CAWANGAN MEDICO LEGAL BAHAGIAN AMALAN PERUBATAN KEMENTERIAN KESIHATAN MALAYSIA

Dr Mohamed Faruqi Uzair Bin Mohamed Sidek Ketua Penolong Pengarah Cawangan Medico LegalBahagian Amalan PerubatanKementerian Kesihatan Malaysia

Case Discussions- Recent Medicolegal cases: What

can we learn    

Content:  

•  Complains  •  Ex  Gra2a  •  Li2ga2on  • Medico  Legal  Hazards  

Complaints    

Why  do  people  complain?  

BILANGAN ADUAN YANG DITERIMA OLEH KKM DAN ADUAN BERPOTENSI MEDICO-LEGAL PADA

2006 HINGGA 2012

TAHUN BILANGAN ADUAN DITERIMA OLEH KKM *

2006 425

2007 3,758

2008 5,044

2009 5,602

2010 6,001

2011 6,692

2012

JUMLAH

5,614

33,136

*  SUMBER  :  UNIT  KOMMUNIKASI  KORPORAT,  KKM  

Potential Medico Legal

Year Cases

2010 202

2011 285

2012 223

2013 235

2014* 186 *Till September 2014

Laporan akhbar/ laporan media elektronik

Sistem SiSPAAA (penugasan

daripada UKK)

Aduan terus melalui

telefon atau datang

sendiri ke CML BAP

Aduan bertulis melalui surat atau email

Aduan melalui pejabat Menteri / KSU / KPK

Aduan yang dipanjangkan daripada JKN beserta Laporan siasatan awal

Ex  Gra2a  

EX  GRATIA

Defini6on:  •  Origin  La2n,  ‘from  favour’        •  adverb  &  adjec2ve  (with  reference  to  payment)  done  from  a  sense  of  moral  obliga1on  rather  than  because  of  any  legal  requirement.  (Compact  Oxford  English  Dic2onary)  

PENGURUSAN  KES  EX  GRATIA  

§  Ex  Gra6a  Rawatan  Perubatan  Kementerian  Kesihatan  Malaysia    1.    Kes-­‐kes  mediko-­‐legal  tanpa  writ  saman  2.    Tuntutan  pengadu/waris  pesakit  2dak  melepasi  julat  masa  3  tahun  

(Public  Authori1es  Protec1on  Act  1948)  

 §  Jawatankuasa  Ex  Gra6a  KKM    

   Pengerusi  (Pengarah  Amalan  Perubatan)     Se2ausaha  (Timbalan  Pengarah)     Wakil  Jabatan  Peguam  Negara     Wakil  Penasihat  Undang-­‐Undang  KKM  [Uruse2a  Jawatankuasa  Ex  Gra2a  KKM    –  Cawangan  Mediko  legal]  

Case  1  

•  Mr.  R  came  to  the  A&E  department  had  an  alleged  MVA  (Van  vs  Car)  

•  Complained  of  :  -­‐Right  sided  chest  pain  -­‐Shortness  of  breath  -­‐Right  sided  abdominal  pain  -  Le`  calf  pain  -­‐No  LOC  no  retrograde  amnesia  

In  A&E  

•  Triaged  to  Red  Zone  •  Chest  X-­‐ray  done  twice,  no  rib  fracture  or  pneumothorax  noted  

•  Treated  for  so`  2ssue  injury  with  mul2ple  lacera2on  wounds  

•  Admided  to  medical  ward    

In  Medical  Ward  

•  Seen  by  Doctors,  pa2ent  was  mildly  tachypnoiec  but  no  respiratory  rate  noted  

•  No  documenta2on  of  lower  limb  findings  •  Staff  Nurse  documenta2on  :  ambula2ng  well  on  wheelchair  with  mild  SOB  seen  on  and  off  

•  Pa2ent  discharged  the  next  day  on    a  wheel  chair  

 

At  Home  

•  Pa2ent  endured  pain  for  3  days  at  home,  s2ll  unable  to  walk.  

•  Went  to    a  different  hospital  who  found:  1.  Fracture  right  1st  to  4th  ribs  2.  Fracture  of  right  superior  and  inferior  pubic  

rami  3.  Fracture  of  anterior  and  posterior  column  of  

right  acetabulum  with  fracture  fragment  inside  the  hip  joint  

4.  Crack  fracture  of  right  pubic  tubercle  and  right  femoral  head  with  slight  posterior  disloca2on  of  right  hip  5.  Slight  diasthesis  of  le`  sacroiliac  joint  6.  Abrasion  wound  over  Lateral  right  eye  and  right  side  of  chest  wall  and  right  knee  

Findings  

•  According  to  Pa2ent,  did  complain  of  Hip  pain  and  inability  to  walk  

•  Complain  taken  lightly  as  pa2ent  is  slightly  obese  and  adributed  not  walking  to  laziness  

•  No  complete  primary  survey  X-­‐rays  done,  only  CXR  was  done  while  cervical  and  pelvic  Xray  not  done  

 

•  Nursing  assesment  was  done  but  inaccurate.  Although  the  pa2ent  was  on  wheelchair,  passing  urine  in  urinal  and  unable  to  go  to  the  toilet  himself,  he  was  assessed  as  ambulatory  and  independent.  

•  None  of  the  SN  or  MO  ever  saw  the  pa2ent  standing  or  walking  but  failed  to  ask  why  or  further  assess  the  pa2ent  again  

 

Conclusion  

•  There  was  substandard  care  for  this  pa2ent  in  term  of  assessment  and  treatment  by  staff  

Case  2  

•  Pa2ent  is  an  18  Years  Old  Student  came  to  the  Hospital  with  a  complain  of  generalized  body  swelling  for  3  days.    

•  Pa2ent  was  treated  for  Nephro2c  Syndrome  and  started  on  Prednisolone  (steroids)  

•  10  months  later  because  pa2ent  has  failure  to  achieve  remission  he  was  referred  to  another  hospital  for  a  renal  biopsy  to  rule  out  Lupus  Nephri2s  

•  Pa2ent  was  discharge  well  with  Prednisolone  •  3  weeks  later  pa2ent  came  to  the  A&E  department  with  rashes  over  the  face  and  chest  with  severe  abdominal  pain.    

•  Pa2ent  passed  away  a`er  3  days  in  the  ward  whilst  in  ICU  

Findings  

•  According  to  Pa2ent,  did  complain  of  Hip  pain  and  inability  to  walk  

•  Complain  taken  lightly  as  pa2ent  is  slightly  obese  and  adributed  not  walking  to  laziness  

•  No  complete  primary  survey  X-­‐rays  done,  only  CXR  was  done  while  cervical  and  pelvic  Xray  not  done  

 

•  The  Prednisolone  was  dispensed  by  PRP  (Provisionally  Registered  Pharmacist)  and  was  unsupervised  by  Pharmacist.  The  pharmacist  in  charge  of  satellite  pharmacy  was  running  a  MTAC  (Medica2on  Therapeu2c  Adherence  Clinic).  A  relieve  Pharmacist  could  not  be  assigned  because  all  the  Pharmacists  were  involved  in  the  moving  of  Pharmacy  office  and  store  to  new  sites.  

 

•  The  father  of  the  pa2ent  realized  that  the  medica2on  was  twice  a  day  and  not  once  a  day  and  asked  the  counter  but  was  scolded  and  to  just  follow  whatever  is  ordered  

Conclusion  

•  There  was  substandard  care  for  this  pa2ent  in  term  of  assessment  and  treatment  by  staff  

The Pains of Court Litigation q  Medical Negligence Litigation has never been a haven

for neither patient nor doctor. q  Although one is innocent until proven guilty, a medical

negligence claim assaults doctor’s credibility, insinuate faulty judgment even though at the end of the trial the doctor is found not guilty.

q  For the patient, there are so many obstacles in

bringing a successful claim in negligence.

Name, Shame and Blame

q  The threat of litigation compels the doctor to view his patient as a future adversary in a courtroom proceeding.

q  “For 7 years it went on, months of sitting in court listening to what a

terrible person you are, no one recovers from that. It is on your mind every day, every minute. It changed the whole way I practiced. The empathy I had, that I was known for, just wasn’t there anymore. Every patient was a potential law suit.” - Canadian retired doctor

  Silversides, A. “Fault/no fault: bearing the brunt of medical mishaps, CMAJ

News, August 12, 2008, 179(4).

Dr Puteri Nemie Jahn Kassim IIUM

Further….

� Medical negligence – longest to try

compared to other personal injury claims.

� Rise in medical insurance premium

rates.

Norizan v Dr Arthur Samuel (2013)

q  Pff and her husband requested for termination of pregnancy and insertion of contraceptive device in a single procedure

q  Defendant agreed to carry out the procedure but did not inform of the risks inherent in performing both procedures at once.

q  During the procedure, def perforated her uterus…required emergency hysterectomy

q  Pff and her husband claimed would not have proceeded if had known about the risks

The choice was theirs…and they needed information..

q  There was an increased risk of aperforation of the uterus due to pff’s previous pregnancies and termination of pregnancy.

q  If they had known…they would have opted for a safer method rather than going for D&C and IUD in a single procedure.

q  By failing to inform the risks, they were denied of considering other alternatives

available.

But Informed Consent is not just a principle

IT IS A PROCESS….which starts from the time which the doctor and patient discusses

the proposed actions, risks, benefits and alternatives….a process which require

disclosure of pertinent information, comprehension and voluntary

agreement…

Case  2  

GURMIT KAUR JASWANT SINGH V. S. TUNG SHIN HOSPITAL & ANOR (2013) 1 CLJ 699

FACTS OF THE CASE

•  The Plaintiff was referred to the 2nd Defendant (O&G) for the removal of a cervical polyp.

•  The polyp was removed and an ultra-

sound revealed that the Plaintiff’s uterus was enlarged due to a uterine fibroid.

•  The Plaintiff claimed that she informed the 2nd Defendant that she planned to conceive again and she intended to enrol in a “baby choice” programme to conceive a baby boy. She thus wanted the fibroid removed.

•  On 19.9.2002, the Plaintiff was admitted

for the removal of the fibroid. On this date, she was asked to sign a consent form which merely had her name and identity card number filled up.

   

•  O n 3 0 . 9 . 2 0 0 2 a t t h e f o l l o w u p appointment, the Plaintiff asked the 2nd Defendant when she could conceive again and was shocked to learn that the 2nd Defendant had instead performed a hysterectomy on her.

•  The 2nd Defendant apologized, stating

that he had performed the hysterectomy, assuming the Plaintiff no longer wanted any more children.

THE PLAINTIFF’S CASE

•  The Plaintiff informed the 2nd Defendant that she planned to conceive again. She was told that the fibroid will not cause her any problems unless she intends to conceive. She agreed to undergo an operation to remove the fibroid because she was planning to undergo a baby choice programme.

THE 2ND DEFENDANT’S CASE

•  The 2nd Defendant claimed that the Plaintiff had complained about having heavy and painful menstruation and that he advised her that the only treatment that would completely overcome her condition was a hysterectomy (that was to be only undertaken if she no longer wanted children).

•  The 2nd Defendant claimed that the Plaintiff did not inform him that she intended to have more children or participate in a “baby choice” programme.

•  The Plaintiff was given an explanation of

the hysterectomy in the presence of her husband and a nurse. (However, at trial, the nurse was not called to give evidence)

•  At the material time, the Plaintiff was 38 years old and had 4 children. The Plaintiff did not inform the 2nd Defendant that she intended to have more children.

COURT HELD:

•  The evidence clearly established that the operation conducted on 19.9.2002 was to r e m o v e a f i b r o i d ( l a p a r o s c o p i c myomectomy), but instead, the 2nd Defendant had removed the Plaintiff’s uterus (hysterectomy).

•  The fact that the 2nd Defendant had

apologized to the plaintiff proved that he had admitted to a mistake.

•  The Court awarded the Plaintiff a sum of RM120,000.00 as general damages for the loss of uterus, inability to conceive, injury and pain and suffering.

•  The hospital was vicariously liable for the

2nd Defendant’s conduct. Although the hospital argued that the 2nd Defendant was practicing as an Independent Consultant, the hospital did not produce any written agreement to prove this

Case 3

47  

Abdul  Razak  Datuk  Abu  Samah  v  Raja  Badrul  Hisham  Raja  Zezeman  Shah  &  Ors  [2013]  3  CLJ  1130,  HC  

 

Material  Facts    

l  Pa2ent  had  intes2nal  obstruc2on  confirmed  by  CT  Scan  l  Urgent  surgery  was  recommended  

l  The  pa2ent  regurgitated  a  large  volume  of  stomach  fluid  which  entered  her  lungs  whilst  anaesthesia  was  being  

administered  l  The  pa2ent  died  of  aspira2on  pneumonia  

l  The  husband  sued  and  claimed  negligence  by  the  doctors  involved      

48  

Material  Facts  :  (Cont’d)    

•  Before  surgery,   the  surgeon  advised  the  Pa2ent  on  the   inser2on  of  Ryle’s   tube  –   to   reduce   the   risk  of  the  Pa2ent  aspira2ng  on  her  stomach  content.    

•  Despite   advise,   the   Pa2ent   refused   the   use   of   a  Ry le ’ s   tube   because   she   had   found   i t  uncomfortable.    

•  The   Pa2ent   unfortunately   regurgitate   a   large  amount   of   stomach   fluid   which   entered   the  Pa2ent’s  lungs.    

•  She   passed   away   the   next   day   from   aspira2on  pneumonia.  

 

Evidence  led  in  Court:    

The  Plain2ff  (the  pa2ent’s  husband)  “Over  the  telephone,  Raja  Badrul  informed  me  that  that  he  had  

to  operate  on  my  wife  that  very  day.  I  agreed  to  the  operaEon”.  

 The  Judge  said  that:  

“According  to  the  plainEff,  that  was  all  the  first  defendant  said  to  him  and  the  plainEff  abided  by  the  first  defendant’s  decision  

and  recommendaEon.”          

The  Court  findings  were  that:-­‐  •  It  was  common  ground  that  the  inser2on  of  a  Ryles   tube   is  a   recognised  and  recommended  technique  

•  The  doctors   tes2fied   that   the  pa2ent   refused  to  have  a  Ryles  tube  inserted  before  induc2on  of  anaesthesia  

•  The   first   defendant   (surgeon)   asked   the  second   defendant   (anaesthe2st)   to   address  this  issue  but  the  second  defendant  was  called  away  on  an  emergency  and   le`   it   to   the  fi`h  defendant  (the  medical  officer)  

 

The  Court  also  found  that:-­‐    §  No  record   to  show  that   the  pa2ent  had  been  advised  of  the  material  risk  of  proceeding  with  surgery  without  having  a  Ryles  tube  inserted  

§  The   pa2ent’s   consent   for   surgery   was  obtained   by   the   surgeon’s   surgical   trainee  who  was  not  called  as  a  witness  

§  No  witness  to  the  signature  of  the  pa2ent  on  the  consent  form  

§  The   surgeon   assumed   that   the   trainee   had  explained  the  risks  of  surgery  but  could  not  be  sure  

During  trial:-­‐     The   Medical   Officer   tes2fied   that   he   had  

explained   to   the   pa2ent   that   a   Ryles   tube   is  needed  to  reduce  the  risk  of  aspira2on.  But  the  pa2ent  refused.  

 So….?  

 Was  the  pa2ent  advised  that  there  was  a  risk  of  death  from  aspira2on  or  an  increased  risk  of  death  because  of  her  full  stomach?  

The  Ruling:-­‐    

•  The  Colorectal  Surgeon,  the  first  Consultant  Anaesthe2st,  the  Hospital  and  Medical  Officer  were  held  liable  

•  However,  the  claim  against  the  other  Consultant  Anaesthe2st  was  dismissed  as  he  played  a  very  limited  role  in  the  care  of  the  deceased  and  the  medical  decisions  that  were  taken.  There  was  insufficient  evidence  to  establish  negligence  

 

Why  are  Medicolegal  Issues    Important  

•  As  Doctors,  we  all  make  mistakes  •  Even  an  experienced  Surgeon  can  slip  up  •  Current  Scenario  -­‐  Doctors  need  to  jus2fy  their  ac2ons  more  and  more  to  pa2ents  

-­‐  Understanding  how  medicine  and  law  interact  is  crucial  to  ensure  a  safe  and  happy  prac2ce  

Top  5  Medicolegal  Hazards    

•  Consent  •  Prescribing  •  Confiden2ality  •  Documenta2on/  Record  Keeping  •  Probity  

1.Consent  

•  Failure  to  take  consent  properly  can  lead  to  medicolegal  problems  

•  If  consent  comes  under  scru2ny  you  need  more  than  a  signature  on  consent  form  

•  Who  should  take  consent?    

Consent  is  implied  when  taking  blood  pressure  if  the  pa2ent  s2cks  out  their  arm  

Tips  •  Always  act  in  your  pa2ent’s  best  interests.  •  Record  in  the  notes  what  a  pa2ent  has  been  told.  •  Use  your  common  sense  –  consent  is  pa2ent-­‐specific  and  depends  on  theindividual’s  circumstances,  including  age,  lifestyle,  occupa2on,  spor2ng  interests,    expecta2ons  etc.  It  may  well  be  that  you  are  not  in  a  posi2on  to  advise  fully  eg,  professional  sports  people  

•  Pa2ents  right  to  refuse  treatment  •  The  law  concerning  incompetent  adults,  who  are  unable  to  give  valid  consent,  is  more  complicated–  if  in  doubt  consult  a  senior  colleague.  

2.  Prescribing  

•  One  of  the  most  dangerous  areas  for  clinicians  •  Always  document  allergies,  doses,  frequency  •  If  unsure  about  prescrip2on,  or  mishear  on  a  ward  round,  always  seek  clarifica2on-­‐  NEVER  GUESS  

 

Prescribing  is  one  of  the  most  dangerous  areas  for  all  clinicians  

Tips  •  Prescrip2ons  should  clearly  iden2fy  the  pa2ent,  the  drug,  the  dose,  frequency  

•  and  start/finish  dates,  be  wriden  or  typed  and  be  signed  by  the  prescriber.  

•  Be  aware  of  a  pa2ent’s  drug  allergies.  •  Verbal  prescrip2ons  are  only  acceptable  in  emergency  situa2ons  and  should  be  wriden  up  at  the  first  available  opportunity  

•   Par2cular  care  should  be  taken  that    the  correct  drug  is  used.  

3.  Confiden2ality  

•  La2n  con  ‘with’  and  fidere  ‘to  trust’  •  Cornerstone  of  a  successful  doctor-­‐pa2ent  rela2onship  

•  Personel  Data  Protec2on  Act  •  Social  Media    

Tips  •  Before  breaching  confiden2ality,  always  consider  obtaining  consent.  •  Take  advice  from  senior  colleagues.  •  Remember  that  confiden2al  informa2on  includes  the  pa2ent’s  name.  •  Competent  children  have  the  same  rights  to  confiden2ality  as  adults.  •  Doctors  can  breach  confiden2ality  only  when  their  duty  to  society  overrides  their  

 duty  to  individual  pa2ents  and  it  is  deemed  to  be  in  the  public  interest.  •  Doctors  are  required  to  report  to  various  authori2es  a  range  of  issues,  including  

 no2fiable  diseases  (eg,  TB),  births,  illegal  abor2ons  etc  •  The  courts  can  also  require  doctors  to  disclose  informa2on,  although  it  would  be  

 a  good  idea  to  discuss  with  appropraite  authori2es  •  High-­‐risk  areas  where  breaches  can  occur  are  li`s,  canteens,  computers,  

 printers,  wards,  A&E  departments,  pubs  and  restaurants.  •  Be  careful  not  to  leave  memory  s2cks  or  handover  sheets  lying  around..  •  Be  careful  what  you  post  on  Social  Media  

4.  Documenta2on/Record  Keeping  

•  Must  be  kept  primarily  to  assist  the  pa2ent  when  receiving  treatment  

•  Secondly,  for  future  li2ga2on,  notes  will  form  the  basis  for  defence  

•  Notes  are  a  reflec2on  of  the  quality  of  care  

Tips  •  Always  date  and  sign  your  notes,  whether  wriden  or  on  computer.  Don’t  

change    them.  If  you  realise  later  that  they  are  factually  inaccurate,  add  an  amendment.  

•  Any  correc2on  must  be  clearly  shown  as  an  altera2on,  complete  with  the  date    the  amendment  was  made,  and  your  name.  

•  Making  good  notes  should  become  habitual.  •  Document  decisions  made,  any  discussions,  informa2on  given,  relevant  

history,    clinical  findings,  pa2ent  progress,  inves2ga2ons,  results,  consent  and  referrals.  

•  Medical  records  can  contain  a  wide  range  of  material,  such  as  handwriden    notes,  computerised  records,  correspondence  between  health  professionals,    lab  reports,  imaging  records,  photographs,  video  and  other  recordings  and    printouts  from  monitoring  equipment.  

•  Do  not  write  offensive  or  gratuitous  comments  –  eg,  racist,  sexist  or  ageist    remarks.  Only  include  things  that  are  relevant  to  the  health  record.  

5.  Probity  

•  the  quality  of  having  strong  moral  principles;  honesty  and  decency  

•  Must  be  honest  and  trustworthy  when  signing  forms,  reports  and  other  documents  

     

Tips  •  If  you  are  uncertain  double  check  your  work  with  a  senior.  

•  Take  steps  to  verify  what  you  are  saying.  Never  sign  a  form  unless  you  have  read  it  and  you  are  absolutely  sure  that  what  you  are  saying  is  true.  

•  Be  honest  about  your  experiences,  qualifica2ons  and  posi2on.  

•  Be  honest  in  all  your  wriden  and  spoken  statements,  whether  you  are  giving  evidence  or  ac2ng  as  a  witness  in  li2ga2on.  

•  Assume  that  all  records  will  be  seen  by  the  pa2ent  and/or  others,  eg,  MMC,  court.  

Thank  You    

Dr  Mohamed  Faruqi  Uzair  bin  Mohamed  Sidek  Cawangan  Medico  Legal  

Bahagian  Amalan  Perubatan  Kementerian  Kesihatan  Malaysia  

Faruqiuzair@moh.gov.my