the surgery D presented with a high body temperature and left hind lameness that worsened over time. Subsequent investigation did not reveal the cause for the high temperature. A ruptured left cranial cruciate ligament and lateral luxation of the patella was diagnosed as the cause of the left lameness. o suggested several possible scenarios for the delayed complications associated with the left stifle. However he noted that it is difficult to prove the exact cause of the problem which is likely to be multifactorial. o reported that he had performed approximately 200 patella luxation surgeries. He uses either a wedge or rasp technique for deepening the groove. He makes the decision of what technique he uses at the time of surgery after opening and assessing the joint. He has had very few complications but the recovery rates varied. o noted that all surgeries routine or other, carry the potential risk for complications. He said the greater the number of surgeries performed the more likely complications will arise. o commented that the treatment of D at E followed standard veterinary diagnostic procedures and treatment options to resolve the problem o regrets that Ms A elected not to return to the clinic for fear the sutures would not be removed unless full payment of her account was made o commented the staff were following practice policy regarding the payments due, however, unfortunately he was overseas at the time and he would have resolved the payment problem if he had been present o stated that E would have resolved the problem at no cost to the owner as he generally guarantees the practices work o that E would refund the $600 put down as payment for the second surgery o hopes D s problems have been resolved for the best.

6 Dr C s response 34. In Dr C s response dated 17 May 2012 he confirmed that he performed a surgery on D on 24 February At this surgery the pin from the previous surgery was removed, the patella groove and patella position assessed and a lateral suture to stabilize the stifle joint was placed. There were no reported complications during the surgery. Dr C: noted in his response that a lateral suture, extracapsular technique for cruciate repair is considered a standard treatment for cranial cruciate rupture. He made the point that in time all sutures will break down but unfortunately this happened early in this case for unknown reasons. quoted from published assessments of the procedure that approximately 10-15% of dogs do not improve with surgery suggested that due to D s previous issues with this joint any complication rate might be higher. He had no figures to confirm this suggestion. stated that although the surgery was unsuccessful he does not consider it to be due to negligence or lack of professional integrity during the treatment of D. The CAC sought additional information from specialist surgeon, Dr G 35. Dr G responded to the CAC s request for information advising: he first examined D on 6 March 2012 noting her past history D had an elevated temperature of 39.8 degrees and had skin sutures present from the previous surgery. She was intermittently weight bearing on the left hind but was non-weight bearing at rest. Her patella was stable but the stifle joint was unstable in a cranial draw test, which indicated failure of the lateral suture. There was a clunk on manipulation of the stifle, which is often associated with medial meniscus damage secondary to stifle instability the following surgical complications that D suffered from: 1. over correction of the medial patella luxation to a lateral position 2. subsequent failure of the cranial cruciate ligament at some stage in the postoperative period. The actual time of failure is unknown and potentially could have been present at the time the time of the 1st surgery and was undiagnosed. This may explain the poor response to surgery. 3. failure of extra capsular lateral suture of the cranial cruciate ligament repair in the second surgery. the above complications are well documented and are reported in the literature as possible sequelae to surgery for medial patella luxation luxation of the patella in either direction (medial or lateral) results in

7 malalignment of the extensor mechanism and predisposes to the cranial cruciate ligament rupture. 36. In Dr G s opinion the appropriate surgical techniques were applied in this case. These include trocheaplasty to deepen the patella groove, tibial tuberosity transposition and extracapsular lateral suture imbrication. Early failure of the extra capsular suture is a well-recognised complication of this technique. 37. Dr G quoted from the literature noting that surgical complications following repair of medial patella luxations range from 18-48% depending on the study. CAC considerations 38. The CAC has given careful consideration to all the information that was provided. The CAC fully appreciates the distress that the duration of D s lameness and health problems has caused both D and Ms A. 39. The CAC was comfortable that the sequence of events and dates concerning D s clinical history that was provided by Dr B and Dr C corresponds to that provided by Ms A and Dr G. 40. The CAC accepts Dr G s opinion that Dr B and Dr C applied appropriate surgical techniques in D's case. These techniques include trocheoplasty to deepen the patella groove, tibial tuberosity transposition, to relocate the patella and extra capsular lateral suture imbrication, to stabilize the joint. 41. In Dr G's report he clearly stated that the surgical complications that D suffered after the medial patella luxation surgery (first surgery) and the repair of the ruptured cranial cruciate ligament with associated lateral patella luxation (second surgery) are all well documented in the literature. The post surgical complications Dr G specified are noted in paragraph 35 of this document. He stated the reported occurrence rate of these complications varies between 18-48%. The committee is of the opinion that D, unfortunately, fell in to the 18-48% of the surgical candidates that develop these well-documented post surgical complications. During review of the complaint and response it was not noted that a discussion of the possible complications was had prior to the two surgeries. 42. The committee did note that many of the E clinical history entries, relating to D, between 28 March 2011 and 29 February 2012 lack detail and information on the clinical examination of D. 43. The CAC accepts that it was unfortunate that Dr B was overseas at the time of the second surgery and notes that he regrets that he was not able to resolve the payment problems between Ms A and E at the time. Provisional Decision

8 44. This decision was sent to Ms A and Drs B and C for consideration prior to finalising. Neither the complainant nor the veterinarians concerned wished to comment on the provisional decision. Final Decision 45. The CAC has given careful consideration to all the information received. The CAC has found no evidence that Dr B or Dr C acted unethically or dishonestly and does not believe there are grounds for further action. 46. The CAC also does not believe there are grounds to consider that Dr B or Dr C have acted outside their level of competence or that they should be referred to the Veterinary Council for competence assessment. 47. The CAC recommends that the practice reviews its policy on clinical note recording to ensure that adequate detail is recorded so that any other veterinarian upon review of those notes would be able to subsequently manage the case. This is stated in the Code of Professional Conduct: Veterinarians must maintain clear and accurate clinical records. The records must: a. Be of such detail that another veterinarian could take over the management of the case at any time; b. Be retained for periods of time as required by statute or for the duration of time for which they remain relevant to the purpose for which they were recorded; c. Not be altered retrospectively unless the changes are marked chronologically on the record, and the additions are dated and noted as being added retrospectively; and d. Be made accessible to clients on request, unless there are justifiable legal reasons to withhold. 48. The CAC recommends that the practice reviews its policy on discussion of potential complications associated with procedures to ensure that the client is adequately informed of potential risks and refers Drs B and C to the following section of the Code: Veterinarians must obtain appropriate consent before proceeding with a proposed treatment/course of action. Veterinarians must provide clients with the information that they need, in a way that enables the client to understand and give consent to the proposed treatment/course of action. Veterinarians must be satisfied that clients are authorised to provide that consent. Depending on the circumstances the information provided to clients may include: a. The condition of their animal(s); b. Treatment options, including likely outcomes, risks, side effects, complications, costs and benefits; c. Referral options where appropriate and how to access;

9 d. The veterinarian's skills and experience in providing the proposed treatment (where appropriate); e. Post treatment requirements and costs. 49. The CAC believes that this case can be closed and no further action needs to be taken.