18th January 2018
CASE REPORTS FOR
CASE NO. 1
An ophthalmic member treated a
woman who was involved in a motor vehicle accident in 2006. She
COMMENTSa) MDM expended a large sum of money to seek justice for our member who was not involved in the treatment of the zygomatic laceration.
b) To recover the RM6,000 MDM would have to spend a sum of more than RM6,000 to proceed to execute Writ of Seizure And Sale or Judgement Debtor Summons.
c) The sum involved is less than the threshold to file the bankruptcy proceedings.
d) MDM did not get the costs.
CASE NO. 2A gynaecologist member performed a TAHBSO in a lady with uterine fibroid and left ovarian cyst. The cyst was very adherent to the sigmoid colon and omentum.
The omentum and sigmoid colon were freed from the left ovarian cyst by “blunt” dissection. There was no bowel injury noted during the operation.
On 1st postoperative day bowels were heard but sluggish.
No flatus was passed.
On 2nd postoperative day there was absent bowel sounds with rebound tenderness over the abdomen. A diagnosis of paralytic ileus was made. The patient was referred to the abdominal surgeon. Abdominal X-Rays were done which was diagnosed as “dilated bowels”. Only on the 3rd postoperative day the radiologist’s report of “dilated loops of bowels and “pneumoperitoneum“ was available.
The abdominal surgeon advised emergency laparotomy. The patient declined and sought treatment at a public hospital where laparotomy confirmed that the perforation was in the rectum. A Hartman’s procedure was performed.
Two years later the member received a High Court Writ of Summons. MDM appointed an abdominal surgeon expert to study the case.
The claim was settled out of court without admission of liability for the MDM’s expert criticized the member’s management.
Reasons for Settling :
i) release of anything other than minor adhesions requires the expertise of surgeons who are routinely trained in both “sharp” and “blunt” dissections for the safe release of adhesions.
ii) the “blunt” dissection was responsible for the tear and the perforation of the rectum that went unrecognized.
iii) the abdominal surgeon should have been called once the nature of adhesions was noted.
iv) the abdominal X-Rays were reported as “dilated loop of bowels” by the surgeon (2nd postoperative day).
v) on the 3rd postoperative day the radiologist’s report on the abdominal X-Rays was available – “dilated loops of bowels with pneumoperitoneum”.
vi) the member should have additionally ordered X-Ray of the chest which is diagnostic of pneumoperitoneum in bowel injury, and normally recognized.
vii) Consent form did not state the risks and complications of bowel injury.
COMMENTS1. The radiologist should be liable because of the “delayed” report. This case is an emergency and the on-call radiologist should have reported immediately.
2. Informed consent was not taken.
3. The member should know his limitations in the adhesiolysis.
CASE NO. 3A spinal surgeon member treated a male patient with extensive cervical spondylosis with cervical stenosis with neurological deficit of the upper and lower limbs. An extensive posterior decompression laminectomy was done from C3 to C7 vertebra and fusion was done from C2 to T1 vertebra with internal fixation.
Postoperatively the patient developed paraplegia.
On the last day of the statute period the patient filed a medico-negligence claim against the member. MDM defended the claim.
- After a lengthy trial the High Court found our member not liable.
- The High Court awarded our member costs of RM50,000.
- MDM’s solicitors failed to collect costs from plaintiff’s solicitors despite repeated reminders.
- MDM hired a private investigator to ascertain whether the plaintiff had any assets under his name. There was none.
- MDM proceeded to file bankruptcy proceedings against the plaintiff.
- Only then the spouse of the plaintiff contacted MDM’s solicitors seeking a reduction to the sum of RM50,000.
- MDM refused to reduce the sum awarded by the Court.
- Plaintiff’s spouse paid the sum with interest on the specified date.
1. On many occasions MDM has failed to recover costs of less than RM30,000 awarded by the Courts.
2. In this instance the threshold for bankruptcy proceedings was met and MDM pursued the matter.
3. The public will get to know that MDM will seriously pursue to claim costs.
CASE NO. 4
An ophthalmic member does his operations at a medical centre. He receives a letter from the Person-In-Charge (P.I.C.) of the centre informing him that forthwith the centre will not provide nurses to assist him in his operations.
The P.I.C. also instructed the member to train the centres’ theatre nurses and the runner to assist him in his ophthalmic operations.
Member writes to MDM for advice.
COMMENTSi) the member pays the Centre operating theatre fees
ii) it is on the onus of the Centre to train their theatre nurses and runner. Reference should be made to –
a) Private Healthcare Facilities and Services Act 1998 (Act 586). Please refer to 107. Power to make regulations (2) (k) : to prescribe the manner or type of training or continuing technical, medical, dental or nursing education or any other type of healthcare professional education to be provided by private healthcare facilities or services to their staff or any other person employed or engaged by the private healthcare facilities or services;
b) And (2) (jj) : to prescribe the minimum standards and requirements for all healthcare facilities, healthcare services and health-related services, in relation to any healthcare services provided by any healthcare professional including medical care services, nursing services, allied health services, technical services, services relating to all disciplines of medicine and surgery including obstetrics and gynaecology, anaesthesia, surgery, psychiatric, paediatrics, pharmaceutical services, critical care or intensive care services, services relating to medical supply, dietary services, linen and laundry, surgical supply, blood transfusion services, blood bank services, haemodialysis treatment services, rehabilitation services, outpatient and inpatient services, ambulatory care services, radiological or diagnostic imaging services, radiotherapy and radioisotope services, telemedicine services, nursing home services, hospice and palliative care services, services relating to autopsies and mortuaries, ambulance services, other support and ancillary services and all other policies and programmes relating to healthcare services provided and maintained by a private healthcare facility or service;
iii) Private Healthcare Facilities and Services Regulations 2006, Part XV “Standards for Surgical Facilities and Services” – Nursing Service 203 (1) : The nursing service of the surgical suite or a combined surgical-obstetrical suite shall be under the supervision of a registered nurse with training and experience in operation theatre nursing to direct operation theatre nursing.
(2) A registered nurse with training and experience in operation theatre nursing shall be present as a circulating nurse during operative procedures.
iv) The Medical Centre should pay the member fees for training the theatre nurses and the runner for the ophthalmic operations.
v) The member must be prepared that the medical centre may stop him from using the operating theatre.
CASE NO. 5A seventy six years lady fell and she sustained backache with no neurological deficit of the lower limbs.
She consulted a MDM orthopaedic member.
The member admitted her for treatment and investigations.
No fracture of the spine was seen on the X-Rays.
She was discharged.
For the next two weeks she was still in pain.
She again consulted our member who did an MRI of her spine. MRI confirmed a compression fracture of the T12 vertebra.
Member suggested a kyphoplasty of the T12 vertebra on the same day.
“Consent” was taken.
Kyphoplasty was performed under general anaesthesia.
Post-kyphoplasty the patient developed severe pain, loss of sensation from waist down, unable to pass urine and control her bowels.
Three days later the member informed the patient, husband and son that the cement has leaked from the site of the procedure.
He suggested an urgent laminectomy the same day to remove the leaked cement. This was done.
Post-laminectomy and the removal of the cement the patient failed to improve or recover from the paraplegia.
Member insisted to the father and son that there was nothing wrong with the patient.
The member attributed the paraplegia to the muscles having expanded and acting on the nerves.
Five days after the laminectomy the relatives discharged the patient and they admitted her to a public hospital where she stayed for six days.
The patient, still a paraplegic, passed away five weeks later.
The son lodged a complaint with the Malaysian Medical Council.
The M.M.C. directed the Preliminary Investigative Committee (P.I.C.) to hear the complaint.
The P.I.C. held the inquiry and framed a charge against the member.
The member appeared before M.M.C. to defend the charge.
The M.M.C. found him guilty and imposed a “punishment of a reprimand” to the member.
Member requested MDM to support his appeal to High Court.
MDM decline to support the appeal.
COMMENTSi) The compression must be mild as it was not diagnosed on plain X-Rays. MRI detected the fracture.
ii) No alternative treatment was offered to the patient – immobilization in a thoraco-lumbar brace.
iii) “CONSENT” – it was alleged the nurse asked the patient to sign the “form”. No evidence was produced it was an informed consent.
Doctors should take the informed consent personally and not to ask the nurse to present the form to the patient.
iv) The kyphoplasty should be done under intravenous sedation to monitor any side effects of the procedure. In this case it was done under general anaesthesia and there was no way to monitor the side effects of the cement leakage.
v) Kyphoplasty was not indicated for this fracture.
vi) Denial that the paralysis was due to the cement leakage was utterly not truthful.
vii) The laminectomy should not have been done. It was three days since the spinal cord has been injured.
viii) It is for the above reasons, which were our expert’s opinion, that MDM declined to support the appeal.
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