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The Medical Council of Hong Kong (Medical Council) recently found a medical practitioner guilty of professional misconduct for disregarding their professional responsibility to a patient by failing to properly and adequately identify and/or treat the patient’s spine injuries.
Background
The defendant doctor, a specialist in orthopaedics and traumatology (O&T), was the medical officer in charge of the patient’s treatment during the in-patient management of his cervical spine injury as provisionally diagnosed on the orthopaedic ward. Upon admission, the patient reported having had a diving accident, which involved the vertex of his head hitting the pool floor, resulting in an episode of temporary loss of consciousness, pain, numbness and weakness in his four limbs, numbness over his anterior chest and abdomen, and mild neck pain.
When the defendant doctor saw the patient, the patient could walk unaided. The patient reported that he was no longer experiencing numbness of his limbs, and underwent a private MRI on the same day. The defendant doctor reviewed the patient on the following day, noting that the patient remained afebrile since admission and could walk unaided. The patient reported decreased neck pain which required no painkilling medication, and had no more limb weakness or numbness. The patient was therefore discharged home with a follow-up appointment scheduled for four weeks later.
One day after his discharge from the hospital, the patient consulted a private O&T specialist and underwent an X-ray examination which revealed “C1-C2 interval measures up to 8mm suggesting C1-C2 subluxation”. The patient subsequently underwent three operations for treatment at private hospitals and lodged a complaint against the defendant doctor for his failure to identify and/or treat his cervical spine injuries arsing from the diving accident.
Relevant legal principles
The Medical Council referred to the relevant legal principles as summarised by Professor Michael A. Jones, in Medical Negligence (6th ed.) at para 4-037:
Keeping alternative diagnosis in mind
The need to consider alternatives was stressed in the case of Rietze v Bruser (No.2) (QB) [1979] 1 WWR 31:
“It is not sufficient … for a medical practitioner to say ‘of the two or three probable diagnoses I have chosen diagnosis (A) or diagnosis (B) or (C)’. It must be expected that the practitioner would choose diagnosis (A) over (B) or (C) because all of the facts available to that practitioner and all of the methods available to check the accuracy of those facts and that diagnosis had been exercised with the result that diagnosis (A) remains at the most probable of all…”
“This point becomes even more important where the consequences of the alternative diagnosis, if it turns out to be the correct diagnosis, are likely to be serious...”
To illustrate the extent of the doctor’s duty to keep a possible alternative diagnosis in mind, the Medical Council also referred to the decision in Bell v Bedford Hospital NHS Trust [2019] EWHC 2704 (QB), where the Court found (as summarised by the above learned Professor) that:
“… [a] consultant in breach of duty for failing to keep a possible diagnosis of TIA (transient ischaemic attack) in mind, even if it was not a probable diagnosis, and even though an alternative diagnosis of migraine was also possible; the defendant’s case was not helped by the fact that, even though the patient’s symptoms were not typical of a TIA, this occurred at a specialist TIA clinic… (where clinicians arguably should be aware of rare occurrences as well as the more common) and more junior doctors at the clinic had raised the possibility of TIA).”
Expert evidence
The expert instructed on behalf of the Medical Council opined that based on the history of the patient hitting his head in shallow water, the duration of neurological deficit and neck pain, and from reviewing the X-ray with negative findings, there was adequate clinical evidence to arrange for additional investigations to confirm or exclude C1/2 injury. The expert’s view was that to diagnose C1/2 injury, apart from clinical suspicion, it is often necessary to have special X-ray views including open mouth and lateral flexion/extension views in order to identify the injury. In addition, the expert opined that CT scanning of the cervical spine is another useful radiological investigation, and can sometimes be more helpful than MRI scans.
The expert also opined that even if there is no typical presentation of the type of cervical spine injury suffered by the patient, it is all the more important for the treating doctor to be on high alert and to rely on investigation rather than just physical examination to diagnose or exclude the condition. The expert considered that the defendant doctor, being a specialist in a major hospital that receives trauma patients on a daily basis, has a responsibility to ensure accurate diagnosis before discharging any patient.
Decision
The Medical Council found that as the medical officer in charge of the patient’s case during his in-patient stay, the defendant doctor had primary responsibility to provide proper and adequate medical care to the patient. The Medical Council’s view was that the defendant had failed to properly and adequately identify and/or treat the patient’s C1/2 cervical spine injuries arising from the diving accident. The defendant doctor was found guilty of professional misconduct, for which his name was ordered to be removed from the General Register for a period of one month - with the operation of the order being suspended for 24 months.
Comment
The crux of this case lies in the failure to stay alert to the possibility of serious, albeit uncommon cervical instability despite a suggestive history and initial neurological deficits. Doctors should be on high alert to the mechanism of injury and early neurological signs, and maintain a high index of suspicion, so as to ensure appropriate or further investigation is arranged. It is also important to avoid relying on short term symptom improvement as a basis for early discharge without adequately excluding high risk pathology, which might have serious consequences.
Healthcare
Hong Kong