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The Health and Disability Commissioner has decided against proposing legal action against a doctor, despite finding serious questions raised by his professional competence.
The doctor's standard of care for an elderly cancer patient, deficient record-keeping and the fact he charged the woman's son $90 for a death certificate were all criticised by the commissioner, Ron Paterson.
The British-trained GP, referred to as Dr C in Mr Paterson's report, was the woman's doctor for the eight years before her death in 2003. She was aged 72 when she first consulted him and she suffered from multiple medical conditions.
She was diagnosed with advanced liver cancer in July 2003 and died later that year.
Her son later queried whether the cancer could have been diagnosed earlier and treated, given the frequency with which she saw Dr C.
Mr Paterson sought expert medical advice, which offered that even though there were "departures" in Dr C's standard of care, it was unlikely the woman's cancer could have been diagnosed earlier or treated differently.
Dr C said that over the eight years he arranged for about 232 laboratory tests and X-rays for Mrs A.
Mr Paterson's medical expert said Dr C's poor record-keeping meant his basis for ordering several blood tests between 2001 and 2002 were unclear.
Dr C also ordered tests that did not need to be done and Mr Paterson said the volume of tests he ordered may have made it harder to focus on what was important.
Mr Paterson found Dr C breached the health and disability code for his deficient record-keeping, his standard of care over his ordering and interpretation of laboratory tests and his follow-up systems.
He found that Dr C, in prescribing Iscador, a complementary cancer therapy not medically recognised, had not advised Mrs A about accepted medical opinion about the drug.
Mr Paterson said Mrs A's son (Mr B) had telephoned Dr C a fortnight after her death, requesting a copy of her death certificate. He received it three months later and shortly after an invoice for $90.
Mr Paterson termed that "unprofessional" in the circumstances.
"Mrs A had been a long-time patient and Dr C had done very little up to that point to resolve Mr B's concerns (apart from sending him a copy of the death certificate).
"Sending an invoice was insensitive and likely to cause offence - as indeed it did."
Dr C had also ignored a letter from the son asking about his management of Mrs A's condition.
He missed an opportunity for "low-level resolution" of Mr B's outstanding concerns, said Mr Paterson.
Dr C later refunded the $90.
He also provided Mr B with a comprehensive written apology, which was "gracious and sincere", Mr Paterson said.
While the commissioner considered referring Dr C to the Director of Proceedings to decide whether legal action was required, he finally decided that the doctor had learnt "salutary lessons" and appropriate steps had been taken by the Medical Council to address any public safety concerns about his practice.