The Western Australian Court of Appeal has approved the Medical Board of Australia’s decision to caution a senior clinician for failing to maintain adequate records of the consent process in relation to a coronary angioplasty.

Background

Dr Woollard was a practising cardiologist in Perth, and the patient was a retired gastroenterologist. They were long-standing acquaintances. In September 2011, the patient attended Dr Woollard’s rooms on referral from his general practitioner. Following a stress echocardiograph, Dr Woollard arranged for the patient to undergo a CT angiogram. The angiogram revealed calcified plaque in the patient’s major epicardial blood vessels and Dr Woollard recommended an invasive angiography. The patient gave his consent and underwent a coronary angiogram, performed by Dr Woollard. On 20 October 2011, following the angiography, Dr Woollard advised the patient that he would benefit from a coronary angioplasty.

Dr Woollard later sent the patient by ordinary post a consent form entitled “coronary angioplasty” together with a hospital pre-admission summary and consent form. The coronary angioplasty consent form outlined a number of risks associated with the procedure, including the rare possibility of complications which could result in permanent damage and even death. The patient signed the consent form and the hospital consent forms. The hospital pre-admission summary and consent form included a declaration that the patient understood the risks, and that the patient had had the opportunity to ask questions and was satisfied with the information received.

A coronary angioplasty was performed on the patient by Dr Woollard. Fifteen minutes after the surgery was performed, the patient was found to have suffered a stroke.

On 30 October 2012, the Medical Board of Australia received a voluntary notification from the patient stating that Dr Woollard had failed to explain the risks and possible complications of a coronary angioplasty, and to discuss alternative, non-invasive treatment options.

Medical Board of Australia - Performance and Professional Standards Panel Hearing

The Medical Board referred the matter to the Performance and Professional Standards Panel, alleging that Dr Woollard had failed to obtain informed consent from the patient for the coronary angioplasty, and also that he had failed to maintain clear, appropriate, accurate and detailed clinical records of his discussions with the patient regarding the risks and potential complications of the coronary angioplasty.

Dr Woollard challenged the allegations on the basis that, in addition to the provision of the consent form and the hospital’s pre-admission summary and consent form signed by the patient, he had also, on 20 October 2011, when the patient was in recovery from the invasive angiography, orally advised the patient of the risks associated with coronary angioplasty, including the remote risk of serious harm from heart attacks and strokes.

The patient’s evidence was to the effect that he did not recall such a discussion with Dr Woollard. Significantly, it was not in dispute that there was no record of any discussion between Dr Woollard and the patient on 20 October 2011 concerning the risks associated with coronary angioplasty.

The Panel was satisfied that Dr Woollard had obtained informed consent from the patient to perform the coronary angioplasty, as the consent forms sufficiently alerted the patient to the risks and potential complications of the surgery. In addition, Dr Woollard had spoken with the patient about the coronary angioplasty procedure shortly after the patient’s coronary angiogram — although the Panel noted that this was not the ideal time for such a conversation because of the medication administered to the patient during the procedure.

However, the Panel concluded that Dr Woollard had failed to maintain clear, appropriate, accurate and detailed clinical records of his discussions with the patient regarding the risks and potential complications of the coronary angioplasty. It was critical of Dr Woollard’s record keeping procedures, with specific reference to his system of providing documentation to patients by post. The Panel also considered that Dr Woollard should have included a reference in his notes to having provided a consent form and the booklet and having discussed the potential risks and complications with the patient.

Ultimately, the Panel found that Dr Woollard behaved in a way that constituted “unsatisfactory professional performance” under the Health Practitioner Regulation National Law (WA) Act 2010. The Panel determined to caution Dr Woollard.

Dr Woollard appealed this finding. However, his appeal was dismissed. Dr Woollard then appealed the primary judge’s decision, and this appeal was also dismissed1 .

Comment

The case is a salutary reminder to health practitioners of the importance of complying with the Code of Conduct, which provides the courts with evidence on which to evaluate health practitioners’ conduct. It is also a reminder of the importance of maintaining good clinical notes, particularly in relation to the consent process and ensuring that the patient both understands and acknowledges the risks of the procedure.