A general practitioner with three decades of experience has been found guilty in the NSW Civil and Administration Tribunal of unsatisfactory professional misconduct, after the Tribunal found a number of errors that led to the avoidable death of a young child.
In 2009, an eight year old boy died after suffering from septic shock caused by a ruptured appendix. Five days earlier, the child’s mother had taken him to a medical practice at Busby, NSW, where he was seen by Dr Hamid Khan. Until the events leading to the child’s death, Dr Khan, who was 77 years old at the time, had an unblemished record as a general practitioner for over three decades.
Dr Khan was the first doctor to review the child, who complained of stomach pain and vomiting. He asserted that he examined the child’s abdomen and asked the child’s father to bring him in the following day, and to otherwise observe his progress. He also prescribed the child Donnalix Elixir for gastritis.
In the early morning of 26 March 2009, the child was seen by another general practitioner from the same practice. That doctor diagnosed the child as suffering a possible ruptured appendix and called an ambulance. The child was taken to Liverpool Hospital and subsequently transferred to the Children’s Hospital in Westmead. After a number of delays, the child eventually underwent surgery.
The child later died on 28 March 2009.
The relevant proceedings
In 2015, the NSW Health Care Complaints Commission (HCCC) filed an application for disciplinary findings and orders against Dr Khan. The HCCC asserted that Dr Khan breached the Health Practitioner Regulation National Law when he failed to take a complete history of the child’s symptoms, failed to conduct a proper examination, prescribed inappropriate medication in relation to the asserted gastritis, and gave improper advice to the child’s parents when failing to recommend that the child be taken to hospital if his condition deteriorated.
The HCCC asserted that:
- Dr Khan had engaged in conduct which demonstrated that his practice of medicine was significantly below the standard reasonably expected of a practitioner with the equivalent level of training or expertise;
- his medical records in respect of the child were inadequate; and
- he suffered impairment and was not competent to practise.
Dr Khan did not seek to defend the complaints.
The Tribunal found that Dr Khan was not fit to practise and guilty of unsatisfactory professional conduct.1 The HCCC subsequently ordered that Dr Khan’s registration be cancelled.
In reaching its decision, the Tribunal considered the opinions of two expert witnesses, each of whom pointed to a number of deficiencies in Dr Khan’s conduct.
Dr Khan’s failure to take comprehensive clinical notes was scrutinised by the Tribunal. It accepted that the history recorded by Dr Khan lacked important details, such as the duration of the symptoms, the frequency and nature of the vomiting, the location and severity of the abdominal pain, whether there had been any fevers or change in bowel habit and whether or not the child had been able to eat or drink.
The expert witnesses opined (and the Tribunal accepted) that:
It is usually accepted that the amount of information required in the notes should reflect the complexity or potential seriousness of the presentation. Abdominal pain is a condition that, whilst common, also has potentially serious causes. Doctors should therefore take a reasonably detailed history to try to exclude significant causes and record this in their notes.2
The Tribunal found Dr Khan’s notes to be so deficient that any other practitioner would have had difficulty appropriately taking over the care of the child upon reading them. They concluded that the clinical records failed to comply with the relevant Regulations.3
The Tribunal also considered Dr Khan’s examination of the child. In doing so, it accepted expert evidence that he ought to have conducted an abdominal examination with the child upright, rather than lying on his back. The Tribunal noted that an adequate examination would have required the practitioner to take more time to feel the abdomen in order to have been able to identify the signs of peritoneal irritability.
It was found that, given the age of the child and that he was “tender in the upper area”, Dr Khan “ought to have been alert that there was something unusual or unexpected going on”, such that a closer examination of the child was required in order to localise the source of the problem.4 Whilst it was accepted that the symptoms could have been consistent with the diagnosis of a viral illness, the experts found that Dr Khan had not done enough to exclude other more serious illnesses. In this regard, the expert reported that the child’s presenting symptoms of upper abdominal pain would have justified obtaining an abdominal X-ray.
Evidence was also presented that, even if the diagnosis had been gastritis, the prescription of Donnalix would not have been an appropriate response.
The Tribunal accepted the expert’s findings that the child’s parents ought to have been advised on how to maintain the child’s hydration, and given clear instructions as to when and where the parents should take the child in the event that his condition did not stabilise.
The above case demonstrates the dangers of becoming complacent in routine clinical practices and highlights the importance of detailed note taking. In particular, it highlights the importance of health professionals remaining conscious that some conditions, whilst relatively common, can have potentially serious causes and possibly fatal outcomes if not properly investigated, identified and treated.