NZMII Case Study : Honesty is the best policy

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Factual background

Dr X was an orthopaedic registrar at a busy city hospital. Mr Y presented with lower back pain, altered sensation bilateral legs and leg weakness. He advised of a previous L5/S1 prolapse but symptoms had resolved. Pain had commenced whilst lifting a heavy object 3 weeks previously. Symptoms, including urinary difficulties, were worsening. A bladder scan demonstrated a raised post-void urine volume of 100ml. The level of urine remaining in the bladder was around the borderline level for cauda equina syndrome. Dr X discussed the findings with the consultant orthopaedic spine surgeon on duty.

Thereafter, there was a miscommunication between Dr X and the surgeon as to the next steps. Dr X thought he had been instructed to determine whether Mr Y could pass any more urine. Upon doing so, Mr Y was discharged with medication and instructions to return to hospital if symptoms recurred. In fact, in order to rule out cauda equina syndrome, the surgeon had wanted a further post-void scan to be undertaken. At the end of the shift, the surgeon asked Dr X for details of the second scan – which had not been carried out. Rather than admit his error, and not appreciating the significance of the second scan, Dr X referred to the volume of urine he would have anticipated to have been in the bladder, based upon the results of the first scan. This false result was also noted in the clinical records. Unfortunately, the causa equina syndrome was not diagnosed until a later MRI scan, by which time emergency surgery was required.

The HDC complaint

The HDC investigated Dr X, including referral to an expert medical advisor. Legal advice and support was provided to Dr X, including advice around Dr X’s admission of a clear misjudgement in falsely stating that a further bladder scan had been undertaken. Dr X was under significant pressure in an already busy Emergency Department. His relationship with the surgeon was such that he felt unable to admit his error. Since the time of the consultation, the Emergency Department had increased staffing and the whole department has undergone training on recognising the red flags for causa equina syndrome. Dr X described the incident as a “wake up call” in his career. Dr X was not criticised for the initial discharge, on the basis that there had been a genuine misunderstanding of the surgeon’s instructions to him regarding a second scan. However, once it became clear to Dr X at the end of the shift that the surgeon’s instructions had been misunderstood, the HDC considered that the services provided by Dr X were in breach of the duty of reasonable skill and care under the Health and Disability Commissioner’s Code of Rights.

The HDC was particularly concerned with the fact that Dr X had a number of opportunities to admit his error, both on the day of the consultation and following Mr Y’s subsequent admission for emergency surgery. He failed to do so, and he knowingly falsified the clinical records. Dr X was ordered to apologies to Mr Y and report to the HDC on his reflections following further training. The HDC also referred the matter to the Medical Council of New Zealand.

Medical Council investigation

The Medical Council conducted its own investigation into Dr X’s actions. Dr X was again provided with full legal advice and support in his submissions to the Medical Council. The Council ultimately accepted that this was a one-off incident and recognised that Dr X had acknowledged his dishonesty and taken steps to ensure such an incident did not happen again, both in terms of his clinical training and interactions with colleagues. It was satisfied that an educational approach was appropriate to address the concerns, although noted that any further instances of dishonesty would be viewed very seriously.


With full legal support, Dr X was able to address the difficult issues that arose as a result of his error of judgement. It is interesting that the HDC considered there was no breach in standards for Dr X’s initial error, resulting from a misunderstanding of instructions. The real concern was the doctor’s failure to admit the error and maintaining that dishonesty. A more serious outcome for the doctor was avoided by his clear and unequivocal admission of his wrong-doing coupled with a commitment to further training and significant insights into the reasons for his behaviour.

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