CASE REPORTS FOR 2015

CASE NO. 1

A 56 year old man who sustained an industrial accident when heavy objects fell on him at 4pm on 1/10/2007.

• He was brought to the A & E department of a private hospital.
• The Orthopaedic Surgeon attended to him.
• The man sustained a closed fracture of the right clavicle.
• He was scheduled for emergency plating of the right clavicle.
• The anaesthetist examined him at 7.20pm in the O. T. He did not take the anaesthetic consent for the procedure.
• The operation started at 7.50pm, and ended at 8.50pm.
• The patient could not be reversed – fixed, dilated pupils were detected.
• An emergency C T Scan of the brain revealed a large left extradural haematoma.
• The patient was referred to another hospital for the neurosurgical operation
• The patient is now brain damaged
• The patient sued the orthopedic surgeon, 2^nd defendant on 25/9/2013 – just 5 days before the

limitation period!

• The anaesthetist was cited as a 3^rd defendant on 12/08/2014 – more than 10 months after the limitation period which ended on 30/09/2013.

COMMENTS

1. The Orthopaedic Surgeon was grossly negligent in failing to take a proper history (there was loss of consciousness) and doing a detailed clinical examination. He was too eager to operate.
2. The fractured clavicle in this patient could have been treated conservatively. If plating had to be done, it should have been an elective procedure.
3. Conservative treatment or elective plating would have allowed the medical personnels to observe for increase in intracranial presence – vomiting and altered state of consciousness.
4. The anaesthetist, an MDM member, was also negligent for not ascertaining the patient was fit for the operation and failing to take consent.
5. The hospital, 1^st defendant, is liable for the episodes of nausea and vomiting which were not recorded by the nurses.
6. The medical defence organization of the 2^nd defendant stated the case cannot be defended and asked for a contribution from MDM.
7. MDM defended the anaesthetist, not because he was not negligent but the claim was time barred.
8. The Session Court Judge insisted that the trial should proceed. MDM. disagreed in view of it being time barred. MDM appealed to High Court. MDM succeeded. The plaintiff appealed to Appeal Court and failed.
9. MDM expended a considerable sum of money to ensure that the Statute period is maintained, otherwise the flood gates to litigation will be opened!

CASE No. 2

A managing director, a medical doctor of a private hospital employed an unregistered doctor as a medical officer for 15 years.

The Health Department visited this hospital and made photostat copies of various documents belonging to the hospital.

The Health Department informed the Ministry of Health. The Ministry of Health informed the Malaysian Medical Council. The Managing Director was asked to attend an Inquiry by the Preliminary Investigation Committee.

The ‘medical officer’ graduated from a non-scheduled medical college. He sat and passed the medical qualifying examination.  He was appointed as a house officer. He served only four months of his housemanship.  Four years later he was appointed as ‘medical officer’ of the private hospital.

COMMENTS

1)         The Managing Director has contravened Malaysian Medical Council Code of Professional Conduct Clause 1.4.1 “Employment of Unqualified or Unregistered Persons.”

2)         It is MDM’s view that any doctor appearing before the P.I.C. and M.M.C. he must have legal representation.  The managing director sought the services of the solicitors on the panel of MDM – at his own expense. MDM does not provide funded legal service to any member who contravenes the M.M.C. Code of Professional Conduct.

3)         The managing director was given reprimand by M.M.C.

4)         He was very fortunate as he could have been charged under the Private Healthcare Facilities and Services Act 1998 (Act 586) and Regulations & Order, Part VI 31.1(C)  and 3  ‘he shall be liable on conviction to a fine not exceeding one hundred thousand ringgit or to imprisonment for a term not exceeding two years or both.’

CASE NO. 3

A 62 year old female with a large septated left ovarian cyst of 20 weeks size, consulted a gynaecologist on 15^th April.

PAST MEDICL HISTORY

1. i) bilateral tubal ligation
2. ii) laser treatment of varicose veins of the right leg.

PRE-OP ASSESSMENT

• Severe aortic valve stenosis detected.
• Gynaecological problem to be treated after the aortic valve stenosis treatment.
• Aortic valve replacement was done on 15 May; started on warfarin, frusemide, slow K and lovastatin.

13 July -  admitted for operation of total abdominal hysterectomy and bilateral saphingo-oopherectomy and omentectomy.

-  Warfarin was stopped 4 days pre-op. – INR was 1.25 a day before the operation

14 July – Operation performed; findings:

1. i) small bowel and the sigmoid colon were densely adherent to the back of the uterus.
2.  ii)        small bowel was adherent to the abdominal wall.

              iii)      the large left ovarian cyst was densely adherent to the small bowel and the anterior abdominal wall.

1. iv)       adhesiolysis  was performed to release the small  bowel and the sigmoid colon.
2. v) a 2.0cm tear of the small bowel occurred during the adhesiolysis.
3. vi)       the abdominal surgeon was called to repair the small bowel perforation.

             vii)      TAHBSO and omentectomy  were completed.

             viii)     peritoneal washings were done before the abdominal closure.

POST OPERATIVE PERIOD

Patient developed:

• fever
• rapid atrial fibrillation on 20 July; treated in I.C.U. with amiodarone with return to sinus rhythm.
• progressive gaseous abdominal distension on 20 July.
• planned for gastrograffin small bowel studies on 21 July.
• severe epigastric pain with abdominal distension.
• another episode of A.F.; transferred to I.C.U. and treated with amiodarone on 22 July.
• T. Scan of the abdomen on 22 July, showed the pelvic abscess and pericardial effusion.

Planned for pericardiocentesis and emergency laparotomy to drain the abscess.

The patient’s vital sign deteriorated and the surgical procedures were postponed.

Patient expired on 23 July.

Throughout the postoperative period she was on parenteral antibiotics.

CAUSE OF DEATH:  Septicaemic shock.

The deceased’s sons were not happy with the delay in the diagnosis resulting in the death of their mother.

The sons lodged a complaint to the hospital

The gynaecologist received a letter of demand for RM 250,000.00

COMMENTS

1. The gynaecologist was advised the demand for RM 250,000/ was exorbitant.

2. The TAHBSO was done too soon after a major operation for a severe aortic stenosis.

3. The omentectomy and excessive adhesiolysis, in today’s circumstances, should have been done by an

            abdominal surgeon, unless the gynaecologist is trained in abdominal surgery.

4. As expected in such extensive adhesiolysis the small gut was perforated. The abdominal surgeon had

 to be called in to do the repair.  On “opening” the abdomen and seeing the extensive adhesions the

abdominal surgeon should have been called to do the adhesiolysis.

5. The abdominal surgeon and the gynaecologist should have been vigilant to investigate sooner when the fever, paralytic ileus and abdominal distension developed in a patient with an introgenic perforated small gut.

            The C.T. Scan was done too late, eight days post-operatively.

6. The sons stated they did not have the financial resources to file a civil suit. They requested for compensation.

7. A negotiated settlement of RM 30,000.00 was reached; the surgeon and the gynaecologist shared the sum.

8. The sons acknowledged the payment with the following conditions:

1. a) no further claim to the hospital and its staff, the surgeon and gynaecologist.

1. b) not to disclose or publish in any way the Terms of Settlement to any party or mass media.

CASE 4

A 41 year old man sustained comminuted fractures of the distal radius with fracture of the ulnar styloid and a

disruption of the distal radio-ulnar joint on 30/10/2007.

The comminuted fractures of the distal radius were reduced and fixed with plate and screws.  The disrupted distal

radio-ulnar joint was reduced and repaired on 30/10/2007 by an orthopaedic surgeon.

Post-op xrays showed good reduction with a normal radiocarpal joint space with the distal screws close to the radial

articular margin.

On 23/11/2007 the patient returned with pain in the left wrist and swelling.  Xrays confirmed that there was early

union and  the tip of the 3 distal screws were in the wrist joint. The distal radial ulnar joint was not subluxed.  The

patient was offered to have the 3 distal screws re-positioned.  He declined and defaulted follow up.

The patient sought treatment at another private hospital where the orthopaedic surgeon removed the 3 distal screws,

manipulated the wrist joint and did a left carpal tunnel release on 28/11/2007.

On 27/11/2008 he sought treatment at a university hospital for severe left wrist pain, numbness on the dorsum of

the left   ring   and little finger and stiffness of the left fingers and thumb.  Clinically he had restricted movements

in the left wrist joint of  10^o    of palmar flexion and 30^o  of dorsiflexion in the left wrist joint. There was stiffness in the

joints of all the left fingers. Xray showed degenerative changes of the left wrist joint with disruption of the distal

radial ulnar joint.

At the university hospital the plate was removed, the left wrist was fused, a partial release of the collateral ligaments

of the left fingers and a decompression of the dorsal branch of the left ulnar nerve were done.

COMMENTS

1. The internal fixation for a comminuted fractures of the distal radius was appropriate.
2. Good reduction of the fractures were achieved.
3. He was followed up for only three weeks by the first orthopaedic surgeon.
4. His subsequent problems were caused by the second orthopaedic surgeon and the orthopaedic surgeon at the university hospital.
5. At the second private hospital the screws should not have been removed till full union has occurred.

            Manipulation of the wrist with a comminuted fractures of the radius which have not united is contra indicated; this would have displaced the fractures.          A release of the carpal tunnel was definitely not indicated.

6. At the university hospital:

1. a) it is unlikely for the patient with a stiff wrist joint to develop end stage osteoarthritis of this joint within a year to have a wrist arthrodesis.
2. b) release of the collateral ligaments of the left fingers and decompression of the dorsal branch of the left

ulnar nerve were not indicated for symptoms of  RDS (reflex sympathetic dystrophy), which he had.

1. c) the RDS was missed.

7. The first orthopaedic surgeon managed the patient for only 3 weeks.
8. His problems all developed when he was managed by the 2^nd and 3^rd orthopaedic surgeons who are liable for all the wrongly indicated, multiple operations.

CASE 5

70 year old man was diagnosed with stage 3 lung cancer (low grade tubopapillary carcinoma with EGFL mutation) by

a physician in November 2012.  The physician, Dr. A., referred the patient to an oncologist, Dr. B, for chemotherapy.

The patient was  refractory to 4 lines of systemic therapy (Gemcitabine and Cisplatin, Tarceva and Iressa,

Taxotere, and Abraxane)

The patient developed recurrent pleural effusions which required pleural taps by a chest physician, Dr. C.

Throughout the management several C.T. Scans of the lungs were done and these showed progression of the cancer.

The treatment and prognosis was regularly counselled to the relatives of the patient.

Whilst the patient was still in the ward another oncologist, Dr. D., visited the patient in the ward and perused the case

notes and asked the staff nurse to show him the chemotherapy regime prescribed by Dr. B, without the knowledge and

the consent of  either Dr. A, Dr. B or Dr. C.

Dr. D. then asked the staff nurse to inform Dr. B. that he was taking over the treatment of the patient.  Neither the

patient nor the relatives informed Dr. B of this.

The patient eventually succumbed to the cancer 13 months from the onset.

The daughter wrote a letter of complaint on 24.2.2014 criticising Dr. B’s management to the C.E.O. of the

Hospital. 

The letter was very detailed in naming the drugs used, dosages and frequency of administration and duration.

Drs. A, B, and C lodged a complaint to the Chairman of MDAC of the hospital on 5.2.2014 regarding Dr. D’s actions.

This was to protect themselves from a negligence suit.

It is most likely that Dr. D instigated the daughter to write the letter after he attended the MDAC hearing.

COMMENTS:

1. Dr. D’s behavior is unbecoming of a medical practitioner in “hijacking” the patient for his personal gain and passing derogatory remarks of a colleague and instigating the daughter to write the letter to the C. E. O.

2. Dr. A, B, and/or C could lodge a report to Malaysian Medical Council on Dr. D’s actions.

3. Dr. D would be charged under Infamous Conduct by M.M.C. for contravening:

1.2.      The Practitioner and Requests for Consultation:

Clause: 1.2.2, “The attending practitioner may nominate the practitioner to be consulted, and should   

advise accordingly, but he should not refuse to refer to a registered medical practitioner selected by the patient or next of kin.”

1.2.3,  “The arrangements for consultation should be made or initiated by the attending

             practitioner.  The attending practitioner should acquaint his patient of the

            approximate expenses which may be involved in specialist consultations and

            examinations.”

1.2.4, “It is the duty of the practitioner consulted to avoid any word or action which might

            disturb the confidence of the patient in the attending practitioner.  Similarly, the

            attending practitioner should carefully avoid any remark or suggestion which would

            seem to disparage the skill or judgement of the practitioner consulted.”

 1.2.5,  “The practitioner consulted shall not attempt to secure for himself the care of the

              patient seen in consultation.  At the end of consultation.  At the end of consultation or

              further management where mutually agreed upon specifically between the referring

              practitioner and the consultant, the patient should be returned  to the referring

              practitioner with a report including results of investigations and advice on further

             care of the patient.”

1.2.6.   “The consultant is normally obliged to consult the referring practitioner before other

            Consultants are called in.”