Williams, Nicole - Medical Council of New South Wales

PROFESSIONAL STANDARDS COMMITTEE INQUIRY
CONSTITUTED PURSUANT TO PART 12 DIVISION 1
of
THE MEDICAL PRACTICE ACT 1992 to HOLD AN INQUIRY INTO
A COMPLAINT IN RELATION TO
DR NICOLE WILLIAMS
Dates of Inquiry:
11 & 12 November 2009
Committee members:
Ms Geri Ettinger, SA LLB Chairperson (Legally qualified, not
a registered medical practitioner)
Dr Joanna Hely (Registered medical practitioner)
Dr Keith Edwards (Registered medical practitioner)
Mr David Jackett (Lay person)
Legal Offcer assisting
Ms Anne Harvey, Legal Officer
Committee:
Appearance for Health Care
Ms Lisa Fackender, Hearings Officer
Complaints Commission:
Appearances for Dr Nicole
Ms Barbara Versace, Solicitor, Avant Mutual Group Limited,
Wiliams
Dr Hugh Aders, Avant Mutual Group Limited
Date of decision:
18 December 2009
Publication of decision:
No non-publication directions have been made
SUMMARY
Dr Nicole Willams is a registered medical practitioner, MPO 337169, and is currently
undertaking specialist training In orthopaedics. On 7 November 2005, the reievant
date for purposes of these proceedings, she was the Neurosurgical Senior Resident
in her third post-graduate year (PGY3) at Royal North Shore Hospital (RNSH), and
had commenced her rotation two weeks prior to this. Ms Vanessa Anderson had
been admitted on the previous day with a depressed skull fracture following an injury
with a golf balL. The Health Care Complaints Commission (HCCC) has alleged that
Dr Willams has been guilty of unsatisfactory professional conduct in relation to
prescription of analgesic medication and record keeping. The Professional
Standards Committee (PSG) noted the less than satisfactory work environment on 7
November 2005, including the shortage of medical staff, which meant Dr Willams
was the most senior doctor in the Neurological Unit. Against this background, the
PSC found that because Dr Wiliams's record keeping contravened the requirements
of clause 5 Schedule 2 of the Medical Practice Regulation 2003 in relation to record
keeping, she has breached section 36 of the Medical Practice Act 1992. A breach of
the Medical Practice Regulation is a strict liabiliy offence, and constitutes a breach
of the Medical Practice Act 1992. Dr Williams is accordingly guilty of unsatisfactory
professional conduct in relation to her record keeping on 7 November 2005. The
Committee decided that no protective orders were required and consequently no
orders were made.
BACKGROUND
1. Dr Nicole Williams graduated with a Bachelor of Medical Science with Honours
Class 1 from the University of Newcastle in 2000, and Bachelor of Medicine, also
from the University of Newcastle in 2002. In 2009 she completed a Graduate
Certificate of Sports Medicine at the University of NSW. Dr Williams is a
registered medical practitioner iri the General category, MPO 337169. She is
currently engaged in specialist training to become an orthopaedic surgeon.
2. In relation to the Complaint before the Professional Standards Committee, (PSC),
we note that Dr Williams commenced as a Neurosurgical Senior Resident at
Royal North Shore Hospital (RNSH) on 24 October 2005.
3. She told us that on Monday 7 November 2005, when she attended work at 7:30
am, the Neurosurgical Fellow told her of Ms Vanessa Anderson's admission the
previous afternoon. Ms Anderson was 16 years old, and had the previous day
been hit by a golf ball, conveyed to Hornsby Hospital, and transferred, to, and
admitted to RNSH. She had a depressed skull fracture, and a Glasgow Coma
Score of 15 (normal).
4. Dr Williams' evidence was that on 7 November 2005 at approximately 8:30 am,
after the Neurosurgical Fellow had left for the operating theatre, she conducted a
ward round with the nurse practitioner, and the Surgical Intern who had been
assigned to the Neurosurgical Unit at short notice to replace the usual resident,
who was away. No-one else was available to attend the ward round. Dr Williams
told us that there normally would have been the Neurosurgical Fellow present,
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and one or both Neurosurgical Registrars, both away on a training day on 7
November 2005. She told us that there were 32 patients in the ward, and in the
Neurosurgicai ICU for whom she had responsibilty, and that on 7 November
2005, she had been there only two weeks.
5. Dr Nichoias Little, the Consultant Neurosurgeon and VMO on cali at RNSH on
Sunday, 6 November 2005 gave oral evidence at the Inquiry. We also had his
report dated 20 March 2006 before us. Dr Littie toid us that he received a cali
from the Neurosurgical Feliow on call at RNSH in the late morning of Sunday 6
November 2005, informing him that he had had notice that a 16 year old,
Vanessa Anderson, had suffered a depressed skull fracture foliowing an injury
with a golf ball, and asking him if he would accept care of the patient. Dr Little
told us that he agreed and that he then received another cali from the Feliow
informing him that the patient had arrived at RNSH, and that she had a GCS
(Giasgow Coma Scale) of 15 (normai). Dr Littie said that during the second call,
the Feliow informed him that the bed manager at RNSH had toid him Ms
Anderson should be transferred to Westmead Children's Hospital due to her age.
Dr Little said that his response was irritation that this "double handling" had not
been sorted out before as the family was being subjected to it, but that he was
satisfied from the reports of the Registrar that Ms Anderson was "quite well
enough to be transferred again". Dr Little said that as he had heard nothing
further, he assumed that the transfer had gone ahead.
6. Dr Little also said that on the evening of 6 November 2005 he had seen a patient
at North Shore Private Hospital (which is co-located with RNSH), and that had he
known Vanessa Anderson had been admitted to RNSH, he would have made a
point of examining her as welL. He added: "In a case such as Vanessa's where
there is a potential for surgery, on learning of her admission in all likelihood I
would have made a special trip to the hospital to see her that evening".
7. We are satisfied from the evidence that because he was not aware that Ms
Anderson had been admitted to the Neurosurgical Unit at RNSH on 6 November
2005, Dr Little did not attend at the Neurosurgical Unit, and did not see Vanessa
Anderson until he came to do his routine ward round at approximately lunchtime
on Monday 7 November 2005. He told us that he expressed frustration to his
team that he had not been told of the admission at the time, that is on the
previous day.
8. On 7 November 2005, on learning that Ms Anderson was in the Neurosurgical
Unit, Dr Little discussed her care and management with Dr Williams, the nurse
practitioner, and the Relieving Intern in the ward, prior to seeing the Patient. Ali
the other relevant persons, including the Registrars were not present at that time.
Unfortunately, with Dr Williams' inexperience, and the lack of staff, certain errors
were made, and as can be seen from the issues raised by the Complaint, which
follows, there were issues with administration of opiates, and with record keeping.
g. We are mindful in regard to the administration of analgesia that Ms Anderson
complained of very severe headache, and that the Endone 5 - 10 mg three
hourly pm which has been commented upon as being excessive was prescribed
not by Dr Williams, but by the Anaesthetic Registrar who should have been well
versed in pain management.
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10. Ms Anderson who. had suffered a mild head injury, and who did not require urgent
surgery on either 6 or 7 November 2005, but was scheduled for surgery to
elevate the fracture, for both medical and cosmetic indications, died in the early
hours of 8 November 2005. An autopsy was carried out, and a number of other
investigations, including a hospital root cause analysis, which do not concern us
directly in relation to this Complaint. The Commitlee did however have concerns
about systemic and staffing issues in the Neurosurgical Unit at RNSH which have
been raised at the end of these Reasons for Decision.
11. We are mindful of Dr Williams' evidence, and her expression of her grief at
hearing of the death of Vanessa Anderson. She said that she felt devastated,
and would do everyhing possible to prevent anything like that ever happening
again, including avoidance of the situation of an environment where a ward was
as short staffed as the one in which she worked on 7 November 2005. The
Committee accepts Dr Williams' statements as a sincere expression of her
feelings, contrition and wish to exert her influence to improve care and safety in
the future.
12. We were pleased that Mr and Mrs Anderson, Vanessa Anderson's parents felt
they were abie to attend the first day of the Inquiry. Mrs Anderson gave evidence
to the Inquiry. Ms Fackender of the HCCC sought agreement of Committee for
Mr Anderson to ask questions of various witnesses. The Committee acceded to
this request. On the second day of the Inquiry, Mr and Mrs Andersan did not
attend. However, at the conclusion of the Inquiry, Ms Fackender requested that
an email sent from Mr Anderson to her that day headed "Comments to the
Medical Board", (which she toid us were directed to the Commitlee, and nat the
Medicai Baard itself), could be read aut. The Committee agreed to that course of
action, noting that in his email, Mr Anderson described how diffcuit it had been
for Vanessa's parents to be present on the first day of the Inquiry. He also
commented on what he and his wife perceived to be problems in the "culture in
the health industry", and the standards of care which resulted, but also. stated
that: "Our message to this forum is not one of wantrng punative (sic) measures
for Doctor Willams or anyone else for that matter on an individual basis".
13. We take this opportunity of expressing our condolences to the parents and family
of Vanessa Anderson, knowing that however well the system operates in the
future, nothing will return her to life, and to them.
ISSUES BEFORE THE COMMITTEE
14. The issues to. be determined by this Cammittee are:
. Whether the Committee is comfortably satisfied of any or all Particulars of
the Complaint of the HCCC against Dr Wiilams being proven;
. If so, whether the Committee is satisfied that the Complaint against Dr
Williams is proven, and that section 36 of the Medical Pracfice Act 1992
(the Act) has been breached;
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. If so, the Committee's decision regarding what, if any, Orders or
Directions pursuant to Division 4 of Part 4 of the Act would be
appropriate.
THE COMPLAINT
15. The Complaint dated 26 May 2008 against Dr Nicole Wiliams was referred by the
NSW Health Care Complaints Commissioner to be dealt with by a Professional
Standards Committee. It was prosecuted before this Committee by the Director
of Proceedings of the Health Care Complaints Commission acting as nominal
complainant. The Complaint against Dr Williams is as follows:
Dr Nicole Wiliams of 54 Appleby Crescent, Norwood, South Australia 5067 (in
2008), ("the practiioner'), being a medical practitioner registered under the
Act,
Has been guily of unsatisfactory professional conduct within the meaning of
section 36 of the Act in that she:
Has demonstrated that the knowledge, skil or judgment possessed, or care
exercised, by the practiioner in the practice of medicine is significantly below
the standard reasonably expected: of a practitioner of an equivalent level of
training or experience.
Contravened clause 5 and Schedule 2 of the Medical Practice Regulations
2003 relating to the requirement to keep proper medical records.
On 6 November 2005 Vanessa Anderson, aged. 16 years, was
transferred from Hornsby Hospital to Royal North Shore Hospital
(RNSH), after sustaining a closed head injury earlier that day. She was
assessed by a Neurosurgical Registrar in the emergency department of
RNSH and charted for analgesia, regular observations and a repeat CT
scan. She was admited to the Neurosurgical Unit. Vanessa Anderson
was scheduled for surgery on 8 November 2005 (amended at hearing)
to elevate the skull fracture.
On 7 November 2005 the practiioner, attended a ward round with the
Neurosurgical Consultant. During this ward round the Consultant
ordered that Vanessa Anderson be prescribed Phenytoin, an
anticonvulsant. The Consultant also viewed Vanessa Anderson's
medication chart. He did not alter or recommend changes to the pain
management regime.
At all relevant times the practitioner was employed as a Senior
Resident Medical Offcer in the neurosurgical unit at RNSH, St
Leonards.
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PARTICULARS OF COMPLAINT
16. The particulars of the complaint are as follows:
On 7 November 2005;
1. The practitioner faiied to discuss the prescribing of oxycodone 10mg
every 3 hours with the Anaesthetic Registrar or a senior member of the
neurosurgical team when she knew or ought to have known that such a
dose was excessive in a young patient with a head injury.
2. In relation to a medication order for parenteral morphine 5mg, 3'd
hourly PRN, the practitioner
(a) Faiied to consult with a more senior member of the neurosurgical
team regarding ongoing pain management issues prior to writng
a prescription for parenteral Morphine 5mg, 3rd hourly PRN,
(b) Inappropriately prescribed parenteral morphine 5mg, 3rd hourly
PRN as an alternative to the prescription of Endone 5-10mg, 3
hourly,
(c) Faiied to document in the medical record instructions for the
dispensing of the parenteral morphine, and
(d) Faiied to communicate to nursing staff instructions for the
dispensing of the parenteral morphine.
3. Failed to make or ensure adequate entries were made in the medical
record, including;
(a) Detaiis of the ward round conducted by the neurosurgical
consultant, including the management plan for Vanessa
Anderson
(b) The reasons for the decision not to prescribe Phenytoin, due to
the possible risk of an allergic reaction,
(c) Detaiis of the discussion with the Neurosurgical Registrar at the
evening 'paper round', regarding the care and treatment of
Vanessa Anderson.
ONUS & STANDARD OF PROOF
17. The HCCC bears the onus of establishing that Dr Willams has been guily of
unsatisfactory professional conduct pursuant to section 36 of the Medical
Practice Act 1992, (the Act), which provides relevantly:
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36 Meaning of "unsatisfactory professional conduct"
(1) For the purposes of this Act, unsatisfactory professional conduct of a
the following:
registered medical practitioner includes each of
(a) Conduct significantly below reasonable standard
Any conduct that demonstrates that the knowledge, skill or
judgment possessed, or care exercised, by the practitioner in the
practice of medicine is significantly below the standard
reasonably expected of a practitioner of an equivalent level of
training or experience.
(b) Contravention of Act or regulations
Any contravention by the practitioner (whether by act or
omission) of a provision of this Act or the regulations, whether or
not the practitioner has been prosecuted for or convicted of an
offence in respect of
the contravention.
18. The Committee noted Dr Williams' admission of certain of the Particulars of
Complaint, and notes that for the Complaint to be proven, the Committee must be
comfortably satisfied on the balance of probabilities that Dr Williams engaged in
the conduct complained of, and that this conduct satisfies the statutory definition
of unsatisfactoiy professional conduct.
1 g. We are mindful also of clause 5 in the Medical Practice Regulation 2003 and
Schedule 2 to the Regulation, compliance with which carries strict liabilty. Thus a
breach of those enlivens section 36(1)(b) of the Act, and a finding of
unsatisfactory professionai conduct. (Re a Medical Practitoner and the Medical
Practice Act dated 3 September 2007).
Cia
use 5(1) provides:
5 Records relating to patients
(1) A registered medical practitioner or medical corporation engaged in the provision
medical services must, in accordance with this Part and Schedule 2, make and
of
the
keep a record, or ensure that a record is made and kept, for each patient of
medical practitioner or corporation.
Note. Although contravlintion of this clause is not an offence, section 36 of the Act provides
a registered medical practitioner is unsatisfactory
that any contravention of the regulations by
professional conduct.
20.ln regard to proof, the Committee is mindful of the Court in Briginshaw v
Briginshaw (1938) 60 CLR 336, which stated as follows:
"But reasonable satisfaction is not a state of mind that is attained or
established independently of the nature and consequence of the fact or
facts to be proved. The seriousness of an allegation made, the inherent
unlikelihood of an occurrence of a given description, or the gravity of
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the consequences flowing from a particular finding are considerations
which must affect the answer to the question whether the issue has
been proved to the reasonable satisfaction of the tribunal. In such
matters 'reasonable satisfaction' should not be produced by inexact
proofs, indefinite testimony, or indirect inferences. ..."
As noted above, the High Court has ruled that decisions by bodies similar to
this Professional Standards Committee must not rely on inexact proof,
indefinite testimony or indirect inferences, and these principles are applied to
this decision.
21. The phrase "signifcantly below" is not defined in the Act. However, it was
considered in the decision of Re A Medical Practitoner and the Medical Practice
2007) where Judge Freeman stated:
Act (40010 of
"As a general principle, the use of the term 'signifcant' may in law be
taken to mean not trivial, of importance, or substantial. J1
22.ln forming our views on the matters before us, the Members of the Committee
have taken into account the seriousness of the matters, the inherent likelihood of
an occurrence of a given description, and the gravity of the consequence flowing
from a particular finding.
23.ln that context, and in applying the standard pursuant to which Dr Williams must
be assessed in relation to the Compiaint of the HCCC, that is whether any
conduct in which she has engaged in relation to Vanessa Anderson
demonstrates that the knowledge, skill or judgment possessed, or care exercised,
by her In the practice of medicine is significantly below the standard reasonably
expected of a practitioner of an equivalent level of training or experience, we
must be mindful of Dr Williams' background, training and experience.
24. Dr Williams graduated in medicine with a Bachelor of Medical Science with
Honours Class 1 from the University of Newcastle in 2000, and Bachelor of
Medicine also from the University of Newcastle in 2002. On the relevant date, 7
November 2005, Dr Willams was in her third year post graduation (PGY3), and
her first rotation in a neurosurgical unit. Dr Williams had previously worked at
RNSH in another department, and on 7 November 2005, was the Senior
Resident Medical Offcer, having commenced in the Neurosurgical Unit on 24
October 2005, that is not more than two weeks before Vanessa Anderson was
admitted to the Unit with a head injury.
25. The evidence before us was that on Monday 7 November 2005 when Dr Williams
came to work åt 7:30 am, and first became aware that Vanessa Anderson had
been admitted on 6 November 2005, there were 32 patients on the ward, the two
usual Registrars were absent on compulsory training, and a Surgical Intern had
Intern was unable to attend on that
been assigned to the ward because the usual
day. The Neurosurgical Fellow was on call, but physically in the operating
theatres for most of the day on 7 November 2005.
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26. Dr Williams stated that her primary responsibility in the neurosurgical team was to
request investigations for all neurosurgical patients, including intensive care
patients, and to follow-up the results. This meant that she spent a part of each
day talking with radiology department staff in person, and physically collecting
scans. She said that she also attended the pre-admission clinics, and looked
after neurosurgery patients on outlying wards and sometimes had to admit
patients in the Emergency Department.
27. We were mindful that on commencement with the neurosurgical team, Dr
Willams had no previous experience in neurosurgery. She was not given any
formal education or orientation regarding general issues, or specifically the use of
anticonvulsant medications, their indications or dosage, or the use of narcotic
analgesics in head injury.
CONSIDERATION OF THE COMPLAINT & REASONS FOR DECISION
28. We are mindful it is not in dispute that on 6 November 2005 Vanessa Anderson
was transferred from Hornsby Hospital to RNSH after sustaining a closed head
injury earlier that day. She was assessed by a Neurosurgical Fellow in the
Emergency Department of RNSH and charted for analgesia, regular
observations, and a repeat CT scan. She was admitted to the Neurosurgical Unit
late in the day on 6 November 2005. Her CT scan which had been done earlier in
the day at Hornsby Hospital could not be located.
29. We have already described that Dr Little, the Consultant Neurosurgeon on call
did not have confirmed for him the fact that Ms Anderson was admitted under his
care on Sunday 6 November 2005, and noted that he expressed frustration that
the first he knew of her admission was when he attended for a routine ward round
at lunchtime on Monday 7 November 2005. We accept that had he known
Vanessa Anderson had been admitted to RNSH on Sunday 6 November, he
would have made a point of examining her on that evening when he attended at
the North Shore Private HospitaL.
30. However, because Dr Little did not know that Vanessa Anderson had been
admitted, he first saw her at lunchtime on 7 November 2005 when he did his
usual ward round. As the Senior Resident Medical Officer on duty, Dr Williams
accompanied Dr Little. During this ward round, and after discussing the pros and
cons of Phenytoin, an anticonvulsant, the Consultant ordered that Ms Anderson
be prescribed Phenytoin. The Consultant also reviewed her medication chart, and
did not alter or recommend changes to the pain management regime.
31. We note by way of completeness that Vanessa's parents were concerned earlier
on Monday 7 November 2005 that she had not been seen by the Consultant, and
asked Dr Williams about transferring to the North Shore Private HospitaL. We are
satisfied from Dr Willams's evidence that she reassured them Dr Little would see
Vanessa when he attended for his ward round, and that that, is in fact, what
occurred. We are satisfied from Dr Williams's evidence that she went back to see
Vanessa and her mother after the ward round with Dr Little to determine if they
had any further concerns or issues they wanted to discuss following the
consultation with Dr Little.
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32. Ms Anderson was scheduled for surgery on Tuesday 8 November 2005 to
elevate the skull fracture. We noted that Mr Anderson, Vanessa's father was
under the impression from Hornsby Hospital on Sunday 6 November 2005 that
the surgery was urgent, and that he was accordingly worried why it had only been
scheduled for 8 November 2005. We were mindful however that Dr Litte
considered the surgery, which had certain medical and cosmetic considerations,
not to be of an urgent nature.
33. Dr Williams admitted certain of the Particulars of the Complaint, some with
qualifications, which we traverse below, but she did not admit that she was guilty
of unsatisfactory professional conduct within the meaning of section 36 of the Act.
In noting that Dr Williams's admissions to certain of the Particulars relating to
record keeping, we are mindful that breaches of clause 5 Schedule 2 carry a
strict liability in relation to section 36.
34. We moved then to consider the Particulars of Complaint which relate to Dr
Williams and the events of 7 November 2005.
35. The Particulars of the Complaint refers variously to "oxycodone" (also known as
oxycodone hydrochloride) and "End
one" (a brand name for oxycodone
hydrochloride.) This decision wil refer to "Endone".
PART/CULAR 1.
On 7 November 2005;
The practitioner failed to discuss the prescribing of oxycodone 10mg
every 3 hours with the Anaesthetic Registrar or a senior member of the
neurosurgical team when she knew or ought to have known that such a
dose was excessive in a young patient with a head injury.
36. We have noted Dr Williams's evidence that on 7 November 2005, when she
attended at 7:30 am, the Neurosurgical Fellow told her of Vanessa Anderson's
admission the previous day. Dr Williams's evidence was that after the
Neurosurgical Fellow had returned to the operating theatre, and at approximately
8:30 am, she conducted a ward round with the Nurse Practitioner, and the
Surgical Intern no-one else was available to attend. Dr Williams remarked that
there normally would have been one or both Neurosurgical Registrars, and/or the
Neurosurgical Fellow.
37. Dr Williams said that this .was her first contact with Ms Anderson. She was
informed Ms Anderson had been nauseous overnight, and that in consultation
with the Nurse Practitioner, she therefore decided to change her medication from
Tramadol to Codeine Phosphate, 30 - 60 mg every four hours, as required. She
noted that Ms Anderson had severe headache. .
38. We have noted from the evidence that the prescription of Codeine Phosphate for
analgesia (pain relief) was standard ward practice for management of skull
fractures with minor head injury, and that as noted below, when Dr Little reviewed
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the medication chart, (at approximately lunchtime), and after seeing Vanessa
Anderson, he did not alter or recommend changes to the pain management
regime, which Dr Williams had ordered.
39. For the sake of completeness, we note that when Dr Little, after conferring with
his treatment team, met with Vanessa Anderson's family at approximately
lunchtime on Monday 7 November 2005, he apologised to the family saying that
he would have seen Ms Anderson sooner if he had been correctly informed of her
admission. Dr Little in his letter of March 2006 to the HCCC, stated he confirmed
to the family that in neurosurgical terms, Ms Anderson's injury was classified
clinically as a mild head injury, but that it would be in the Patient's best interests
to elevate the depressed skull fracture for cosmetic reasons, and to avoid long
term risks such as seizures caused by the penetration of the bone in Ms
Anderson's brain.
40. Dr Little also recalled in his letter that he advised Mrs Michelle Anderson he had
ordered an anticonvulsant be prescribed for Vanessa, and that he had a
conversation with her regarding Vanessa suffering severe headache. Dr Little
said that he explained to Mrs Anderson that he was constrained by the amount of
analgesia he could prescribe in the context of a head injury. Dr Little also recalled
that he did not alter or recommend changes to the pain management regime. He
said that he only discovered after Vanessa had died that further analgesia,
Endone 5 - 10 mgs 3 hourly, and morphine 5 mg three hourly had been ordered
later in the day (7 November 2005).
41.ln reply to the matters raised in Particular 1., Dr Williams said that during the
afternoon of 7 November 2005, Mrs Michelle Anderson was worried about her
daughter's very severe headache, and asked her if she could have intravenous
morphine as she had received in the Emergency Department, saying that this
was the only medication which provided Vanessa pain relief. Dr Williams said that
she explained it could not be administered on the ward, and that she would write
up an intramuscular or a subcutaneous injection of morphine (that is, parenteral
morphine), or that Vanessa could decide instead to have Endone, an oral
analgesic. Dr Willams said that she was satisfied she had made clear to both
Mother and Patient that Vanessa could have either morphine OR Endone, but not
both.
42. We noted that the Anaesthetic Registrar, who attended Vanessa Anderson for a
routine pre-operative anaesthetic consultation in the late afternoon of 7
November 2005, adjusted the dosage of the already charted Endone from 5 mg
six hourly as charted by Dr Williams, to 5 - 10 mg three hourly pm (that is, as
required). This occurred prior to the prescription of morphine as an alternative.
43. Dr Williams admitted that she did not discuss the change in prescription with
more senior staff, including the Anaesthetic Registrar. She gave evidence that
the actions of the Anaesthetic Registrar did not raise any queries for her, in
particular as that doctor was a more senior clinician than she was, and
experienced in pain management.
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44. Dr Williams later charted morphine as an alternative, noting that the dose she
charted was the parenteral equivalent of the Anaesthetic Registrar's Endone
order.
45. We then considered the opinions of the peer reviewers. Dr McGee-Collett, a
neurosurgeon was critical of Dr Williams for not querying the dosage of Endone
prescribed by the Anaesthetic Registrar. His opinion was that there was no
detailed neurological knowledge required, and that a Resident such as Dr
Williams should have known what dosage was excessive. He opined that Dr
Williams failed to appreciate that the dosage was problematic, and felt that she
should have contacted the Registrar or Dr Little about it. We also noted Dr
Chaseling's opinion that as a junior doctor, it was not unreasonable for Dr
Willams not to have questioned the Anaesthetic Registrar.
46.ln summary, in relation to Ms Anderson, on 7 November 2005:
. At the morning ward round Dr Williams ceased Tramadol (due to the
patient's nausea), and prescribed Codeine Phosphate;
. Later that morning Dr Wiliams substituted the Codeine Phosphate with
regular Panadeine Forte and Endone 5mg prn six hourly;
. In the afternoon, the Anaesthetic Registrar ceased Dr Williams's Endone
prescription, and substituted 5 - 10 mgs Endone prn every three hours;
. Late in the afternoon Dr Williams prescribed parenteral morphine intended
as an alternative to the Endone; the morphine was not administered.
discussed
the prescribing of oxycodone 5 - 10 mgs three hourly with the Anaesthetic
47. We noted Dr Williams's evidence that she could not recall whether she
Registrar. She admitted however, that the Anaesthetic Registrar may have
informed her of the change in dosage.
48. Dr Williams said that she deferred to and did not question the Anaesthetic
Registrar because of the Registrar's seniority, and because the Anaesthetic
Registrar would have had specific training in pain management. Dr Willams also
noted that the Anaesthetic Registrar was at the time doing a term in
neurosurgery. Dr Willams also told us that she did not question the Anaesthetic
Registrar's increase in analgesia for Ms Anderson because the Patient had
severe headache, but was alert and not drowsy, and that she herself was
unaware that the dosage may have been excessive.
49. In coming to a decision regarding Particular 1., we give no weight to the "Clinical
Practice Guideline" Dr Wiliams provided as part of her evidence emanating from
the Port Macquarie Base Hospital (Tab 9A) which deals with analgesia, because
it appears to be a general directive rather than related specifically to head injury,
which, we are satisfied, (per Dr Little), has quite different requirements.
50. We were satisfied to the requisite standard that Dr Wiliams communicated with
Mr and Mrs Anderson about their daughter's headache, and the medication she
could have, which was, (after the Anaesthetic Registrar's prescription) to be
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either Endone OR morphine. However, notwithstanding morphine was not given,
we make the finding below that Dr Williams did not document her instructions
adequately to make this clear to nursing staff. Notwithstanding the extreme
shortage of staff in the ward on that day, we are satisfied from the evidence that
Dr Williams spoke to, and assisted Mr and Mrs Anderson as far as she could.
51. We noted that Dr M McGee-Collett wrote in his report of 16 October 2006 in
relation to the dosage of analgesic drugs, and by reference to the autopsy report:
"I note the toxicology results showed a concentration of codeine above the
therapeutic blood level but below the toxic and fatai ranges. Oxycodone (Endone)
was detected within the therapeutic range. Paracetarnol was detected within the
therapeutic range."
52. We are satisfied taking into account the evidence of Dr McGee-Collett and Dr
Litte that the dose of Endone given by the Anaesthetic Registrar was excessive
in a young patient with a head injury. In that regard we noted Dr McGee-Collett's
evidence that no specialised knowledge was required, and that a junior doctor
ought to have known that the dosage was excessive. That may be so, but we are
satisfied that Dr Williams did not have sufficient knowledge about head injury to
consider that the dosage prescribed was excessive, and that in addition, in
deference to a more senior doctor, she did not query the Anaesthetic Registrar or
any other senior doctor about the dosage of Endone.
53. We are satisfied to the requisite standard that Particular 1. is proven, in that Dr
one) 10 mg three
Williams failed to discuss the prescribing of oxycodone (End
houriy as prescribed by the Anaesthetic Registrar with her, or with another senior
member of the neurosurgical team.
54. We accept from Dr Williams's evidence that she did not know that such a dose
was excessive in a young patient with a head injury, and that she deferred to the
seniority of the Anaesthetic Registrar. We have also noted Dr McGee-Collett's
evidence that no specialised knowledge was required, and that a junior doctor
ought to have known that the dosage was excessive. We do not accept that a
young doctor with two weeks' experience in the neurosurgical field should
necessarily be vested with that knowledge. Accordingly we do not accept Dr
McGee-Collett on that point.
55.
In applying the standard pursuant to which Dr Williams must be assessed in
relation to Particular 1. of the HCCC's Complaint, that is whether any conduct in
which she has engaged in relation to Vanessa Anderson demonstrates that the
knowledge, skill or judgment possessed, or care exercised, by her in the practice
of medicine is significantly below the standard reasonably expected of a
practitioner of an equivalent level of training or experience, we must be mindful of
Dr Williams' background, training and experience. We are mindful that Dr
Williams graduated in medicine with a Bacheior of Medical Science with Honours
Class 1 from the University of Newcastle in 2000, and Bachelor of Medicine also
from the University of Newcastle in 2002. On the relevant date, 7 November
2005, Dr Willams was in her third year post graduation (PGY3), and had been in
the Neurosurgical Department at RNSH for less than two weeks. We noted that
on that day, there were 32 patients under her care, the two Registrars were
absent on compulsory training, and a relieving Intern had been seconded to the
13
Unit because of the absence of the regular Resident. The Neurosurgical Fellow
was on call, but physically in the operating theatres for most of the day on 7
November.
56. We accordingly do not find that any conduct in which Dr Williams has engaged in
relation to Vanessa Anderson demonstrates that the knowledge, skil or judgment
possessed, or care exercised, by her in the practice of medicine in relation to
Particuiar 1. is significantly below the standard reasonably expected of a
practitioner of an equivalent level of training or experience. We do not find a
breach of section 36 in relation to Particular 1.
PARTICULAR 2.
In relation to a medication order for parenteral Morphine 5mg, 3rd hourly
PRN, the practitioner (on 7 November 2005)
(a) Failed to consult with a more senior member of the neurosurgical
team regarding ongoing pain management issues prior to writing
a prescription for parenteral Morphine 5mg, 3rd hourly PRN,
(b) Inappropriately prescribed parenteral morphine 5mg, 3rd hourly
PRN as an alternative to the prescription of Endone 5-10mg, 3
hourly,
(e) Failed to document in the medical record instructions for the
dispensing of the parenteral morphine, and
(d) Failed to communicate to nursing staff instructions for the
dispensing of the parenteral morphine.
Particular 2.(a)
57.
In relation to Particular 2.(a), Dr Wiliams agreed that she had not consulted with
a more senior member of the neurosurgical team regarding ongoing pain
management issues prior to writing a prescription for parenteral morphine 5mg,
3rd hourly pm, and we so find. She explained that the practice in the
Neurosurgical Unit was that the resident medical officers regularly charted
analgesia orders without consulting more senior members of the team. We noted
that Dr Little's opinion that this was the duty of the junior doctors, and we
accepted that.
58. We were mindful also of Dr Williams's evidence that the morphine was intended
as an alternative to the Endone prescribed by the Anaesthetic Registrar, and that
the dose of morphine she prescribed was equivalent to the dose of Endone
prescribed. We accepted that she explained that to the Patient and her mother.
Unfortunately, as noted later in these Reasons for Decision and notwithstanding
the morphine was not administered, Dr Williams did not adequately document the
morphine as an alternative to the Endone.
14
59. We accept Dr Chaseling's oral evidence that if the Anaesthetic Registrar
prescribed Endone 5 - 10 mg three hourly, then, in his opinion, the Resident
would not question that. We also noted Dr WilHams's evidence in that regard.
60. Ms Fackender referred to Dr Little's evidence, and submitted that had he been
contacted regarding the prescription 5 - 10 mg three hourly of Endone, he would
not have permitted that dosage. We accept that submission.
61. Given the admission by Dr Williams, who agreed before us, that she had not
consulted with a more senior member of the neurosurgical team regardin'g
ongoing pain management issues prior to writing a prescription for parenteral
morphine 5mg, 3rd hourly pm, we find Particular 2(a) proven. We accept however
from the evidence of Drs Little and WilHams that such charting of medication was
regularly carried out by junior doctors.
62. We find Particular 2.(a) proven. However, applying the standard referred to in the
paragraphs above in relation to Dr WilHams, and the practices of the
Neurosurgicai Unit in 2005, we do not find a breach of section 36.
Particular 2.(b)
63.ln relation to Particular 2.(b), Dr Williams admitted she had prescribed parenteral
morphine 5mg, 3rd hourly pm as an alternative to the prescription of Endone 5 -
10mg, 3 hourly by the Anaesthetic Registrar, but did not admit that it was
inappropriate.
64.ln assessing Particular 2.(b), we noted that the Anaesthetic Registrar prescribed
the increase in Endone to 5 -10 mgs three houriy pm when she saw Ms
Anderson in the afternoon of 7 November 2005 at a pre-operative assessment
prior to the surgery scheduled for the following day, and in response .to the
Patient's reports of severe headache. Dr Littie told the Committee that the
Anaesthetic Registrar did not consult him about the amount of Endone she
prescribed. He opined that the dosage was excessive, and that he would not
have allowed that prescription if he had been consulted.
65.ln that regard we noted that on 7 November 2005, 10 mgs of Endone had been
administered to Vanessa at 20:00 hrs, 10 mgs at 23:00 hrs; a further 10 mgs
were given at 02:00 hrs on 8 November 2005. Dr Little said that what struck him
most when he saw the medication chart on 8 November 2005, was that the
Endone had been given so regulariy.
66. Dr Little also remarked that at the relevant time Dr Williams was very
inexperienced in the management of patients with head' injury, and that the
experience she had had in the orthopaedic ward where she had been prior to
joining the Neurosurgical Unit was a very different one.
ling who also gave oral evidence, produced a report dated 17 April
2007 which was before the Committee. He told us that in his opinion the dosage
of Endone prescribed by Dr WilHams of 5mg six hourly pm was not inappropriate
in the circumstances. Dr Chaseling commented on the chain of authority, and
67. Dr R Chase
15
opined that the Complaint sought to make Dr Wiliiams, one of the most junior
doctors in the team, responsible for the administration of excessive Endone when
the responsibiiity should have been that of the anaesthetic and pain teams. He
commented that a new and young doctor would be unlikely to ask a more senior
doctor about the appropriateness of particular medication.
68. When asked about whether Endone 5 - 10 mg three houriy was an appropriate
dose of opioid, Dr Chaseling, who is a neurosurgeon, said that he did not know,
but that he thought fourth or six hourly would have been a more reasonable dose.
69. Dr Chaseling said that Dr Wiiiams's notation on the Medication Chart in regard to
Endone and morphine was not clear but if they had been shown as alternatives
rather than that the drugs be given concurrently, he would not be critical of Dr
Williams. He noted that in fact Ms Anderson was not 9iven the morphine.
70. We also had before us, Dr McGee-Collett who wrote in his report of 16 October
2006 in relation to the dosage of analgesic drugs, and by reference to the
autopsy report: "I note the toxicology results showed a concentration of codeine
above the therapeutic blood level but below the toxic and fatal ranges.
Oxycodone (Endone) was detected within the therapeutic range. Paracetamol
was detected within the therapeutic range."
71. Dr McGee-Collett also opined that the recommended adult dose (and Ms
Anderson's size and weight equated with that of an adult), should be Endone
5mg every six hours. He opined that this was knowledge required in basic
medical practice, and he did not accept that Dr Wiliiams should be excused due
to her inexperience in brain injury. He described the communications he would
expect Dr Williams to have had with the Patient regarding her pain, any
apprehension or anxiety she had with regard to surgery, queries of the
Anaesthetic Registrar with regard to high doses of opiates, and good record
keeping.
72. Dr McGee-Collett opined that it was a serious error to prescribe such large doses
of regular Endone as Ms Anderson received, because of the depressant effect on
the respiratory system. He opined that the prescription of morphine after the
Endone (even though the morphine was not given), indicated a lack of
appreciation by Dr Wiiiiams of opioid problems. Dr McGee-Collett stated that he
would be less critical than otherwise if the morphine was an alternative to
Endone, but was critical because that had not been made clear by Dr Wiliiams in
the ciinical notes. He was also critical that Dr Wiiliams had left the choice to the
Patient of how the morphine would be administered, stating that it should have
been discussed, and then decided and documented by Dr Williams. The
Committee accepted his opinions on those points.
73.ln coming to a decision regarding Particular 2.(b), we are mindful that Dr
Williams admitted she had prescribed parenteral morphine 5mg, 3rd hourly pm
as an alternative to the prescription of Endone 5 -10mg, 3 hourly by the
Anaesthetic Registrar, but did not admit that it was inappropriate.
74. We noted that the recommended dosage of Endone, as discussed by the expert
witnesses referred to above, was precisely the dosage which Dr Wiliams had
16
originally prescribed, and which the Anaesthetic Registrar had altered. We
accepted Dr Williams's evidence that her knowledge with regard to higher doses
of Endone was limited, and that she would not query a senior practitioner with
specific training in anaesthesia and pain management. We noted also Dr
Williams's reliance on the fact Ms Anderson was alert and not drowsy.
75.ln coming to a decision the Committee must take into account the level of training
and experience Dr Williams had at the relevant time as discussed earlier in these
Reasons for Decision. Accordingly, we do not hold her responsible for the
prescription of Endone made by the Anaesthetic Registrar, or responsible for not
querying it.
76. The Committee was satisfied in relation to Particular 2.(b), that if the
communication, both to the nursing staff and in the notes had been clear that the
morphine was an alternative to the Endone, then we would not be considering
Particular 2(b). However both the method of dispensing the morphine, and the
instruction that the morphine was an alternative to the Endone were not clearly
enunciated in writing as they should have been. We have dealt with this failure
further on in these Reasons for Decision.
77. The Committee finds the admission (i.e. that Dr Williams prescribed parenteral
morphine 5mg, 3rd hourly pm as an alternative to the prescription of Endone 5 -
10mg, 3 hourly by the Anaesthetic Registrar), proven, and accepts that the
morphine as an alternative to the Endone was not inappropriate. Particular 2.(b)
is not proven.
Particular 2.(c)
78.As to Particular 2.(c); Dr Willams admitted that she failed to document in the
medical record instructions for the dispensing 'of the parenteral morphine.
However she told us she relied on the practice in the Unit, which considered a
written entry in the Medication Chart without a corresponding entry in the medical
record as adequate documentation. She agreed at the Inquiry that she should
have documented in the medical record the instructions for the dispensing of the
parenteral morphine. However she had spoken to Mrs Michelle Anderson, and
left it open for Vanessa to choose whether she wanted to have the morphine
intramuscularly, subcutaneously or as a tablet. Dr McGee-Collett was critical of
Dr Willams for having left open to Ms Anderson to select which form of analgesia
she should have, whether it was to be morphine or Endone. He opined that Dr
Willams should have made clear in the notes, after discussion with the Patient,
how any morphine was to be administered, and the Endone suspended.
79. We have noted that Dr McGee-Collett criticised the illegibilty of the medication
chart. We have already noted above however, that it was the Anaesthetic
Registrar who prescribed Endone 5 - 10 mgs three hourly. We accept the
evidence that the Anaesthetic Registrar overwrote Dr Williams's lower dose
which the latter had prescribed and written on the medication chart, thereby
causing the illegibility for which Dr Williams cannot be held responsible.
17
80. The Committee finds that Particuiar 2.(c) proven, and finds that Dr Williams faiied
to document in the medical record, instructions for the dispensing of the
parenteral morphine which is a breach of clause 5 and Schedule 2 of the Medical
Practice Regulation 2003 relating to the requirement to keep proper medical
records. This is a strict liabiiity requirement, the breach of which constitutes a
breach of section 36 of the Act. That means that in relation to Particular 2.(c), Dr
Williams is guilty of unsatisfactory professional conduct.
Particular 2.(d)
81. Particular 2.(d) was the HCCC Complaint that Dr Williams faiied to communicate
to nursing staff instructions for the dispensing of the parenteral morphine. Dr
Wiilams told us that she could not recall whether she communicated the relevant
instructions to the nursing staff, but thought she had. She admitted however that
she did not document those instructions. We noted Dr Williams's recollection that
she hadexpiained the alternatives in regard to the morphine to the Patient and
her mother, and that she was satisfied they had both understood.
82. We noted that there was no specific allocated field for those instructions in the
Medication Chart, but are satisfied that it is nevertheless possible to document
instructions elsewhere in the chart, and recommend that such charts be amended
in the future by the Hospital in order to ensure that appropriate documentation
can be achieved more efficiently.
83. The Committee noted from the nursing notes dated 7 November 2005, at Tab 14,
pp 34135 as follows:
"... Pi has had headaches Ihe .entire shif, scoring 9110. PI's analgesia
ONE and sic
has been reviewed by team, and now on Pm END
Morphine. Pt also on regular panadeine forte..."
84. We are satisfied that this entry suggests that the morphine and Endone were not
recorded as alternatives, but with the conjunctive AND. The nursing record
corroborates the evidence that Dr Willams did not communicate instructions to
the nursing staff for the dispensing of the parenteral morphine, nor that it was
intended as an alternative to Endone. We are satisfied however, that
notwithstanding the annotations in the nursing notes, although Vanessa's
headache was very severe. she was not given the morphine.
85.Accordingly, we were satisfied that there were no specific instructions to the
nursing staff regarding the dispensing of the parenteral morphine, and that
Particuiar 2.(d) is proven. Having considered the evidence and the standard by
which Dr Wiilams is to be judged, we do not find a breach of section 36 in regard
to Particular 2.(d).
PARTICULAR 3.
Failed (on 7 November 2005), to make or ensure adequate entries
were made in the medical record, including;
18
(a) Details of the ward round conducted by the neurosurgical
consultant, including the management plan for Vanessa
Anderson
(b) The reasons for the decision not to prescribe Phenytoin,
due to the possible risk of an allergic reaction,
(c) Details of the discussion with the Neurosurgical Registrar at
the evening paper round', regarding the care and treatment
of Vanessa Anderson.
Particular 3.(a)
86.ln regard to Particular 3.(a), we noted the complaint that on 7 November 2005, Dr
Willams failed to make, or ensure adequate entries were made in the medical
record, including details of the ward round conducted by the Neurosurgical
Consultant, including the management plan for Vanessa Anderson.
87. Dr Williams admitted that she did not make entries in the medical record referred
to above, including details of the ward round conducted by Dr Little. However she
told the Committee that she expected the junior resident (in this case, the
inexperienced relieving Intern), or Nurse Practitioner would do so, but accepted
that it was her responsibility to either make the appropriate entries, or ensure that
they had been made. Dr Willams accepted that the records in regard to Vanessa
Anderson and the Consultant's ward round and on 7 November 2005 were
inadequate.
88. Dr Little told the Committee that it was generally the Resident who made the
entries in the records, noting that the nursing notes are a separate issue. Dr
McGee-Collett, was critical of Dr Williams, and stated that as she, and the
relieving Intern, appeared to have been the only medical officers present in the
ward round with Dr Little, and involved in the patient care at the relevant time on
7 November 2005, it was their joint responsibility to maintain the records,
including:
. those in relation to the prescription of Phenytoin (anticonvulsant
medication) which ultimately was not given;
. the intention that Ms Anderson proceed to surgery the following day; and
. the results of the CT scan performed on 7 November 2005.
89. Dr McGee-Collett opined that lack of detail to the above represented a. significant
departure from an acceptable standard. He a9reed that in hospital practice not
everyhing is recorded, but that significant issues must be, and he was critical of
the fact the Phenytoin issue had not been recorded in the notes.
90. The Committee noted also the submission by the HCCC that, in addition, the
issue of the difficulty of pain control for the Patient should have been the subject
of notes. We agree with Drs Little, McGee-Collett and the HCCC on the above.
91. We have already noted in the paragraphs above that, in mitigation, the standard
by which Dr Williams is judged in this case is that of a junior doctor who was left
19
without adequate supervision or assistance to virtually operate the Neurosurgical
Unit singlehandedly on 7 November 2005, two weeks after she had commenced
her rotation there.
92. We are also concerned that Dr Little, whose responsibilities under the Medicai
Practice Act and the Medical Practice Regulation are judged by the standard of a
Consultant (rather than those of a junior doctor), did not either make notes or see
that they were made in relation to the ward round on 7 November 2005,
particularly as he expressed frustration at not havin9 been notified of Vanessa
Anderson's admission before then.
93. Failure to make adequate records or ensure they are made appropriately
constitute breaches of clause 5 and Schedule 2 of the MedIcal Practice
Regulation 2003. We are mindfui that breaches of record keepin9 in regard to the
keeping of proper medicai records are strict liability offences which result in a
breach of section 36 and a finding of unsatisfactory professional conduct. The
Compiaint made in Particular 3.(a) is proven.
Particular 3.(b)
94.ln regard to Particular 3.(b), we noted the Complaint stated that on 7 November
2005, Dr Williams failed to make, or ensure adequate entries were made in the
medical record, including the reasons for the decision not to prescribe Phenytoin
due to the possible risk of an allergic reaction.
95. We are mindful of the evidence before us which was that Dr Little discussed with
Dr Williams and with the Patient's mother, his decision to prescribe Phenytoin. Dr
Williams told us that after Dr Little had left, Vanessa's mother told her that the
Andersons' son (Vanessa's brother), had suffered a reaction as a result of a
similar drug. Dr Williams said that she had perceived Dr Little had been equivocal
about the risk of Vanessa suffering a convulsion and therefore whether or not it
was necessary for her to have Phenytoin or a similar anticonvulsant. Based on
this perception and after a discussion with the Nurse Practitioner, Dr Williams
decided not to give the Phenytoin until she had discussed this with the
Neurosurgical Fellow. We noted that she did not record that decision, or the
reasons for making it in the medical record.
96. We had before us as a letter from the Neurosurgical Fellow to the HCCC dated
12 July 2006, in which he stated that the administration of Phenytoin was
discussed at the evening hand-over to which he referred as the "board round", or
which was also known as the "discussion round", and routinely held in the
Registrar's common room. He stated that after consideration of the fact
anticonvulsant medication had not been commenced due to the risk of possible
allergy, "we decided no/to start any anti-convulsion (sic)." The Committee noted
therefore that the Neurosurgical Fellow was involved in the decision not to give
Phenytoin, but that he did not document that decision. We are mindful from her
evidence that Dr Williams was present at the meeting to which the Neurosurgical
Fellow referred, and that she did not document the decision either.
20
97. When asked if Dr Williams should have consulted him regarding any changes in
the decision to prescribe Phenytoin, Dr Littie replied that as he was not present,
the Neurosurgical Feliow should have been consuited. He also told the
Committee that there were no guidelines on prescribing anticonvulsanls or
analgesia avaiiabie in the ward, although on-line information was availabie.
98. Dr McGee-Collett noted that aithough anticonvulsant medication is not uniformly
prescribed for depressed skull fracture, he was miidly critical of Dr Willams's
failure to communicate with the Neurosurgical Fellow and clear up any issues
regarding whether such medication was to be given to Ms Anderson. He was also
critical of Dr Willams for not having overseen .the maintenance of adequate
medical records.
ling opined he was critical of that the lack of documentation regarding
the Phenytoin issue, but added that "surely no-one ImagInes this is a causal
99. Dr Chase
fac/or in a tragic case that remInds us that nothIng Is 'sImple'." He added one
could not spend all day writing, but opined that significant changes in a patient's
condition had to be documented.
1 00. We have already noted in the paragraphs above that the standard by which Dr
Williams is judged is that of a junior doctor who was left without adequate
supervision or assistance to virtually operate the Neurosurgical Unit
singlehandedly on 7 November 2005, two weeks after she had commenced her
rotation there. We noted that Dr Willams had no induction into the Neurosurgical
Unit and no training with regard to the administration of anticonvulsants in that
context.
101. We have noted elsewhere that traditionally no notes were kept of the ''paper
round", but note by way of completeness that as the Neurosurgical Fellow made
the final decision (at the ''paper round" in the evening hand-over), not to give the
Phenytoin, it was his responsibility to have documented that. In addition, Dr
Williams should have documented her decision during the day not to give the
Phenytoin.
102. The Committee is mindful that failure to make adequate records or ensure
they are made appropriately, constitute breaches of clause 5 and Schedule 2
of the Medical Practice Regulation 2003. We mindful that breaches of record
keeping in regard to the keeping of proper medical records are strict liabilty
offences which result in a breach of section 36 and a finding of unsatisfactory
professional conduct. The Complaint made in Particular 3.(b) against Dr
Wiliams is proven.
Particular 3,(c)
103. In regard to Particular 3.(c), we noted the Complaint that on 7 November
2005, Dr Williams faiied to make or ensure adequate entries were made in the
medical record, Including details of the discussion with the Neurosurgical
Registrar at the evening "paper round", regarding the care and treatment of
Vanessa Anderson.
21
104. Dr Williams's evidence was that the ''paper round" was held in a room away
from the patients, which was known as the "command centre", that it was a
brief hand-over meeting, attended by the day medicai staff and the Registrar,
or in this case the Neurosurgical Fellow who was to be on call that night. She
told us that no written records of that meeting were generally made. Dr
Willams said that in relation to Vanessa Anderson, she told the Neurosurgical
Fellow about the surgery scheduled for the next day, and discussed the
anticonvulsant medication issue with him. She said that her impression from
Dr Little had been that although he ordered Phenytoin, it was not a "black and
white" issue, and that she left any further action to the Neurosurgical Fellow,
who was on calL. She said that after the "paper round" on 7 November 2005,
she left the ward at approximately 17:30 hrs to go home.
105. Dr Little confirmed in his oral evidence that the evening "paper round" was
conducted without seeing the patients, and that it was a hand-over as the
Residents were going off duty, and the Registrar would be on calL.
106. Dr McGee-Collett stated that he was moderately critical of Dr Williams for not
having made an entry in the notes following the "paper round" as he felt that
issues surrounding Dr Little not having been informed of Ms Anderson's
admission in a timely way, and the issue of the anticonvulsant medication
required documentation.
107. Dr Chaseling opined in relation to the hand-over that changes in patient
management should be documented, was however not surprised, he said,
that the hand-over was not documented in the Anderson case. He opined that
routine practice in the hospital system was not to formally document such
meetings in the clinical notes, although he expected in the future that might be
the case.
108. We are satisfied to the requisite standard that the practice in the
Neurosurgical Unit at RNSH at the relevant time was that no written records
were made in relation to the "paper round", and that accordingly, Dr Williams
did not make records of the ''paper round". She admitted she did not, and we
cannot hold her responsible for it. Accordingly we do not find that she
breached Clause 5 and Schedule 2 of the MedIcal Practice Regulation 2003
which relate to the keeping of proper medical records in relation to the "paper
round" on 7 November 2005.
109. We are satisfied however, and note by way of completeness that as the
Neurosurgical Fellow made the final decision not to give the Phenytoin, and
as this was a significant issue being a departure from an instruction given by
the Consultant, he should have documented that.
REFERENCES
110. Dr Williams tendered the RACS Basic Surgical Training - In Training
Assessment Form for the period 25/10/05 to 22/1/06 from the Department of
Neurosurgery. She attained "above average" and "excellent" ratings in most
categories as well as several "satisfactory" ratings. The overall remark by Dr
22
Litte who signed off the assessment, was that she was an "excellent
candidate" and should continue in the training position.
111. Dr Williams also tendered her Australian Orthopaedic Association Quarterly
Assessment Report - Trainee Evaluation Form for 19/7/09 to 19/10109 for the
orthopaedic hand and upper limbs surgical unit at the John Hunter HospitaL.
All the categories were marked either "Competent" or "Excellent': and the
remarks indicated that Dr Willams has "a high ievei of generai surgical
competence ieading into her final year of training".
112. Dr Wiliams also tendered a number of referee statements. None of them were
sworn statements, and none of the witnesses were called to give evidence.
The referees were asked by Avant Law Pty Ltd to provide references. We
have dealt with them in the following paragraphs in the order of appearance in
the documents.
. Dr 0 Dewar stated in his unsigned leiter or 14 September 2009 that he is
an Orthopaedic Trainee, and worked with Dr Williams in July 2008 when
he was an Orthopaedic Registrar in Maitland HospitaL. He praised Dr
Willams for her communication skills, her surgical skills, her clinical
decision making skills, and the fact she is dedicated to the care of her
patients. Dr Dewar noted that Dr Williams is well-respected, and that she is
now a Senior Registrar and National President of the Australian
Orthopaedic Registrars Association.
. Professor A Ghabrial, Orthopaedic Senior Staff Specialist at the Royal
Newcastle Centre stated in his leiter of 31 August 2009 that he had known
Dr Williams for the past six years, noting she had been a Trainee Registrar
for the past three years. He praised her unreservedly for her work and
atttudes, and stated that she would be favourably considered for a senior
position at the Newcastie Bone & Joint Institute. He referred to Dr Willams
being involved in an incident at RNSH, and remarked how distressed she
had been in that regard, and what genuine remorse and contrition she had
expressed.
. Dr S Ruff, Orthopaedic and Trauma Surgeon who is the Senior
Orthopaedic Surgeon to the Dubbo Base Hospital and the Spinal Injuries
Unit at RNSH, wrote on 19 September 2009 that Dr Williams had been a
Resident Medical Offcer on his team in 2004, describing her as
personable, effcient, dilgent and universally admired by staff and patients
alike. Dr Ruff referred to the incident of 7 November 2005, and remarked
that Dr Williams had been devastated by the events of that day, and
continually questioned and evaluated her role and involvement in the care
and outcome of the Patient.
. Dr B Meads, a hand surgeon wrote on 22 September 2009 in support of
Dr Willams. He stated that he had had contact with her work over a period
since 2004, and that she was currently the Hand Surgical Registrar at the
Royal Newcastle HospitaL. He praised her knowledge and diligence, and
mentioned the remorse and contrition she expressed over the Vanessa
Anderson case.
23
. Professor M Gleeson, Director of the Hunter Medical Research Institute
is an active medicai researcher in the field of immunology, and has 35
years experience in diagnostic pathology. Professor Gieeson supervised
Dr Williams in 1999 when she did the Bachelor of Medical Science,
investigating the causes of upper respiratory infections in elite athletes.
She praised Dr Wiilams for her commitment and excellence.
. Dr D Nicholson, Orthopaedic Foot and Ankle Surgeon who is a VMO with
the Hunter New England Area Health Service wrote an undated letter to
Avant date stamped "received on 10 November 2009". He mentioned Dr
Williams's dedication and competence, and mentioned that she had
received the Centenary Medal for Contribution to Australia Society and the
NSW Young Australian of the Year for Science and Technology in 2002.
Dr Nicholson stated that he had discussed with Dr Williams the incident in
which she had been involved at RNSH, and commented that she is
strongly committed to the process to try and prevent such disastrous
circumstance arising in future.
EXHIBITS
113. The Committee has considered the foliowing documents which were provided
by the parties prior to the hearing: 1 to 17 from the HCCC and 1 to 3 from Dr
Wiilams.
114. Mr Anderson provided an emaii to Ms Fackender on the second day of the
Inquiry, which is referred in the "Background" section above.
FINDINGS
115. The Committee must be reasonably satisfied of any findings that it makes. In
forming its views on these matters the Committee has taken into account the
seriousness of the matters, the inherent likelihood of an occurrence of a given
description, and the gravity of the consequence flowing from a particuiar
finding.
116. The Committee has considered the written and oral evidence and the
submissions by the parties, and must decide the following:
. Whether the Committee is comfortably satisfied of any or all Particulars of
the Complaint of the HCCC against Dr Williams being proven;
. If so, whether the Committee is satisfied that the Complaint against Dr
Williams is proven, and that section 36 of the Medical Practice Act 1992
(the Act) has been breached;
24
. If so, the Committee's decision regarding what, if any, Orders or
Directions pursuant to Division 4 of Part 4 of the Act would be
appropriate.
117. We are mindful also of Clause 5 and Schedule 2 of the Medical Practice
Regulations 2003, which are strict liability requirements. Thus a breach of
those enlivens section 36(1 )(b) of the Act, and the finding of unsatisfactory
professional conduct (Re a Medical Practitioner and the Medical Practice Act).
118. We accepted Dr Williams's evidence that she was devastated by the death of
Vanessa Anderson. We note that she has undertaken a great deal of medical
studies and work since that time. We accept the submissions made on her
behalf that the incident affected her intensely on a personal level, that there
are now in place changes to the Neurosurgical Unit policy, and that there is a
pain protocol in regard to head injury patients. We are satisfied that the risk of
a repetition of what occurred in Ms Anderson's case is low. The Particulars of
the Complaint in relation to Dr Williams which we have found proven relate to
medical records and documentation, and it is significant to note that in her
most recent training assessment form, relating to the period July to October
2009, Dr Williams' record keeping has been rated as excellent.
119. We have referred to two progress reports, one dealing with Dr Williams's work
in 2005, and the other with her current performance. Both have praised her
commitment and her work.
120. We have also reviewed the referee reports, mindful that it is unlikeiy that a
person would tender unfavourable reports. However we were impressed that
although the referees emanate from different periods in Dr Williams's training,
her competence and commitment to patients and her work is universally
spoken highly of. It is noteworthy that she is National President of the
Australian Orthopaedic Registrars Association.
rise the findings, and is comfortably
121. The Committee turned then to summa
satisfied in relation to the Particulars of Complaint as follows:
. Particular 1. is not proven. We do not find any conduct in which Dr
Williams has engaged in relation to Particular 1. that demonstrates that the
knowledge, skill or judgment possessed, or care exercised, by her in the
practice of medicine is significantly below the standard reasonably
expected of a practitioner of an equivalent level of training or experience.
We do not find a breach of section 36 in relation to Particular 1. The
Complaint of unsatisfactory professlonai conduct is accordingiy not
established in relation to Particular 1.
. Particular 2.(a) proven. However, applying the standard referred to in the
paragraphs above in reiation to Dr Williams, and the practices of the
Neurosurgical Unit in 2005, we do not find a breach of section 36 of the
Act.
. Re Particular 2.(b), the Committee notes the admission (I.e. that Dr
Williams prescribed parenteral morphine 5mg, 3rd hourly pm as an
25
alternative to the prescription of Endone 5 -10mg, 3 hourly by the
Anaesthetic Registrar). However the Committee finds it was not
inappropriate for Dr Williams to have done so. Particuiar 2.(b) is
accordingly not proven.
. The Committee finds Particular 2.(c) proven, and finds that Dr Williams
failed to document in the medical record, instructions for the dispensing of
the parenteral morphine which is a breach of clause 5 and Schedule 2 of
the Medical Practice Regulations 2003 relating to the requirement to keep
proper medical records. That is a strict liability requirement, the breach of
which constitutes a breach of section 36 of the Act. That means that in
relation to Particular 2.(c), Dr Williams is guily of unsatisfactory
professional conduct.
. The Committee was satisfied that there were no specific instructions to the
nursing staff regarding the dispensing of the parenteral morphine, and that
Particular 2.(d) is proven. Having considered the evidence and the
standard by which Dr Wiilams is to be judged, we do not find a breach of
section 36 in regard to Particular 2.(d).
. Failure to make adequate records or ensure they are made appropriately,
constitute breaches of clause 5 and Schedule 2 of the Medical Practice
Regulation 2003. We are mindful that failure to maintain records in
accordance with the Regulation are strict liabiliy offences and such failure
results in a breach of section 36 and a finding of unsatisfactory
professional conduct. The Complaint made in Particular 3.(a) is proven,
and a finding of unsatisfactory professional conduct is made.
. The Committee is mindful that failure to make adequate recdrds or ensure
they are made appropriately, constitute breaches of clause 5 and
Schedule 2 of the Medical Practice Regulation 2003. We mindful that
breaches of record keeping in regard to the keeping of proper medical
records are strict liability offences which result in a breach of section 36
and a finding of unsatisfactory professional conduct. The Complaint made
in Particular 3.(b) against Dr Wiilams is proven, and a finding of
unsatisfactory professional conduct is made.
. With respect to Particular 3.(c), concerning the keeping of proper medical
records in relation to the ''paper round" on 7 November 2005, the
Committee does not find that Dr Williams breached clause 5 and Schedule
2 of the Medical Practice Regulation 2003.
122. We add that we have concerns regarding the system under which Dr Williams
was working, and have expressed those in a section below in these Reasons
for Decision entitled "Matters of Further Concern to the Commitee".
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DETERMINATION
123. The Committee finds Dr Williams guilty of unsatisfactory professional conduct
within the meaning of section 36 of the Act in that she contravened clause 5
and Schedule 2 of the Medical Practice Regulation 2003 relating to the
requirement to keep proper medical records.
ORDERS
124. The purpose of disciplinary proceedings is both to protect the public and to
assist in maintaining the appropriate clinical and ethical standards of the
profession. With the object of protecting the public in mind, we must take
account of both the likelihood of Dr Williams repeating the conduct in which
she has been found to have engaged, and also the need to deter others from
falling short of the expected standards. It is not our role to punish Dr Williams.
We are satisfied that Dr Williams has undertaken further serious study since
2005, and that she is focused on teaching other doctors and medical students
the correct way of carrying out and documenting their work. We find that the
risk of her engaging in a repeat of what occurred in relation to record keeping
on 7 November 2005, very unlikely.
125. In such circumstances, the risk of any repetition has been addressed, and the
health and safety of the public protected. It follows then that it is not necessary
for the Committee to exercise any of its powers pursuant to section 61 (1 )(c)(f) in order to protect the public.
126. The Committee does not make any orders in this matter.
PUBLICATION OF DECtSION
127. Pursuant to section 180(1) of the Act the Committee provides a copy of this
written Statement of Decision to:
Dr Williams, the Respondent
Avant Law, Dr Williams's adviser
Health Care Complaints Commission
Mr Warren and Mrs Michelle Anderson, Vanessa's parents
NSW Medical Board
Royal North Shore Hospital
Northern Sydney Central Coast Area Health Service
The NSW State Coroner
27
128. Pursuant to section 180(3) of the Act the Committee provides a copy of this
written statement of decision to:
Dr Little
Dr McGee-Collett
Dr Chase
ling.
THE COMMITTEE'S FURTHER CONCERNS
129. The Committee noted several points during its Inquiry which relate to the
hospital system under which the Complaint regarding Dr Williams arose, and
feels it would be useful to refer to them here wilh a view to having rectification
measures taken.
130. We were mindful that on commencement with the neurosurgical team in
October 2005 Dr Williams was not been given any formal education or
orientation regarding general issues, or specifically in the use of
anticonvulsant medications, and analgesics in head injured patients, or their
indications or dosage. Specific targeted education of new junior members of
the medical team is essentiaL.
131. This Complaint arose in circumstances in 2005 where Dr Williams had been at
the Neurosurgical Unit for less than two weeks. As the evidence and findings
above indicate, she was left unsupervised, and virtually in charge of the ward
on 7 November 2005. Staffing issues are of concern here.
132. We noted Dr McGee-Collelt's evidence that he was critical of the
Neurosurgical Unit at RNSH as it appeared not to have a protocoi wilh regard
to analgesia. He. said that he regarded this as a basic medical care issue.
Protocols are important.
133. We noted Dr Lilte's evidence regarding the notification he, as the Consultant
Neurosurgeon on call at RNSH on Sunday 6 November 2005, received with
regard to Vanessa Anderson. The fact that he was not accurately apprised of
her admission by the Neurosurgical Fellow on 6 November 2005 may have
exacerbated the adverse oulcome of this case. We noted Dr Littie's evidence
that had he known Vanessa Anderson had been admitted to RNSH (on 6
November 2005), he would have made a point of examining her. He added:
"In a case such as Vanessa's where there is a potential for surgery, on
learning of her admission in ail likelihood i would have made a special trip to
the hospital to see her that evening". Failure to nolify a Consultant preciseiy
regarding a head injury patient under his care is a serious breach in what
should be well established procedures.
134. We noted Dr M McGee-Collett's evidence that the inattention to detaiied
record keeping was an indication of what may be "a culture of inattention to
28
small detail creeping into our health system... ". In that regard we noted that
neither the Neurosurgical Feilow nor Dr Litte, Consuitant Neurosurgeon and
VMO who were in attendance at Vanessa Anderson's attempted resuscitation
on 8 November 2005 made any notes on 8 November 2005.
135. The Committee agrees that more education regarding medico-legal issues
and the content of the Regulation under the Medical Practice Act be provided
for medical students and junior doctors.
136. The Committee has dealt with the Complaint before it as it must. However we
feel we must make clear our opinion that this Complaint should have been
referred to the Board to be dealt with by way of its Performance Program.
APPEAL
137. An appeal against this decision is available under section 87 of the Act or
section 88 if the appeal is with respect to a point of law. Such an appeal is to
be made within 28 days of the handing down of the decision (or such longer
period as the Registrar may allow in any particular case).
C';I
.,
Ms Geri Etting r
Chairperson
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