Veterinary care

The Board considered that the veterinary care provided was of a satisfactory standard and was that which could be reasonably expected of a veterinary practitioner. The Board considered that it was both standard and reasonable for the veterinary practitioners to treat the dog’s vomiting conservatively in the first instance, as initial diagnostic investigation revealed no marked abnormalities. It is standard practice in veterinary medicine to treat cases based on the clinical evidence and to investigate further if initial treatment is unsuccessful.

Diagnostic investigation is generally a case of excluding those disease processes that most commonly cause the presenting symptoms. The dog’s clinical management was undertaken appropriately based on this principle. Blood testing, radiographs, ultrasound and dietary monitoring were all undertaken in an attempt to ascertain the cause of the dog’s vomiting. Many possible causes of the dog’s vomiting were able to be excluded based on the results of diagnostic testing. Radiographic investigation was ultimately successful in diagnosing megaoesophagus. The dog was to undergo endoscopy in an attempt to ascertain the cause of his megaoesophagus; however, he developed aspiration pneumonia, which resulted in a grave prognosis and the decision to euthanase.

The Board noted the owner’s concerns that endoscopy was not performed in a timely manner and that the dog was left without adequate veterinary attention. The clinic is a large veterinary hospital that cares for large numbers of patients per day. In any hospital (animal or human), it is necessary to triage patients according to their level of need. Those who are seriously ill will require more urgent treatment than those whose condition is less serious. The Board recognised that until the time that the dog developed aspiration pneumonia his medical condition was (reasonably) not classified as an emergency or urgent case, as he was not gravely ill. The hospital records indicate that for the majority of the dog’s hospital stay, his condition was considered stable, with normal clinical parameters and a bright and alert demeanour.

Endoscopy

The hospital uses a consultant to perform and assess all endoscopies. Thus there was a period of time before the consultant could be on site. Due to the need to prioritise cases, the consultant had to attend to other more urgent cases before performing the endoscopy for the dog in this case.

As the hospital is not staffed over a 24 hour period, the consultant expressed concern with anaesthetising the dog later in the day, as the dog would not be monitored overnight and there was a high risk of complication in an animal with oesophageal dysfunction following anaesthesia. The Board agreed that it would have been dangerous for the dog to be left unattended in the post-operative period, and it was appropriate for the endoscopy to be postponed until a time when recovery from the procedure could be adequately monitored. The dog developed aspiration pneumonia before the endoscopy could be performed.

An endoscopy would have only confirmed the diagnosis of megaoesophagus, and would not have resulted in any change in the dog’s health status.

Megaoesophagus

Megaoesophagus is difficult to treat and the risk of aspiration pneumonia is ongoing and ever present. The outcome of megaoesophagus is generally poor, with or without treatment, and most animals will succumb to aspiration pneumonia at some stage, even if the underlying cause is found. The Board considered that it was unfortunate that the dog developed aspiration pneumonia while in the care of the clinic, but found that this could not have been foreseen or prevented. It was almost certain that the dog would have developed aspiration pneumonia at some stage, and in this case he was afforded immediate and intensive veterinary care.

Communication

The Board noted the owner’s concern regarding continuity of care and communication at the clinic. The clinic employs large numbers of staff and it is not possible for a patient to receive ongoing care from the same veterinary practitioner. Patient care is handed over to a new staff member at the end of each shift, and an ongoing record of treatment is provided via the patient’s clinical history. Clients are asked to phone the hospital at certain times during the day to receive information about their pet’s condition. The clinical record indicates that the owner was aware of these times as it is recorded that it was sometimes difficult for her to phone at the prescribed time due to her own prior appointments. The clinical record indicates that the owner was phoned by the veterinary practitioners on numerous occasions. Due to the busy nature of the hospital, it is not reasonable to expect the veterinary practitioners to be in a position to return calls immediately.

The dog received extensive veterinary treatment during his stay, much of which was not charged for. The Board considered that the veterinary care provided to the dog was appropriate and did not consider that the outcome would have differed had he received care elsewhere.

The Board acknowledged the distress suffered by the owner due to the loss of such a young and seemingly otherwise healthy pet. However, with the available information, the Board found no evidence of unprofessional conduct.

The informal hearing panel made its finding based upon the following reasons.

Clinical management

The panel discussed the clinical management of the dog’s case with Dr P. Dr P informed the panel that an initial thorough exam was not possible due to the dog’s nervous disposition. As a precautionary measure they had advocated a conservative treatment plan; they administered Buscopan® and advised the dog’s owners’ to observe his behaviour. The dog was re-presented the following day. The dog had been experiencing symptoms of pain, emesis, inappetence and a reluctance to drink for approximately 48 hours. Dr P elected to sedate the dog to perform further diagnostic procedures. Dr P stated that they took a radiograph of the dog’s abdomen, but it did not yield any useful diagnostic information as to the probable cause of the gastrointestinal upset, and the radiograph was subsequently destroyed.

The panel questioned Dr P on their decision not to administer intravenous fluids before, during or after the enterotomy procedure. Dr P stated that they did not place the dog on a drip because of the dog’s nervous disposition. Dr P further stated that they did not believe it was necessary as it was their clinical opinion that the dog was not dehydrated. Dr P conceded that, while the lack of intravenous fluids may not have altered the ultimate outcome of the case, it is possible that the dog’s dehydration may have been a contributing factor to the intestinal dehiscence. The panel advised Dr P that when major surgery, such as an enterotomy, is undertaken there is an expectation amongst both the profession and the public that intravenous fluids will be administered, and that this expectation is even greater when an animal has not consumed any fluids for a 48 hour period.

The panel further questioned Dr P about their failure to recognise the possibility of post-operative complications. Dr P described the surgery as routine, and the recovery as normal. Dr P dismissed the owners' concern for their dog as "over indulgent owners" that "underestimated" the seriousness of the procedure. The owner presented to Dr P on the morning after the dog’s discharge and advised that the dog continued to suffer from inappetence and refused to drink. The panel was of the opinion that Dr P should have recognised the possibility of post-operative complications at this stage and either re-examined the dog comprehensively or referred him to another veterinary practitioner who was willing or able to perform further examinations.

Record keeping

The Panel noted that Dr P failed to enter a clinical record for the day the dog presented in collapse. The owner had presented at the clinic that morning, seeking advice and help for the dog’s continuing symptoms, and later that day the dog had been re-presented in a collapsed state. The panel reminded Dr P that even though no drugs were dispensed, these events should have been documented in the clinical record. The panel also considered that Dr P’s decision to destroy the radiograph was inappropriate. The panel reminded Dr P that both radiographs and radiographic reports form part of the clinical history, provide evidence of an animal’s treatment, and should be retained as part of the clinical record and kept for five years.

The panel discussed with Dr P the apparent alteration of their clinical records. Clinical notes had been altered from what was faxed to the emergency clinic at the time of the dog’s admission and those they forwarded in response to the Board’s request arising from this investigation. Dr P admitted that they had altered the clinical records only after they had received notification from the Board that a complaint had been lodged by the dog’s owners. The panel acknowledged that it is reasonable for a practitioner to amend or update a clinical record after an event, as long as it forms a contemporaneous record of events. It is permissible to write a more fulsome history at the end of the day, relying on notes taken during consultations and examinations. However, the panel noted that this was not done by Dr P. The panel counselled Dr P regarding the altering of the clinical record some months after the event and only upon receipt of a formal notification that a complaint had been lodged.

Options

The Board’s Guidelines outline that, before undertaking veterinary procedures upon an animal, the attendant veterinary practitioner will fully discuss the available options for treatment, their associated costs, the prognosis and potential complications. The panel noted that the dog’s owners were not presented with options for treatment. They were not offered the option of intravenous fluids and/or pre-operative blood testing, as Dr P had judged that these were not necessary. Dr P further stated that because of their concerns regarding the dog’s nervous disposition, they were unwilling to administer fluids as it was too difficult. The Panel reminded Dr P that difficulty in handling an animal does not negate a practitioner’s obligation to provide options for veterinary care. Aggressive or uncooperative animals are common in veterinary practice and need to be medically managed as diligently as any other animal.

The informal hearing panel further reminded Dr P that they should have presented a range of options to the owners when the dog presented in a collapsed state, including euthanasia and referral to another veterinary practitioner. The panel stated that the owners should not have had to insist on a transfer to an emergency clinic.