Doctor's care of vulnerable patient results in breach of Code - 20HDC00289

A doctor has breached the Code of Health and Disability Services Consumers’ Rights (the Code) in his management of an extremely vulnerable woman with complex physical and mental health needs.

The Deputy Health and Disability Commissioner noted significant concerns about the care provided by the doctor, and about assumptions he made regarding the woman’s health conditions, in her decision released today.

The woman, in her sixties, lived with post-traumatic stress disorder (PTSD), anxiety, depression and a very low body mass index (BMI). Deborah James’ report focused on the doctor's management of the woman’s care between 2015 and 2019.

Ms James found the doctor breached Right 4(1) of the Code by not providing an adequate standard of care for the woman’s heart issues, mental health conditions and weight management. She said the doctor’s documentation was inadequate, which made it difficult to assess the standard of care, and did not meet the necessary professional standards, breaching Right 4 (2).

The woman had presented to the doctor several times for symptoms suggestive of heart failure. Ms James said "...the lack of documentation relating to treatment plans, impressions and recording of vital signs and symptoms at these consultations between 2015 and 2019 leads me to consider that Ms A's heart failure was not managed by Dr C appropriately.... I am also concerned that no further action was taken regarding [a] recommendation for a chest X-ray and echocardiogram ...in 2016...."

Ms James also noted that there were no referrals for mental health assessments or treatments between 2015 - 2019 despite the woman’s PTSD, depression and anxiety, nor were there clinical notes explaining the lack of referral.

"Ms A was a vulnerable health consumer and had complex health and social needs. I am concerned that Dr C made assumptions about the treatment (or lack of treatment) of Ms A’s mental health conditions without seeking specialist advice or input," she said.

The woman had difficulty keeping a healthy weight, with a very low BMI. The doctor did not make a treatment plan for her persistently low weight other than to prescribe nutritional supplements.

Ms James was critical of the doctor's management of the woman’s weight issues, "…Dr C appears to have made assumptions about the value of psychological treatment for Ms A and whether a dietician's advice would have assisted her. Dr C did not seek specialist advice on these matters or make any referrals for Ms A to receive psychological or nutritional support."

Ms James made an adverse comment about another doctor at the practice for not following up on his intention to refer the woman for an echocardiogram, and for his documentation of the woman's symptom history.

She has recommended Dr C review guidance on heart failure, mental health and older adults’ weight and nutrition.

She has also recommended Dr C audit the medical records of 20 patients with PTSD using a Royal College of GPs checklist. The results of these actions are to be reported back to her within three months of this report.

The medical centre has made height, weight and blood pressure tests mandatory for all patients as a result of the complaint.