2016 December - Complaints Committee
Report from the Complaints Committee
The Board has reviewed and determined 33 complaints made against veterinarians since March 2016. Of these, one case was withdrawn, 22 complaints were dismissed and 2 complaints were dismissed with a recommendation to the veterinarian.
Unsatisfactory professional conduct
Three veterinarians were found guilty of unsatisfactory professional conduct:
1. A veterinarian was cautioned and fined as a result of failing to ensure that she or another veterinarian was available for the ongoing post-surgical care of a critically ill animal. The animal was discharged from an emergency centre for transport by the client to another veterinary practice where the dog died soon after arrival.
The decision to discharge and transfer the dog (which had had a surgical procedure performed at the emergency facility and had not recovered from anaesthesia) without ongoing supportive treatment and veterinary supervision showed a lack of judgment and care by the veterinarian in breach of s 35(k) of the Veterinary Practice Act 2003.
It was also not considered to be of the standard of care expected of a facility that is operated as an emergency centre. The option of referral to another facility where higher staffing levels and ongoing postoperative care could have been provided should have been given prior to treatment being undertaken by the veterinarian or the dog should have been treated at the emergency facility until fit to travel.
2. A veterinarian was cautioned and fined as a result of his inability to provide adequate medical records for procedures performed and medication given to a dog whilst hospitalised and in his care. Records were reported to have been made on treatment cage cards that were not retained. The lack of medical records is a breach of clause 15 of the Veterinary practitioners code of professional conduct which requires that medical records are kept in sufficient detail to enable another veterinary practitioner to continue treatment of the animal and that records of any procedure or treatment be retained for at least 3 years after they are made.
The Board also made a recommendation to the superintendent of the veterinary hospital that he put in place procedures to ensure that all records of any consultation, procedure or treatment are retained for at least 3 years after they are made.
3. A veterinarian was cautioned and fined for breaching conditions on his registration (Veterinary Practice Act 2003 (s 35(d)).
Five veterinarians were found guilty of professional misconduct:
1. A veterinarian was found guilty of professional misconduct under the Veterinary practitioners code of professional conduct (Code) (clause 14) for a breach of Greyhound Australia (GA) Rule 106(4) which states a certification of euthanasia can only be made by the person performing the euthanasia.
2. A veterinarian was found guilty of professional misconduct under clause 14 of the Code after having been found by the Racing Appeal Panel NSW to have breached the Australian Rules of Racing (AR175(l)).
3. A veterinarian was found guilty of professional misconduct, cautioned and fined when it was found that the surgery he performed, ovariohysterectomy (OHE), and his post-operative care was not in accordance with current standards. In this case, a 5 year old, 33 kg bitch died within hours of an OHE as a result of intra-abdominal haemorrhage and no record of post operative monitoring could be provided. Necropsy examination showed that both ovarian pedicle ligatures had failed. His actions were in breach of clause 4 of the Code.
There was no record that the bitch was intubated or that any O2 or gaseous anaesthesia was provided for this surgery. There was no evidence of any monitoring during anaesthesia, surgery or postoperatively that may have alerted the veterinarian to a possible complication. Both intubation and monitoring during anaesthesia are expected levels of care for OHE in a bitch. Close post operative monitoring in recovery is also an expected standard of care after OHE.
The medical record of the animal’s anaesthesia, surgery and the events postoperatively was inadequate and the veterinarian was also found to be in breach of clause 15 of the Code in that his records were not in sufficient detail to enable another veterinary practitioner to continue the treatment of the animal (if required).
4. A second veterinarian was found guilty of professional misconduct due to breaches of the Code after it was found that the anaesthetic protocol used and the surgery (OHE) performed on a 6 year old Shih Tzu bitch were not to current standards (clause 4) and that he failed to ensure that he was available for the ongoing care of the animal (clause 8).
Intravenous access (catheterisation) and endotracheal intubation and delivery of oxygen were not undertaken in this case. All of these procedures were considered the current standard of care during general anaesthesia for abdominal surgery in a mature brachycephalic breed especially in dorsal recumbency due to the increased risk of respiratory obstruction. Only parenteral anaesthesia using a combination of drugs at doses that are no longer commonly recommended was provided.
In a small dog (< 5kg) any errors in the weight measurement and the difficulty in measuring very small drug volumes may have been associated with a significant margin for error in the doses administered. No record was kept of any observations during surgery or post operatively. The dog was discharged to the owner when not normally responsive and was reported not to have been able to stand unaided from the time of discharge until her death.
Some haemorrhage from the surgical incision was noted by the owner later in the day and a body bandage was applied and the dog again discharged to the owner. Multiple attempts were made by the owners to contact the veterinarian during the evening after her surgery when the dog was distressed but the veterinarian could not be reached and no emergency contact number was provided.
The bitch was treated by another veterinarian at another veterinary clinic where an exploratory laparotomy found evidence of abdominal haemorrhage. The bitch died the following day after a seizure without regaining the ability to walk. It was considered highly likely that the anaesthetic protocol given during the first surgery caused significantly reduced cerebral perfusion which would have been exacerbated by any hypovolemia (as a result of surgery or post surgical haemorrhage), hypoxia, hypercapnea and/or hypothermia.
5. A veterinarian was found guilty of professional misconduct, reprimanded and fined after it was found that his actions were in breach of the clause 4 of the Code and the Veterinary Practice Act 2003 (s 35(k)) in that a record of S8 drugs had not been made at his veterinary hospital for more than 3 years.
There was no indication that S8 drugs were being misappropriated for any other purpose than the treatment of veterinary patients however as the superintendent of a veterinary hospital it was his responsibility to ensure that an accurate record of S8 drug inventory and use was kept in a drug register as required by NSW Poisons and Therapeutic Goods Regulation 2008 (clauses 111 and 118).
A drug register must be kept on veterinary premises where drugs of addiction are stored. Entries must be made on the day of any receipt, supply or use of any S8 drug. The lack of maintenance of a drug register was not in accordance with current standards of the profession (clause 4) and whilst not wilful, the veterinarian’s conduct also showed a lack of care and judgment in his practice of veterinary science (s 35(k)).
The Complaints Committee can make a recommendation to the Board to dismiss a complaint against a veterinarian and may also make a recommendation to advise either an individual veterinarian or to the Board (to make known to the wider profession) with the aim to prevent similar adverse events or similar complaints.
Two complaints were investigated in this reporting period that were dismissed by the Board however both involved concerns that have been recurrent themes with respect to complaints previously - namely lack of communication regarding the cost of veterinary services and thermal burns sustained during veterinary treatment.
Client communication and the provision of an estimate of fees
A complaint was made against a veterinarian after diagnostic tests were performed during the course of a routine consultation (ear cytology and skin scraping) where the additional cost of these tests was not specifically advised to the client prior to the tests being undertaken. The complainant had agreed to the tests being performed but felt she should have been given the opportunity to decide on treatment with known costs. It was the opinion of the Board that many practitioners may not consider it typical for a client to repeatedly ask the cost of each individual test or minor treatment during a routine consultation nor is it typically always expected by a client that the veterinarian would provide such information however clause 16 of the Code requires veterinary practitioners to provide an estimate of the extent and cost of veterinary services where practicable before providing veterinary services.
Clause 16 would be similarly interpreted by many practitioners as applying to services that require significant investigation, treatment, hospitalisation and/or surgery rather than those incurred in a routine consultation. Previously this interpretation has been reinforced by Board communications which also recommend written consent and estimates for hospitalised cases. Board communications in the past have not specifically highlighted the requirement for an estimate to be given for any additional charges (regardless of amount) when incurred during a routine consultation but the Board’s recommendation has been reviewed.
While providing an estimate of costs for all minor procedures and treatments carried out during routine consultations is not common practice currently, the provision of an estimate is not likely to be impracticable and all consultations, treatments and diagnostic tests can be considered veterinary services. As such, an effort should be made to provide an estimate (verbal or written) of costs to the client, in addition to client consent, prior to any service (including during a consultation) unless the veterinarian client relationship suggests that this is not always necessary or this is not practicable.
Poor communication remains an ongoing source of complaints against veterinarians. Complaints may arise due to poor communication (or perceived poor communication) regarding the treatment given, diagnostics performed, prognosis or the cost of services provided. An estimate of the cost of veterinary care including diagnostic tests and treatment where practicable is a requirement and this can be given verbally or in writing (preferred).
It can be difficult to provide an estimate for the total care of patients where the extent of the treatment that may be necessary is not predictable however the estimate of total costs to date should be updated (daily or more frequently) to the client and permission for additional diagnostic tests and treatment should be obtained before they are performed where practicable (i.e. emergency treatment may be given if the owner cannot be contacted). Consent must be given by a client for necropsy examination (verbal or written).
Maintaining an accurate record of all communication with clients is important. This is especially critical in veterinary practices where multiple veterinarians are involved in an animal’s care and where the client may not have face to face communication with the veterinarian attending their animal. Communication is critical to enable an owner to understand their animal’s condition, the treatment options available and the costs involved but communication is also important between veterinarians to provide a continuity of care both for the animal and the client.
Current standard of practice for warming patients
A complaint was dismissed against a veterinarian after a dog sustained thermal burns during a dental procedure where hot water bottles were used to prevent hypothermia. Small animals are susceptible to hypothermia during any period of anaesthesia and surgery and hypothermia may significantly increase morbidity and recovery times.
Prevention of heat loss during anaesthesia is recommended and various heating methods are routinely used in veterinary practice to minimise heat loss during anaesthesia, procedures and in recovery. Burns are unpredictable and have been reported as a complication in anaesthetised animals warmed by different heat sources. Even with adequate precautions burns may still occur but hot water bottles are known to be a possible cause of burns.
The Board published an article in Boardtalk May 2016 stating that it no longer considers the use of hot water bottles and other uncontrolled heating methods to be in accordance with current standards. This advice article was prompted by previous complaints concerning dogs that had sustained thermal burns during veterinary treatment. The Board considered a suitable time frame for veterinarians to transition to other heating methods would be approximately 6 months from the publication of this advice.
The Board reminds veterinarians that any heating source used from now on should incorporate the ability to control temperature (has a thermostatic controller) with a maximum upper limit that is not expected to cause burns and that the onus is on the operator (the veterinarian) to ensure that the device used is functioning normally and is properly serviced (as required).