Quick remedy vital when doctors fail

Wanted: a complaints system for medicine that is better, faster and fairer. Health reporter MARTIN JOHNSTON concludes his investigation.

Accident compensation officials decided not to report two doctors to the Medical Council over how they treated Christine Marinkovich.

It would have been unfair to single out Dr Graham Parry and the anaesthetist, ACC said, because a number of other Whangarei Hospital staff contributed to "a series of errors resulting in inadequate care ... "

ACC instead alerted the doctors' employer, Northland Health, advising it to take what action it saw fit.

Northland Health refuses to discuss disciplinary matters regarding Dr Parry, an obstetrician-gynaecologist, because he goes before the Medical Practitioners Disciplinary Tribunal on Monday.

The tribunal last month suspended him until the hearing on a charge of disgraceful conduct in his 1997-98 care of Colleen Poutsma, aged 48, who is dying of cervical cancer.

Dr Susan Gathercole, Mrs Marinkovich's anaesthetist, says Northland Health took no action against her. It carried out an "in-hospital review of practice and prescribing."

Health watchdogs have become alarmed about the failure of medical authorities to blow the whistle despite persistent mistakes.

After publicity about Mrs Poutsma, many other Northland women raised concerns about Dr Parry. The Health and Disability Commissioner is examining three to see if they merit formal investigation.

The patient-focused commissioner's office was set up in 1994 to investigate complaints about any health and disability services, from breast surgery to aromatherapy. It gets more than 1100 complaints a year, most direct from "consumers."

Former commissioner Robyn Stent took more than 18 months to investigate Mrs Poutsma's complaint, which landed just as a marathon investigation into Christchurch Hospital ended.

When Mrs Stent announced she was stepping down in July last year, the backlog of complaints stood at more than 500 and she complained of having insufficient support.

New commissioner Ron Paterson has apologised to Mrs Poutsma for the "inexcusable" delay, and is making changes to ensure that similar cases are dealt with urgently.

Waiting months or even years for a case to grind through ACC, the medical disciplinary system and occasionally the courts puts patients under immense strain.



But delays can be unfair on doctors, too, especially if they are eventually cleared. Unless their names are suppressed, their reputations will have been tarnished.

The chairwoman of the Medical Association, Dr Pippa MacKay, describes the present environment as "very doctor-unfriendly."

She knows many who are contemplating hanging up their stethoscopes for good.

But statistics point to a drop in the number of prosecutions taken to the tribunal to 13 in the last March year, compared with more than 70 a year for the old committee. Mr Paterson suggests the reduction is due to official encouragement to resolve complaints at a lower level.

In the 15 disciplinary tribunal cases concluded in the last March year, three doctors were found guilty of professional misconduct. None was found guilty of the more serious charge of disgraceful conduct, which can lead to being struck off the register. Three were found not guilty.

The Medical Council was asked to review the competence of 61 doctors. Around 30 went to a review or competence programme. Almost 10,000 doctors practise in New Zealand.

In the case of Mrs Marinkovich, Dr Gathercole wrongly prescribed the anti-inflammatory painkiller Voltaren for her after the caesarean birth of her twins in 1995. She developed kidney failure, which kept her in hospital for weeks and means any subsequent pregnancy will be risky.

Voltaren may have contributed. The Ruawai woman, aged 37, should not have been put on it as she was at risk of renal failure owing to pre-eclampsia, a pregnancy complication.

ACC criticised Dr Parry for not delivering the twins sooner, and also the whole team's postoperative care of Mrs Marinkovich. Had it been up to scratch, ACC said, the anaesthetist's error would have been picked up and the Voltaren, although prescribed, would not have been given.

The Government has been forced to start an investigation of error-reporting systems in response to pressure from lawyers for Dr Parry's ex-patients and concerns about the delays in picking up his mistakes.

It is fast-tracking legislation designed to encourage doctors to report colleagues they suspect of incompetence.

It would also let the Medical Council suspend doctors while investigating their competence or behaviour. Now, the council can suspend only while assessing a doctor's health. The disciplinary tribunal can suspend before hearings.

Similar legislation is proposed for most other health workers.

ACC made six findings of medical error (which can include negligence) involving Dr Parry dating back to 1992 and six more of medical mishap (rare and severe complications).

At that time, ACC was required to report suspected negligence by doctors and other registered health workers to the "appropriate body with a view to the institution of disciplinary proceedings."

Of the six error cases, it appears two were handled by the Medical Council and three by the old Medical Practitioners Disciplinary Committee, which met in secret.

Council spokeswoman Susan Pattullo says the committee cases were "low-level" incidents. Two were not "substantive enough" for a hearing; the third was, but the charge was not proven. The sixth ACC referral cannot be traced.

In Mrs Poutsma's case, referred by the commissioner a year ago, the council put Dr Parry under supervision in July, a move overtaken by his suspension.

Mrs Marinkovich took Dr Parry to the council, but a complaints assessment committee decided the allegations were not proven and arranged for conciliation.

She says that Dr Gathercole has apologised, but Dr Parry has not.

The ACC ceased reporting suspected negligence after the Accident Insurance Act 1998 removed the obligation. The National-led Government wanted it to focus on rehabilitation rather than policing, a role it felt could be left to the Health and Disability Commissioner.

ACC decided to resume reporting last month, after calls by the council and commissioner Paterson. But it says the move is a bid to reduce injury rather than a response to public opinion. The Government plans to make reporting mandatory again.

Patient advocates want the health disciplinary system simplified and wish to break its domination by doctors and other health workers, changes which the medical establishment would fight.

A select committee wanted to end the medical majority before the existing doctors' disciplinary system began in 1996, but last-minute medical lobbying ensured its retention. Review tribunal hearings are now held before a lawyer, three doctors and a lay person. The Medical Council comprises six practising doctors, a medical-school professor and three members of the public.

Women's Health Action executive director Sandra Coney recalls that, after the Cartwright inquiry, a medically dominated disciplinary system was retained as a tradeoff for the creation of the patient-centred commissioner's office.

Paterson, the commissioner, wants a single health-workers disciplinary tribunal, one option canvassed by the Ministry of Health in a review of disciplinary and registration legislation.

He believes the disciplinary bodies for all health workers need equal numbers of health professionals and lay people because having a health-worker majority undermines public confidence.

But the Medical Association would not accept doctors' losing their majority or a move to a single health disciplinary tribunal, says Dr MacKay, "because you are being judged against appropriate standards for a doctor ... against your peers."

During the interview, Dr MacKay erupted about the "constant" criticism of doctors, saying, "It's really got much worse in the last year."

She believes society has become much more "punitive and litigious" towards doctors, partly because the accident compensation system largely prevents people from suing, yet leaves them without adequate compensation. Victims become embittered and seek revenge - against doctors.

But doctors harbour serious misgivings about "their" disciplinary system and feel that they are not being treated fairly, she says.

"Doctors' reputations can be completely ruined even though they are found innocent. We're not trying to protect anyone here. We're just saying that the principles of natural justice must apply."

Dr MacKay does not have any specific proposals for change, but she complains: "All the changes that are happening are for more rights for complainants; more punishment, more difficulty for doctors."

Peer review - doctors watching over one another - is being strengthened under provisions of the 1995 Medical Practitioners Act. It will become a formal requirement before the council issues doctors' annual practising certificates.

Council chairman Dr Tony Baird says peer review has always happened, but not in a sufficiently organised way to ensure public safety.

Some doctors are still worried, particularly after the cervical-smear under-reporting in Gisborne, about limited access to peer review and medical education for isolated health workers in the provinces.

Mrs Marinkovich - like Mrs Poutsma - wants other women protected from the inadequate treatment they suffered, and she has discussed joint legal action with other former patients of Dr Parry's.

Her claim went before an ACC medical misadventure committee four times before the members concluded she had suffered a series of errors. At first they could not work out who had prescribed the Voltaren - the doctor's signature on the hospital chart was indecipherable.