A case of alleged failure to consider patient’s deterioration in condition thereby missing the diagnosis of Peritonitis

The Medical Council of Hong Kong (MCHK) acquitted the defendant doctor (whom we represented), after accepting his evidence, despite the lack of adequate clinical records to support his version of events, which conflicted with that of the patient’s daughter (the Complainant).

Background

On 2 March 2013, the patient (with a history of end-stage renal failure and who had been receiving continuous ambulatory peritoneal dialysis (CAPD)) attended another doctor at the same private clinic complaining of abdominal pain, vomiting, diarrhoea and cough with sputum. She was diagnosed with Gastroenteritis and prescribed medication.

On 3 March 2013, the patient attended the clinic with the Complainant and was seen by the defendant doctor. According to the Complainant, the patient complained of more severe vomiting with cough syrup colour liquid. The Complainant further alleged the patient was dull, non-responsive and moaned persistently throughout the consultation. When the Complainant indicated she would send the patient to hospital if the defendant considered it necessary, the defendant said nothing.

On the other hand, the defendant claimed that the patient’s fever, diarrhoea and abdominal pain had subsided, but she felt generally unwell and suffered from generalised muscle pain. Throughout the consultation, the patient was attentive and alert. She could breathe normally and speak coherently. When asked whether the patient’s CAPD fluid was clear, the Complainant answered in the affirmative and confirmed drainage was smooth. The defendant considered the possibility of peritonitis, but advised it was unlikely. His provisional diagnosis was gastroenteritis with dehydration and electrolytes disturbance.

The defendant advised the patient to attend an Accident & Emergency Department (A&E) for further investigation and offered to write a referral letter. However, the Complainant rejected this advice and offer. The defendant further advised the patient to stop all medications, apart from the medicine prescribed on 2 March 2013, to avoid masking symptoms.

According to the defendant, he also advised the patient to look out for signs of recurrent fever, abdominal pain or if the dialysis turned turbid. If any such symptoms occurred, the defendant advised that the patient should attend A&E.

Later in the evening, the patient was admitted to A&E and her condition was noted to deteriorate after admission to ward. Unfortunately, she passed away on 5 March 2013 and the cause of death was Peritonitis (which was not disputed).

The Charges and Findings of the MCHK

1. The MCHK found the defendant not guilty of the first charge:

“Failure to properly take into consideration the deterioration of symptoms and the general condition of the patient thereby missing the diagnosis of peritonitis”.

• The MCHK did not accept the Complainant’s evidence on the patient’s condition in the consultation with the defendant. This was inconsistent with the defendant’s contemporaneous clinical records and the A&E records. The claim that the symptoms during the consultation suggested peritonitis was rejected.

2. The MCHK also found the defendant not guilty of the second charge:

 “Failure to refer the patient to A&E or a public hospital for further treatment when the circumstances required.” 

• Despite the lack of contemporaneous written record, MCHK accepted the defendant’s evidence that he had explained to the patient that patients with end-stage renal failure with repeated vomiting, were prone to suffer from dehydration and electrolyte disturbances. So the patient was advised that she should better be admitted to hospital for treatment.

• The defendant’s evidence that he had reminded the Complainant to look out for symptoms of recurrent fever, abdominal pain, or deterioration in the patient's condition and to seek hospital treatment immediately if this happened was accepted.

• MCHK also accepted that according to the A&E records, the patient was not suffering from haemodynamic instability when she was seen at the A&E, hence found that her dehydration was not so severe to warrant immediate referral to A&E when she was seen by the defendant some 8 hours earlier.

Comment

While the defendant was acquitted of both charges, it is imperative to note MCHK’s comment that doctors should maintain systematic, true, accurate, clear and contemporaneous medical records.

It is common for Courts and the MCHK to accept only evidence documented in the medical records. However, in this case, despite the lack of detailed contemporaneous clinical records, the MCHK accepted the defendant’s evidence that he had explained and advised the patient to attend the hospital for treatment as well as the A&E records. The decision to dismiss both charges was largely based on objective findings and documentation in the public hospital’s records, as well as the defendant’s evidence at the inquiry.

Had the Complainant’s evidence been more credible or there been an absence of documentary evidence (in the public hospital’s records), the MCHK could have found the particulars of the charges made out and the defendant guilty of professional misconduct.

This decision reiterates that medical records form such an important part of the management of a patient. Apart from assisting in the provision of appropriate clinical care, clear contemporaneous clinical records are crucial evidence in handling complaints and/or claims made against doctors.

Read more items in Hong Kong Medical Law Brief - October 2019