Medical Claims: 2009 year figures released.

 The Australian Institute of Health and Welfare has published another of its annual reports, providing statistics on public and private sector medical indemnity claims in Australia.  These cover the 2009 year.  Interesting reading..

Total 'new' claims in the year totalled 2,600, roughly equally split between public v private medical care.

The more interesting figures came in terms of cases closed/finalised in that year.  The total here was 3,100, which sounds like a lot until it is appreciated that 30% of these were resolved without any payment (so 930).  Then we take out another 36% in which the payment was $10,000 or less (another 1,1116).  This leaves 1,023 claims, of which 124 (4%) recieved payouts of $500,000.00 or more.

Interestingly, there was no suggestion at all in the report (at least that I could see) to suggest any increase in claims costs/incidence.  This in real terms probably indicates a fall, given the increasing costs of remedial medical treatment etc, that would fall within many claims.

Crisis, aint no sign of one... for all the info, see here.

Study: Caesarean v Vaginal Delivery Outcomes

Was interested to read in the West of the James Cook Uni study to follow up outcomes and attitudes (after the event) of women choosing vaginal -v- elective caesarean section.

While I defer to the experts, the more information and hard evidence, rather than 'old wives tales' and medical-politics, assisting women to make health decision relating to childbirth the better..

For one thing, some accurate and verified information about incidence/severity of pelvic floor injury/dysfunction following vaginal delivery, I would have thought useful in assisting women with their choice.

I was once told that a study of UK female obstetricians overwhelmingly supported elective c-section, because of the avoidance of potential urinary incontinence/bowel dysfunction/sexual dysfunction perceived to arise with a vaginal delivery. How many obstetricians warn patients of this risk, when discussing birth options, particularly with an anticipated large baby?

I appreciate that this is a complex decision for the mother, involving evaluating the risks and benefits for both mother and baby. Nonetheless it is their decision + our Law recognises an obligation on those advising, to ensure they are aware of all the information likely to be significant to them in making their choice.

I was surprised to read the RANZCOG President's comments that "One of the issues facing obstetricians is the lack of information about the underlying reason a woman may want to choose a caesarean section where there is no medical reason."

Isn't there an obvious solution to this... in a non-confrontational, non-judgemental context, ask her........ 

Cosmetic Surgery Tourism: My Proposal!

As a post-script to the recent resolution of my client's claim against a travel agency, promoting Thai cosmetic surgery, I now have to drive each day past a massive billboard on Railway Rd, Subiaco, promoting the services of another such agency. Clearly its a thriving business sector...

To protect those uninformed enough to think that breast augmentation surgery or laser eye surgery, in conjunction with 5 Star Accomodation in SE Asia, is a good idea + the 2011 equivalent of a beach massage in Bali or a pedicure at the local shopping centre, my modest proposal is to introduce legislation:

1) requiring such agencies to have comprehensive insurance against claims by those travellers suffering serious complications/adverse outcomes from their cosmetic procedure.

2) requiring such agencies to recommend and have prospective clients/patients sign an acknowledgement that they have been advised to seek indepedent local medical advice as to the sense (or otherwise) of the proposed treatment.

3) holding such agencies liable in the event of an avoidable adverse outcome from the foreign treatment.

Can't see it happening, but .... 

Medical Inspiration = Barry Marshall + a neurosurgeon who cannot be named...

Following on a recent post, in recent days I have again been reminded of how jaundiced my perspective on medical care is and how the great majority of careful, skilled medical practitioners "fly under the radar," in my world of medical litigation.

My wife required a micro-discectomy last week, due to a disc protrusion, no doubt attributable to 20+ years of nursing..  

The neurosurgeon brave enough to operate on my wife (I suspect he does not know + my wife certainly would have been slow to volunteer her relationship to me), provided a shining example of cautious, well explained and reasoned advice, followed by technically proficient surgery.  The 'icing' on the cake was his call to me (as next of kin), at about 9:30 pm last Friday to confirm all had gone well + he was optimistic of a good outcome.  In no way part of his contractual obligations, but very much appreciated

The second example was the press club interview with Barry Marshall I happened to catch today on daytime telly...  How inspiring!  Although not quite ready to hand over the $2,000 per head for genome testing + registration, he certainly painted a clear picture of the enormous benefits genetic testing can offer to medicine in the surprisingly near future.

On that note, back to work + preparing claim against a lesser surgeon, who's muddy thought, awful communication skills and oaf-like technical acumen is more what keeps me busy day to day.

 

Medical Negligence + Morality...

Odd and uncomfortable territory for a lawyer to touch upon...

As is now a matter of public record, I act for Saba Button and her parents in relation to her claim arising because of her terrible complications from the flu-vax in 2010.

There has been recent media interest in the fact an approach has been made to the WA State Government, seeking an ex gratia payment, given the circumstances surrounding Saba's flu-vax.

I have stated publically that in Mick and Kirsten Button and my view, the Government has a moral obligation to Saba, quite discrete from any legal liability for compensation.

More than 1 colleague and friend (legal and otherwise) have 'tongue in cheek' passed comment on the heresy of a lawyer speaking about 'moral,' as distinct from legal obligations. I concede it is not an area in which I have any more knowledge or skill to comment than any other member of our community.

Thinking about this has however highlighted in my mind the fact that the Law 'only' serves to set the minimum standards of behaviour set for society; the limits of what is and is not acceptable. It says absolutely nothing and has no meaningful role in seeking to encourage our best. To define what we should hope of each other, or aspire to, as a community and individuals, rather than what is the point beyond which we will not tolerate...

Little wonder then that Law can be a depressing field to work in, from time to time. In medical negligence law, I spend my entire time focussing on whether care was below the minimum that ought be expected of our health professionals. I see nothing and have no contact with the inspirational, standard-setters in medical and other practice, defining best practice.

In any case, whether expert or not, I am convinced the Government should (though it can't be forced to) do the right thing by Saba.... 

Lap Band Surgery + Alternatives: The Risks + Benefits

Working yesterday and today on a very tragic case for the family of a young women who died after weight-loss surgery, in 2007.

The women underwent a sleeve gastrectomy, one of the 2 most common forms of weight-loss (or bariatric) surgery, performed in Australia today.

While working on the case, I thought it worth sharing the advice we have recieved in recent cases, as to both the success + the risks associated with these 2 most common forms of surgery. Don't hesitate to contact me if you disagree with these figures, which are taken from expert advice from a very experienced bariatric surgeon we have asked to consider such cases:

LAP BAND SURGERY
This is the most common procedure. Completed over 11,000 times in Australia per annum.

average effectiveness: 50% of the excess weight carried by the patient (on average patients lose 1/2 the weight they wish to). Effectiveness does vary significantly.

risks: 0.1 - 0.5% of major complication risk. So 1 in every 200 patients to 1 in every 1,000 patients will experience this. From simple maths, each year, 11 - 55 patients will suffer such major complications in Australia from this procedure. 1 in 2,000 risk of death: so 5 - 6 patients per year will die from lap band surgery.

SLEEVE GASTRECTOMY
average effectiveness
: 70% of the excess weight carried by the patient (on average, patients lose 70% of the weight they wish to: this is obviously an advantage of such surgery over lap banding).

risks: 2 - 5% major complication risk. Risk of major complication therefore up to 50 times higher than with lap band. Most common major complication, as in our case, is anastomotic leak (leak from the staple line where the 'new' stomach edge is sewn up). Mortality rate is 1 in 500-600. So about 4 times higher chance of death.

Comment

Interesting features of this are, in my view:

  • the fact such surgery, if successful, should be accepted as only assisting with weight loss. It will not on its own be a 'quick fix' to obesity issues. With lap bands, the morbidly obese will remain obese even if such surgery is effective.
  • the lap band is safer but less effective than a sleeve gastrectomy.
  • patients undergoing such surgery need to appreciate and be comfortable with taking the risks, including a clear risk of death associated with such surgery. This should be particularly borne in mind, when such bariatric surgery is for cosmetic reasons, rather than genuinely medically driven. For someone to undergo such surgery, with the aim of becoming 'thinner,' and then lose their life through such process is tragic, and yet from the above such risk is clear + should be recognised and considered by the patient, before they agree to proceed.

 

Peer Defence: Bolam + the Civil Liability Act - Experiences in Practice

 I read with interest an article in the MJA earlier this month, which comments on the status of the 'peer defence,' introduced, in WA, via the Civil Liability Act section 5PB(1).  This section, provides that:

An act or omission of a health professional is not a negligent act or omission if it is in accordance with a practice that, at the time of the act or omission, is widely accepted by the health professional’s peers as competent professional practice.

This provision and similar ones in other States was introduced based on a concern (misplaced I have always thought) that Courts were setting standards for doctors which were too high and failing to appreciate real world considerations.

Despite concerns at the time this section was introduced, that it would significantly 'water down' legal expectations of health professionals, years on, I cannot think of a case I have handled since, in which this test, compared with the previous 'reasonable care' as determined by the Courts, would (or has) changed the outcome.  

In my experience, if a claim would succeed under the pre-section 5PB Law, it would succeed now.  If it would fail under the section 5PB Law, it would probably have failed before.  This includes the facts in the Melchior case, referred to in the MJA article.

It is theoretically possible that a Judge may consider care or advice provided by a health professional was not reasonable, despite it being in accordance with accepted practice followed by a significant number of the health professional's colleagues.  Obviously this would be very exceptional.  We all hope (and believe) it is not going to be common for a significant number of doctors, for instance, to be all acting unreasonably in their care or advice they provide to their patients.

Even in such an unlikely scenario, it is unclear whether section 5PB would give a defence.  This is because of sub-section (4), which via a convoluted path, probably says that such defence does not apply if the practice by this group of peers is not reasonable...

Overall, as I have thought for some time, my present view is that section 5PB is/was primarily a reassurance to the medical profession that it will only be in an exceptional case that Judges will find a doctor negligent, when he has followed well-recognised and broadly followed and justified practice in their care.  In my view this was the case before the section was introduced and remains the same.  The section changes perception of the legal position, more than it changes its application in the 'real world.'

fn: it needs to be remembered that such section has no application in relation to the required warnings as to risks associated with treatment.  Peer consistent practice (ie 'none of us tell patients about this risk') is no defence in such context (see s5PB(2)).

The Radiologist + GP: Communication with the Patient

I recently came across an interesting article in a medical insurance journal, discussing the responsibilities of a radiologist to ensure communication of important x-ray or other radiology test results.  The conclusion of the article was that the radiologist has responsibility for prompt first-hand communication with the referring GP, but the article stopped short of suggesting a need for the radiologist to inform the actual patient of their test result.  

The patient is obviously the radiologist's patient, as well as the GP's.  The patient (or his insurer) pays for the radiologist's services and a duty to take care is owed by the specialist to the patient.  Why then no obligation to tell the patient of the result of their investigation?

This is an issue I have had cause to consider recently, in the context of a delay in diagnosis of breast cancer case.  In that case a radiologist's report indicating likely breast cancer was not acted upon by the GP practice (it appears the report went astray + was not followed up), leading to a delay of several months before the patient, re-attending the GP practice, raised the issue of the earlier test, resulting in (a very unhappy) realisation of the oversight.  

Claim was brought against the GP practice + was indefensible.  It did however occur to me that quite apart from liability in a medical negligence claim context, the whole problem could have been avoided, had the radiologist conveyed the findings of the scan to the patient.  

I have seen several cases in the past in which recommendations for further investigation were made by radiologists in their reports, yet not passed on by the patient's GP to the GP.  

Quite apart from having an obvious opportunity to advise and explain concerning test results, it occurs to me that often such specialist radiologists may be in a better position to put the test results in context and recommend further forms of investigation if warranted (FNA, core biopsy etc), than the GP referrer.

It is accepted that in cases like this, it is important that 'bad news' is conveyed in an appropriate setting + with appropriate supports.  Nonetheless, it is not easy to see why no responsibility for communication to the patient seems to be accepted as arising on the part of this form of specialist (or other similar areas, pathology etc).

Study Results: Medical Claims Improve Quality of Medicine

I read with interest a recent article, referring to research being published in the well respected, Medical Journal of Australia.

The research related to a survey of 3,000 doctors, concerning their attitudes towards medico-legal issues.

The thrust of the article is along the lines of "isn't it terrible such doctors practice in fear of a medico-legal claim.'

More interesting + significant in my view was a peripheral comment which confirmed that 66%+ of the surveyed doctors said fear of litigation improved their communication of risk to patients. They also said it led to better systems for tracking results and auditing clinical practice.

This is a clear endorsement of the role of tort law (the law of negligence as applied to health professionals) in improving standards of medical practice. As our 'new' website homepage (to be published in the next week or 2) says, clients we see are often concerned at the effect their bringing a claim will have on the practices of the doctor, hospital or other health professional concerned. This is a primary motive for many clients wishing to pursue claim. To make sure lessons are learnt and the same mistakes not repeated the next time. This study validates our view that claims do indeed lead to alter (improve) health practices.

I agree that ideally a threat of litigation should not be a first line mode of seeking to improve doctors' communication skills or other practices. In my view a 'carrot' is always better than a 'stick.'

Further, there is clearly a distorted sense of the significance of a claim being made against a doctor, which has lead to a disproportionate fear of such claims and resulting phobia, which is not desirable. With respect, the answer to this is counselling/education of doctors concerning medico-legal processes (to the extent their fear is unfounded and over emphasised by them as indicative of an attack on 'their life's work').

National Health Professionals Regulation

A couple of weeks ago I attended a CPD presentation dealing with the new scheme for National Registration + Regulation of the majority of the health professions. It is beyond doubt that this is a good idea, in terms of consistency of practice registration. One interesting aspect of the reforms that I was not previously aware of, and which I see as having potentially interesting longer term consequences, is the 'new' National body's capacity to set standards for medical and other practice. It occurs to me that this could develop into a challenge/supplement to the College's self-regulation of the specialties. It could for example, allow regulation as to those surgeon's permitted to perform cosmetic breast surgery, bariatric surgery etc + set minimum standards of experience and training for such areas of work. Another alternative may be to set standards in terms of disclosure of surgical results/complication/infection rates etc. Given the College's understandable competing interests (and those of their members), this may present a valuable opportunity for consumer interests to be given voice.

Delay in diagnosis of Cancer: Compensation post Gett

One of the most emotionally demanding, complex and ultimately, often rewarding categories of case handled by medical negligence lawyers, are those cases arising from a negligent delay in diagnosis of cancer. At any one time, I am generally acting in 4 or 5 such cases.

Following the High Court's decision earlier this year, in Tabet v Gett [2010] HCA 12, uncertainty has been expressed, particularly by those representing medical defence organisations, as to the recovery of compensation in such cases.

I thought it interesting to conduct a 'straw poll' of lawyers (and others) reading my blog, as to whether they think recovery will be possible, in the following categories of case, following Tabet.

As can be seen, the categories depend on the assumed expert opinions as to the likely effect of the relevant delay in relation to the client/patient's outlook. I think these categories cover the ambit of such claims commonly seen. In each category it is assumed that there has been negligent care and this has caused the delay in diagnosis and treatment of the cancer - for argument's sake, lets assume a 12 month delay. As can be seen, I have sub-divided the categories into 2 categories, being those in which recurrence/spread of cancer has occurred v those in which it has not (but potentially may do).

The categories are:

Where Recurrence of Cancer Has Occurred and it is likely the Client will not survive

In the first 3 scenarios, recurrence has occurred and the client/patient is likely to die from their cancer. In this group, the 3 scenarios are:

  1. where it is likely (more than 50% probability) that if diagnosis had occurred at the time it should, the cancer would have been successfully treated and the recurrence/spread would have been avoided.
  2. Where it is less than a 50% chance that earlier diagnosis, when it should have occurred, would have led to successful treatment and avoidance of the recurrence/spread. In such category there is nonetheless an appreciable chance (though less than 50%) that appropriately timed diagnosis and care would have altered the tragic outlook.
  3. the same scenario as (2), but were the chance of successful treatment and a different outcome, had appropriately timed diagnosis and care occurred, is only very small (<5%).

Where No Recurrence of Cancer has Occurred

In these 3 categories, no recurrence has occurred yet. In this group, the 3 scenarios are:

  1. where it is a better than 50% chance that recurrence will occur in the future (say within 5 years). It is also likely that if diagnosis had occurred at the time it should, the cancer would have been successfully treated and the risk of recurrence/spread would have been very much less (and < 50%).
  2. Where it is less than a 50% chance that recurrence will occur in the future, but this chance is greater than it would have been, if diagnosis had occurred at the time it should, and such difference in likelihood is significant (say 25%).
  3. the same as scenario (2), but the difference in likelihood of recurrence is small (say < 5%), in other words, the effect of the delay in diagnosis and treatment has been a slightly increased chance that cancer will recur in the future (though the overall chance remains < 50%).

It will come as no surprise that I think recovery should occur in all such categories, though obviously its quantification will vary greatly depending on the category:

Let me know your views on whether damages can be recovered in each of these 6 scenarios, anonymously if you like. I will (assuming I get a reasonable number of replies!), post a blog entry summarising the consensus of views expressed.


Northam Tragedy: An Addendum

As the media coverage continues, another thought that occurred to me today, is why is it not possible for there to be a well-recognised easy to follow chart for Accident and Emergency staff at remote hospitals (accepting for present purposes Northam would be accepted as such), as to observation or triage findings which should mandate a medical consultation?

For example, why should a temperature greater than a set limit in a teenager not be something that mandates such a review? As I understand the media reports, Andrew had a temperature of 40 degrees at attendance.

Why is it too hard to have simple guiding 'sign post' protocols to assist staff across the State?

I do not suggest that medicine can be run by computer software. There is obviously no substitute for an experienced, skilled clinician's evaluation of a patient. When this is not available however, why not assist the staff to avoid tragic mistaken calls...?


Andrew Allan: Northam Tragedy Accident Emergency - Questions to be Asked

I, along with probably a large portion of the West Australian adult population read with horror the story in this weekend's papers, concerning the tragedy relating to Andrew Allan who died within hours of being seen and sent home at Northam Hospital's accident and emergency on Thursday evening. The cause of death for young Andrew seems likely to be determined only after autopsy etc. It would seem likely that a Coroner's Inquest may follow.

While it is to be applauded that acting CEO Wayne Savage from the WA Country Health Service has indicated a 'full and thorough' investigation will follow, what is not reported as having been said is whether the full findings and report of such investigation will be:

1) made public;
2) made known to the family.

Far too often in my experience, in cases like this, investigations and their conclusions are withheld, with claims of legal privilege (sometimes I suspect 'retrospectively') asserted.

It is to be hoped that in this instance, appreciating that this is a matter primarily requiring investigation because of the need to ensure it does not occur again, no such grounds for secrecy will be asserted.

It is certainly true that the relevant hospital's insurer may well wish to conduct an investigation in terms of its potential legal liability. This should however in my view (predictably) be an entirely separate investigation from that undertaken in accordance with Mr Savage's undertaking to the family

Legal compensation or liability is not the primary issue at this point. What I am sure is the primary issue for the Allans is an explanation how this could happen to their son. Perhaps equally important to them and for the rest us, an assurance and explanation why we can be sure that this will not happen next time...


Responsibility: The flip-side of Autonomy following Rogers

As those who know me will attest, I have always been an advocate for patient autonomy, and informed and involved decision-making by patients, aided (but not dictated) by their clinician. In other words, a fan of the Rogers v Whittaker sanctioned 'approach' to medicine following the High Court's decision.

Recently, with the growth of claims arising in the expanding elective/cosmetic medicine arena, the flip side of autonomy has been highlighted.

It is clear that with autonomy, there comes responsibility....

I have seen several cases of late that we have investigated, where on reflection it is clear that our clients were well informed as to their choices, but simply made 'foolish' decisions concerning their care and are now left with very poor outcomes/disfigurement.

Most obviously, breast augmentation surgery gone wrong, when no such surgery was sensibly justified, or lap band surgery for weight loss that could have been achievable by far less radical means.

In a former era of 'doctor knows best,' and medical paternalism, such patients would not have proceeded. The doctor would simply have said 'no.'

Whilst I do not advocate in any form a return to such era, this result is interesting. The High Court's recognition that the patient should be informed and make choices concerning their health care etc, also results in their having to accept responsibility for such choice (and consequences), if poorly made.... A result I had not foreseen... But.. you can't have it both ways. Either this is right and the patient must 'wear' the consequences of their poor choice, or we return to a process where their decision-making is in form only....


Medicine (and diagnosis) still 'first and foremost' for doctors + not the internet!!

Thanks to the Australian Lawyers Alliance's weekly newsletter to members, for bring this recent case to my attention:

Australian Associated Motor Insurers Ltd v Motor Accidents Authority of NSW [2010] NSWSC 833 (30 July 2010), is a recent case in which the NSW Court of Appeal per Barr AJ overturned aĀ damages claimĀ of more than $335,000 awarded to a woman injured in a traffic accident because he found that a claims assessor had used Wikipedia to determine that she had developed Complex Regional Pain Syndrome. Ā He also found that such diagnosis was not supported by medical opinion.

Although obviously a motor vehicle accident claim, this seemed to me worth mentioning in the med neg context, given the ever growing resources online for consumers/patients (+ it seems even judicial officers!) to learn more about health concerns.

While I for one use this phenomenal resource ever single day in the course of my work (and recently, in particular, the absolutely amazing array of youtube videos available of various medical procedures and conditions), it is always worth bearing in mind that it is a supplement for first hand expert medical advice + not its replacement.

I am reasonably frequently reminded of this when reviewing expert reports from medical specialists concerning claims we are investigating, who reasonably commonly conclude:

  • the issue as to the medical care my client and I were concerned about is a red herring or readily explainable, and not the result of any lack of care...
  • another issue we had not identified is present, the result of sub-standard care + the crux of why the poor outcome eventuated.

Supervision of junior medical staff - medical malpractice, medical negligence consequences

Trawling the net I came across a US study 2 months ago, led by University of California-San Diego researchers which reported a 10 percent increase nationally in medication errors that killed (!) patients during the month of July, the traditional start date for new residents.

One of my recurrent soap box topics is the lack of adequate systems to protect and avoid medical practitioners from making mistakes due to inexperience, inadvertence or otherwise. Obviously this is most important of all in relation to junior doctors.

If (as I suspect) Australia mirrors the US, even if at 1/10th the rate, this is a staggering statistic....

Ā 

Vioxx Litigation - Mind Boggling Costs of Unsafe Drug (in money + lives) Mounts Up

Just saw some figures in relation to the Vioxx litigation in the US. Ā According to Bloomberg News, Merck + Co, the US manufacturer has now paid claims to the families of 3,468 users of Vioxx, who died of heart attacks or strokes, accepted as a result of the Vioxx medication.

Apparently a fund of $4.85 billion (US) has been established and made these payments.

It will be interesting to see the total costs of these claims in Australia, following our Federal Court's decision some months ago, finding the drug's importer to Australia was liable for breaches of the Trade Practices Act relating to the drug's fitness for purpose etc.... Ā Strongly suspect these sorts of figures will never see the light of day...

Dingle + Disaster

 I like many have watched with horror and fascination the waste that was the end of Penelope Dingle's life.  Amongst it all, Cameron Platell, by reputation a quiet and careful surgeon, stood out for me, when explaining on 720, his frustration that his advice was being ignored, as he assured Ms Dingle of the favourable outcome expected with surgery he recommended but she would not have.

The case raises important and difficult questions about the role of our society in protecting its members from their own abject foolishness and influence.  Self-determination is great, as long as informed and based on sense...  

Importantly this is not an isolated example.  Only weeks ago we all heard of the ill-informed and sinister exploitation of the vulnerable by a West Australian psychotherapist on Sarah Ferguson's excellent 4 Corners expose.

In these days, with every more stringent (or so it feels) regulation of our traditional professions, how can these 'fringe' health disciplines continue unregulated?  I suspect Coroner Hope will have something to say on the topic.

On a lighter note, if there can be one, see below - as my UK relatives would say 'nuf said'

 

Vioxx class action litigation, a bitter pill!

In a case which in some respects seemed more like a John Grisham novel than a serious piece of Australian litigation, as well publicised, on 5 March 2010 Justice Jessup of the Federal Court found in favour of Graham Peterson (and in relevant respects, in favour of the other members of his representative class) in his case against Merck Sharpe and Dohme, the Australian manufacturer of the anti-inflammatory drug Vioxx.

Mr Peterson had suffered from back pain for many years prior to being prescribed Vioxx by his GP, Dr Dickman in May 2001.  He found, as did many other patients, that Vioxx provided relief from his pain without the adverse gastro-intestinal side effects which were encountered with other drugs providing similar pain relief.  

In December 2003 whilst still continuing to regularly take Vioxx, Mr Peterson suffered a serious heart attack for which he received prompt and effective medical treatment leading to his making an uncomplicated medical recovery.  At the time this heart attack occurred neither he nor his GP or the cardiac team considered that his heart attack was related to his consumption of Vioxx.  This all changed following the withdrawal of Vioxx from the market in September 2004 and subsequent revelations as to its potential side-effect.

Interestingly, the basis upon which Justice Jessup found in favour of Mr Peterson was in many ways the least contentious.

Continue Reading...

Lets Start on a Positive Note...

Happy NY to those reading!  Feel free to let me know if you have any thoughts on content since I started the blog, suggestions how to improve the blog or requests for topics or comment.

As the title says, thought it apt to start the new year on a positive note...

My wife has for sometime suffered from a sore shoulder (no doubt in part from carrying the heavy load of being married to me...!)  Anyway, she finally got around to having it investigated following which it was identified she had rotator cuff tear and bursitis, requiring repair and acromioplasty.  Off she then went to see the best shoulder orthopod we could find.

Anyway, pleased to report that said orthopod, in addition to technical proficiency in the way the repair is to be performed, also demonstrated exemplary communication skills in his contact with my wife.  My wife returned from her pre-operative appointment with a formidable looking folder which contained a wonderful, easy to read explanation of the surgery, the risks associated with it and a very easy to follow guide to post-operative rehab.  

I couldn't fault it and am starting the new year with the attitude that the medicine I generally encounter in practice represents the exception rather than the rule and despite the odd dark moment, my almost continuous belief that the overwhelming majority of Drs are fabulously skilled, hard-working professionals, is the right one.  Lets see if and how 2010 shakes this!

West Australian Public Hospital Performance 2009 year

 While trawling around looking for some information on trauma surgery, came accross this neat and convenient summary of our public hospital system's performance against several key performance indicators for the 1st 6 months of 2009. 

Makes interesting reading, particularly the ongoing 'battle' with accident and emergency services.  

I particularly noted the pretty awful results concerning times to see accident and emergency patients assessed with triage ratings 2 onwards (72%, 62%, 72% of patients in such categories being seen within the recommended timeframe).  

The report doesn't say what the average time for seeing such patients was, but presumably there are some such patients not seen for well and truly more than the recommended review timeframes.

No doubt some of such patients suffered prejudice to their positions due to such delay in being seen, investigated and treated.  Given the scale of demand for accident and emergency services it seems likely to remain a fertile ground for medical negligence claims, while this performance remains well behind the Australian College's recommendations.

A continuing battle for our public health system.

Personal Responsibility + Society's "Parenting" Role

Again, slightly off topic, though the broader consequences apply in a healthcare context.

Read with interest the Editorial in the Weekend Australian yesterday about the High Court's recent decision, with the less than informative name, C.A.L. No 14 Pty Ltd v Motor Accidents Insurance Board [2009] HCA 47.

The facts in the case were simple:

  1. the case concerned a claim of negligence against a Tasmanian hotel owner who handed back motorcycle keys lodged for safe-keeping to an insistent, belligerent patron who on leaving the pub was killed in a crash while showing a blood alcohol level of 0.253.
  2. A reading of 0.05 doubles the risk of a crash. At 0.08, the risk increases seven times. At 0.15, it is 25 times higher. Data was too scant to reliably calculate the risk at the level taken by the dead man.
  3. The man had drunk seven or eight cans of bourbon and cola between 5.15pm and 8.30pm. According to the judgment, the licensee told him he had had enough, that it was time to go home, and asked for his wife's phone number so that she could fetch him. The patron became agitated and said "If I want you to ring my f'ing' wife, I'd f'ing ask ya." The Licensee responded: "Whoo hang on, whoo, whoo, whoo, this is not, you know, don't go crook at me, this is not the arrangement that was made." Not having the wife's phone number, and not wanting to push the issue into further confrontation the licensee then gave the keys to the patron, after asking him three times if he was OK to drive

As has been widely reported (to the joy of many in the hotels industry), the High Court dismissed the claim against the publican, finding that no duty was owed to the driver that had been breached.

I accept the points made in the Australian, concerning the need for our society to accept individual choices and responsibilities.

On the other hand, when regard is had to the carnage each year on the roads due to alcohol, such 'individual responsibility" is hardly a promising or pro-active step to saving our bright young things from self-destruction on the road.  

Quite apart from the case of habitual heavy drinkers, who has not had opportunity to intervene when friends and loved ones might out of character have had a bit much to drink and required a tap on the shoulder and gentle insistence on a lift home?  It is a consequence of intoxication that it impairs judgement, not just behind the wheel but in getting behind the wheel in the first place.

The Court's decision seems to ignore the more complex issues behind public safety and the 'cost' of irresponsible alcohol sale, instead championing a self-determinant right to self-destruction (and potentially harm to innocent third parties on the road).

With respect there is much to be said of the comments in the Age, concerning this decision, which reach a very different conclusion to the Editorial in the Weekend Australian.

 

 

 

credit where credit is due - the value of an apology

 All due credit to our West Australian Minister for Health, Kim Hames, for his apology today to the family of the 17 year old who tragically died at Albany Hospital, and who's death was recently the subject of a scathing report/finding by our coroner.

Always hard to know, but the sound bite I heard sounded entirely genuine and his response is to be applauded 'in spades.'

Anyone who has worked in medical litigation for persons pursuing claim, can tell how on almost every instance, clients are motivated by more than monetary compensation and almost invariably speak of the need for someone to take responsibility, to be accountable and as importantly, to ensure that steps will be taken to ensure it does not occur to the next unfortunate patient.

As I say, all credit to Minister Hames.  I am sure his gesture will aid the family's path, following this tragedy.

No Use for Old Doctors!

Long awaited reform finally arrived this year with introduction of the Medical Practitioners Act 2008 (WA).  This was much needed and welcomed, replacing the antiquated and outdated previous legislation, the Medical Act 1894.

The system for registration of practitioners and importantly, in the context in which I practice, the handling of complaints and disciplinary issues for the medical profession in Western Australia has been overhauled and significantly improved.

As with many legislative reforms, the new scheme appears however to have a perhaps unexpected, unfortunate adverse consequence in terms of the continuation of practice/provision of service by older retired or semi-retired doctors.

This week I was informed that a retired anaesthetist living in Kalbarri (for those of you who don't know, a beautiful seaside holiday town north of Perth) will because of the new legislation be unable to provide relief/locum services when the town's GP is unavailable, for example on no doubt much needed annual holidays.  Such relief has been provided for the last few years, ensuring continuity of service to the community.   The position now seems that when the town's GP is away, the town will have no doctor and presumably residents will need to travel to the nearest town for medical care etc (and some significant distance in this respect).

More seriously perhaps, such retired anaesthetist is the only medical practitioner in Kalbarri able to perform an intubation in the event this is required (as in the event of a major traffic accident or boating collision etc).  The GP apparently does not have this skill.  Because of the stricter registration requirements under the new legislation, such anaesthetist is probably no longer able to lawfully perform this service, even in an emergency situation.

This situation seems absurd, particularly as we approach school holidays in the West, when it is likely the local population will swell considerably.  

Whilst it is understandable that those persons able to perform medical services needs to be closely regulated, the "cost" of losing the remaining skills of experienced retired or semi-retired practitioners seems unnecessary and potentially harmful, particularly in areas outside the metropolitan area where attracted and providing such services is already very difficult indeed.

Something for further thought and refinement I suspect.

 

 

 

 

 

 

The Power of Open Disclosure

 I have often been asked at presentations I have given for health professionals, what is the single step they can take which will reduce their chances of facing a claim of medical negligence.  

My answer has been the same for 10 + years.  

It is surprising how many clients I see, who apart from concern at financial consequences of the poor outcome they have experienced from medical care, are driven by a sense that there has been a refusal to accept responsibility.  This is often why client's say their claims are a matter of principle.    Further it is remarkable how many clients appear motivated by a desire that the same outcome not be experienced by 'the next patient.'

Given this, in my view, apart from taking reasonable care in the medical advice and care provided, the best thing a health care professional or hospital can do, is ensure there is a clear, frank and honest dialogue when the adverse event occurs.  It would I am sure surprise some health professionals, how much a patient will 'shrug off' if they believe an honest mistake has occurred, that the person involves accepts responsibility and that there will be concerted efforts to ensure it does not recur.  This is even more so, in circumstances where the adverse outcome has not been a result of any lack of care.

With this in mind, I was very interested indeed to read this in a recent Wall St Journal article.  This is the 1st statistical measure I have seen of the effect of adoption of an 'open disclosure' policy and is entirely consistent with my anecdotal experience.  Given the results, I would have thought health care bodies and their insurers would be very interested indeed in further investigation of 'claims management' on the ground.  Given our Civil Liability Act's protection for apologies, this is even more so the case in West Australia.

 

Sarah Palin and Tort Reform

 The power of the blog!  I get to write about the remarkable Ms Palin, who I suspect would get on like a house on fire with our own Pauline H.

Anyway, came across this amusing response post concerning Ms Palin's recent ruminations on tort reform in the US, published (well self-published) via the ubiquitous facebook, which I though worth sharing.

Death and Medical Negligence Claims

Reasonably often, clients consult us following the death of a loved one, resulting from apparent negligent medical care.

I have spoken to a potential new client this week, traumatised by the tragic death of their child as a consequence of what seems from the client's account to be clearly negligent care on the part of a GP (who failed to take any action despite complaints that the child had vision disturbance and excruciating headaches for weeks prior to their death).

In Australia, in such circumstances, claim can be brought by the surviving parent/child/relative, but 'only' for the psychological injury suffered by them.  No claim can be brought for the suffering and death per se of the victim of the negligent care.  This is different from the US, though some strange rules appear to apply there (for example see here).

Sadly, the most common situation in which I have seen such claims, concerns negligent obstetric care, leading to the death during childbirth (or in utero) of the baby.  In such claims, the parents' entitlement to compensation for the loss of their child, if it can be shown that the obstetric care was negligent, is limited to compensation for their psychological or psychiatric suffering.  No claim exists for the loss of the child in itself.  No claim can be made for the loss of an opportunity for life by such child.

Further, no claim can be brought at all if all the parents suffer is "normal grief" (whatever this may mean!) falling short of amounting to a psychologically or psychiatrically diagnosable condition.  This is an entirely illogical (and utterly absurd in practice) restriction upon those who can claim.  It is justified on (dodgy) policy grounds of limiting the scope of people able to bring claim.

Clients are often dismayed to hear of these restrictions (as was my client this week), which mean that where death of a child results from negligent care, in most cases, entitlements to compensation will be modest.  For now (and there is no sign of any inclination for the courts to expand the scope or extent of liability at present), unfortunately these limits will however continue to apply, whether fair, just or not.

Tort Reform in the US - another reason I'd be a Democrat!

 Have been following (loosely) recent discussion in the US concerning health care reform.  

As usual, a self-interested group, have sought to tag 'tort reform' (I've always thought a neat term for the removal of rights from the negligently injured, not sure it is 'reform' rather than 'remove') on the agenda.  

Twitter (yes, I know...) is alive with endless calls for reform to stop the 'lottery malpractice' verdicts and greedy lawyers.

Came across this very interesting article, summarising the real evidence as to costs of medical malpractice in the US (often characterised as the most litigious country for such claims).  

All of the comparable evidence in Australia that I am aware of, points in the same direction.  The 'crisis' is with the quality of health care provided, rather than the very small minority of those who could pursue compensation claims, that actually do so.

Have to say I'm with Bill, Hillary and Barrack on this one.

Accreditation - Promises about Quality of Care?

I read with some interest a recent decision by Judge Sleight in Pollard v Endale Pty Ltd [2009] WADC 97. The decision concerned an application by an injured patient seeking that Mount Lawley Private Hospital, the hospital at which their care was provided, should be obliged to disclose documentation relating to its accreditation with the Australian Council of Health Care Standards ("ACHCS").

Such accreditation is a voluntary process.  To be accredited a hospital must agree to maintain various standards, in terms of adverse event monitoring and avoidance.

Intriguingly in such claim, criticisms were made of the private hospital for failing to adequately show care and skill in its assessment of medical practitioners, before giving them rights to admit and treat patients at the Hospital, to monitor their performance thereafter and to ensure the Hospital's facilities were utilised competently.

Judge Sleight ordered that the Hospital produce documentation passing between the private Hospital and ACHCS in relation to its accreditation application.

The case is intriguing because it has long been known that particularly the better run private hospitals compile and have access to enormous volumes of data concerning the performance of surgeons and other clinicians practicing at their hospital. Notoriously such things as complications rates and their type and cause are captured and readily available, though never released to potential claimants (or prospective patients).

Pursuing allegations of the unusual type apparent in this case may be a useful way of obtaining access to this information, otherwise jealously protected by the hospital's operators. Quite apart from having an additional ground for criticisms of Hospitals, no doubt very useful information may be obtained to support claim against the primary surgeon/ clinician responsible for the treatment which led to the poor outcome    

Suppression Order about Awful Doctor's ID

It was interesting to read the Sunday Times newspaper's, front page article a week ago in relation to the unnamed obstetrician/ gynaecologist recently struck off from practise in Western Australia. 

I was particularly interested to read the newspapers' editorial column concerning their strong view that the ongoing suppression order, prohibiting publication of the particular Doctors details, was inappropriate. 

There is a clear public interest in the broader community being made aware of the identity of the relevant practitioner (or other doctors in such cases).  This has 2 primary aspects:

  • an entitlement on the part of former and prospective patients to be aware of the conduct of this practitioner.
  • as a strong deterrent against similar conduct by other health professionals (the “shame” factor) 

Clearly from the report there were 2 factors tempering this, in this particular case.  These no doubt lead to the relevant suppression order being made by Judge Chaney:

1. Firstly, it is clear that though doubts may exist concerning such opinions, there was evidence before the Tribunal that the relevant Doctor was psychiatric fragile and at some risk of suicide or self harm in the event that his name was published. 

As no doubt emphasised by his representative before the Tribunal, the potential for such harm if the suppression order was lifted would seem a very powerful consideration indeed.

2. Secondly, it is clearly the fact that the relevant Doctor is no longer practising in Western Australia or elsewhere in Australia. As such, there is no necessary concern for the Tribunal as to potential harm to future patients coming under his care. 

There is also some suggestion that former patients of the practitioner had been informed of the allegations brought which further ameliorates this consideration.  

In these circumstances, I can well understand Judge Chaney’s conclusions, unpopular though they may be. Certainly though, it would be hoped that once "risk" to the Doctor’s health has reduced, his details will be released.  

Surgery-Tourism - the Pitfalls?

We are presently acting for a young women who paid $1,000s for cosmetic breast surgery in a well known Asian holiday destination, only for a terrible outcome.

This idea of "cosmetic surgery-tourism" seems on the increase, which I think is worrying.  My concerns are reinforced given the independent plastic surgeon's advice we have now received concerning the standard of advice and surgery our client received in this case.

Not that I am an expert, but anyone contemplating this sort of combination of a holiday and cosmetic surgery, should seek a local surgeon's advice.  Based on this case, it is not a comparison between apples and apples (unless one of them is rotten!) and any potential costs savings need to be carefully considered !

IPL - the Dangers

 We have for some time been investigating a potential claim for a young women in her 20s with a fair complexion who underwent IPL for freckles on her face, including eyelids. Our client suffered quite severe iris damage as a consequence of the treatment.  It seems the IPL damaged the pigment in her iris, leading to an asymmetrical appearance.

We have now received our expert's report. This has confirmed the inappropriateness of such treatment to this area, the danger of the sort of complication our client experienced and the need for titanium (or other effective) eye protectors for any IPL treatment in proximity to the eyes (our client was given paper 'protectors').
 
This case raises concern quite apart from for our poor client who is left permanently disfigured. As with many such cases, the treatment was provided by a beautician, and at present we have no idea as to her training/qualifications (other than suspicions from the way the treatment was performed).
 
This seems clearly another area of 'cosmetic' medicine, crying out for better regulation.

Nurse Practitioners

Just noting the Federal Government's budget move approving prescribing rights for nurse practitioners.

No doubt some serious 'turf' wars and posturing to come, between the AMA, the major corporate GP practice operators and the entrepreneurial elements of the nursing profession.  

It will be interested to see how the standard of care issues arising from this pan out.  How will the standard of care to be expected of such practitioners be set? If less than the standard for a GP, how is this lower standard to be communicated to patients? How readily is such a practitioner to be expected to refer to a GP (given likely issues with referral rights to specialists or for expensive investigations {MRI etc))?

Yet another interesting aspect of the times we live in, and the ever changing dynamics of modern health care delivery