Case study on clinical management, communication and failure to refer
Published in the February 2013 issue of Vetboard Victoria's newsletter
The following case study provides an opportunity for general reflection. The case study is based on a complaint about an individual set of circumstances at a particular time. As veterinary knowledge and professional and community standards and expectations change over time, readers should not assume that the Vet Board would make the same decision when presented with a similar complaint.
Summary
A five-year-old dog was presented to Dr B because the owners were concerned that the dog had been lethargic and refusing to eat. With the information that the owners provided, Dr B formed the opinion that the dog was probably suffering from anti-coagulant poisoning caused by rodenticide ingestion.
The dog was hospitalised at the veterinary clinic for 6 days before being sent home after showing signs of improvement. The dog was returned to the clinic 4 days later for blood tests, which revealed a low platelet count. The dog was sent home with strict instructions for rest.
The dog was returned to the clinic after 5 days as its health had begun to decline again. A blood test revealed low platelets and a high white cell count: The dog was given anti-inflammatory agents, anti-emetics and antibiotics, and then was discharged. A few days later the dog was presented to Dr B after-hours, as its condition had worsened. The dog died later that day while hospitalised.
The owners alleged that Dr B was negligent in the care of the dog: they were not given a definitive diagnosis and the dog was not given the appropriate treatment, which led to the dog’s death. The owners also alleged that: they were not given adequate justification for treatment; Dr B did not inform them of the possibility that the dog’s illness might be fatal; and Dr B did not seek the advice of more experienced practitioners, offer referral or other options for care.
The matter was referred to an informal hearing into the professional conduct of Dr B. It was alleged that Dr B:
- did not keep clinical records of an acceptable standard, and
- failed to adequately communicate to the owner the nature and consequences of the dog’s illness/condition; the nature of the after-hours care being offered; and alternative treatment options including referral.
Dr B was found to have engaged in unprofessional conduct and the Panel determined that Dr B be cautioned.
A caution is a formal notification, in the form of an advisory warning, to a registered veterinary practitioner. It warns the registered veterinary practitioner that a change in their manner of practice is required to conform to the minimum professional standards as defined in or considered by, for example: (1) veterinary practice or ancillary legislation (e.g. Drugs, Poisons and Controlled Substances legislation), (2) Board-issued Guidelines, (3) veterinary peers’ commonly understood practise standards, and (4) commonly understood community standards. The outcome is permanently recorded on the veterinary practitioner's file and may be referred to in any future hearing or action that the Board may undertake.
Reasons for the panel's decision
The informal hearing panel made its finding based upon the following reasons.
Regarding Allegation 1: that Dr B did not keep clinical records of an acceptable standard
Dr B informed the panel that clinical records comprise daily reviews, hospital notes and the results of any tests or procedures performed and that these notes are entered onto the computer daily or weekly. However, they informed the panel that, being a sole practitioner for the last 8 to 9 years, they kept their "thought processes" in their head rather than recording them in case notes.
The panel emphasised the importance of case documentation, noting that clinical records are for future use, referral and information for other veterinary practitioners who are or may become involved in a case. The panel acknowledged that for sole practitioners the clinical records may not initially appear to be necessary as a means of communication between veterinary practitioners; however, they are legal documents and should be completed and stored properly.
The panel acknowledged that Dr B made notes about conversations and communication with the owners but did not record important information about the dog’s condition, hospitalisation and test results. The panel said it was concerning that the records were fragmented and partly contemporaneous, partly retrospective. The panel was also concerned that the case records did not indicate a comprehensive approach or methodical diagnostic plan. From the clinical records, the panel could not ascertain the purpose of or interpretation of many of the tests undertaken.
Based on the available evidence and information, the panel was of the opinion that Dr B’s clinical records were incomplete and inconsistent with the requirements of the Board’s Guideline 11. [VPRBV Note: Board Guideline 7 - Veterinary Medical Records, contains current Board expectations in relation to the keeping of medical records.]
Regarding Allegation 2: that Dr B failed to adequately communicate to the owner the nature and consequences of the dog’s illness/condition; the nature of the after-hours care being offered; and alternative treatment options including referral.
Dr B informed the panel that when the owners brought the dog to the clinic, it was unwell and, based on the information provided, they made the judgment that it was suffering from anti-coagulant poisoning caused by ingestion of a rodenticide. Dr B stated that the main reason that the owners refused the blood transfusion was due to an inability to pay. They told the panel that the owners made it clear during the first consultation that ‘finances were a concern’ and had advised a spending limit during a discussion about costs. However, Dr B was not able to remember the amount of the limit and there was no documentation to corroborate this discussion.
Before the hearing, the panel had questioned the owners about their complaint and whether the issue of costs was discussed. The owners claimed finances were not an issue, that they had never discussed costs with Dr B and had paid more than $1200 for tests, treatment and care before the dog died. They stated that they had declined the blood transfusion due to Dr B not having provided justification for the procedure.
While treating the dog, Dr B performed many tests including radiography, haematology, agglutination, urinalysis and biochemistry profile and administered antibiotics and Vitamin K. The Panel expressed some concern that a coagulation test had not been performed despite Dr B initially thinking that the dog had been poisoned with a rodenticide. Dr B's answers in response to the Board's questioning included: ‘trying to keep costs down’, ‘didn’t think about it’ and ‘couldn’t remember’ why the test was not performed.
The owners were concerned that Dr B had not informed them that the dog's condition was potentially fatal. Dr B admitted not realising how ill the dog was until the final day it was presented. The dog died that afternoon but Dr B was not present. The panel was concerned that Dr B did not fully appreciate the seriousness of the dog's condition that day and did not adequately convey any concerns to the animal's owners, which meant they were unaware and unprepared for the dog's death.
Dr B expressed "feeling" that the owners did not want a referral to another veterinary practitioner because the owners were reluctant to follow through with some suggestions. The panel considered that Dr B's admissions and assumptions indicated they had not fulfilled the obligations related to the Board’s Guideline 8, clauses 4 and 8. [VPRBV Note: Board Guideline 4 - Communication between veterinary practitioner and animal owner, contains current Board expectations on communication issues.]
Dr B also stated they had not sought the advice or assistance of a colleague. The dog was treated at the clinic for approximately three weeks, during which time the dog’s condition fluctuated. The panel was concerned that even though Dr B performed many tests, they were unable to reach a definitive diagnosis; yet they did not seek the advice of other veterinary practitioners or specialists. Dr B told the panel that they do contact colleagues for advice about difficult cases but offered no explanation for not doing so in this case. The panel noted that, where costs are a concern, obtaining advice on a difficult case from a colleague might provide useful treatment or diagnostic information and may reduce the cost burden. The panel also emphasised the importance of a veterinary practitioner seeking advice and undertaking continuing education, especially when they are a sole practitioner.
Conclusion
While acknowledging that the initial treatment of the dog may have been appropriate in the circumstances, the informal hearing panel noted the unsatisfactory nature of the extended time taken in attempting to establish a diagnosis; the lack of justification for or interpretation of tests performed; the failure to seek assistance from colleagues or to offer referral when there was no satisfactory improvement; and the failure to appreciate and advise the owners of the seriousness of the dog’s condition. The panel determined that, while this case showed an error of judgment and inadequate communication rather than a wilful act of negligence, there was sufficient evidence that Dr B had engaged in unprofessional conduct.
The panel formally advised Dr B that they needed to change their current practice and seek assistance from other veterinary practitioners in difficult cases. The panel also advised Dr B that they must detail their "thought processes" in their clinical records, and it emphasised the importance of consolidating records into a coherent case management plan.
Relevant guidelines