Medical practitioner reprimanded by tribunal for unprofessional performance

16 Jan 2017

A tribunal has reprimanded a medical practitioner and ordered him to pay a fine of $2,500 plus costs incurred by the Medical Board of Australia (the Board) for behaving in a way that constitutes unsatisfactory professional performance.

The Board referred Dr Jack Bryn Seys Davies to the State Administrative Tribunal of Western Australia (the tribunal) alleging that Dr Davies had engaged in professional misconduct, unprofessional conduct and/or unsatisfactory professional performance while undertaking his role as a registered medical officer for patient retrieval and transfer with the Royal Flying Doctors Service (RFDS).

Dr Davies was an international medical graduate with limited registration for area of need. On 12 October 2012, Broome Hospital requested that RFDS transfer two patients to hospitals in Perth. One patient was an involuntary patient (Patient A) who required transfer to a psychiatric hospital following suicide attempts. Patient A had been given significant amounts of sedation prior to transfer. The other patient (Patient B) had sustained a life threatening neck injury and required intubation and ventilation.

Patient A and Patient B were transferred on the same flight on 12 October. During the flight, Dr Davies had focused on Patient B who required significant clinical treatment including administration of blood products and respiratory care. As Patient A had become very agitated during the flight, the nurse administered haloperidol. Once she realised the drug error, the nurse informed Dr Davies that she had administered the patient with a total of 50 mg of haloperidol instead of 5 mg. Dr Davies told the flight nurse to document the incident as a drug error and that they would need to complete a clinical incident form.

During the flight, Dr Davies had various telephone discussions with an RFDS operations coordinator and a duty medical officer regarding the patient, but did not inform them of the drug error. He did however alert the coordinator that Patient A was very sedated.

Patient A was transferred from the flight to an ambulance and admitted to the psychiatric hospital. The patient died on 13 October 2012. On 11 April 2014, the Western Australia coroner found the patient’s death occurred from combined drug effect and myocarditis.

In referring the matter to the tribunal, the Board alleged Dr Davies had engaged in professional misconduct, unprofessional conduct and/or unsatisfactory professional performance in that he (among other things):

• failed to tell the clinical coordinator and duty medical officer about the drug error, in circumstances where doing so would have provided crucial information to inform decisions regarding the patient’s admission to a general hospital and regarding treatment, and
• breached Good Medical Practice: A Code of Conduct for Doctors in Australia due to failures in communication and failing to seek necessary help and advice in relation to the drug error.

Dr Davies admitted that his professional performance had been unsatisfactory. However, he contended that there were a number of mitigating factors including:

• Patient B was critically ill and demanded his full attention throughout the flight
• The telephone discussions took place while he had competing demands and communications from a transfer flight via satellite or mobile phone are extremely difficult due to time delays, signal loss and significant background noise
• The haloperidol that had been given to the flight nurse by staff at Broome Hospital had been an unusual concentration and the patient did not appear to be overly sedated so he had some uncertainty about the dose of haloperidol administered
• this conduct was very much out of character and the isolated incident occurred over four years ago. References were provided from employers that confirmed that Dr Davies is a conscientious and knowledgeable clinician
• there have been no subsequent concerns raised in respect of his practice, and
• he was open and honest immediately following the event and prior to any investigation in acknowledging his communication of the drug error could and should have been clearer.

Dr Davies’ submitted that the patient’s death had impacted on him and would continue to do so. He has demonstrated insight and remorse and has taken extensive remedial steps to ensure the events are not repeated.

The tribunal ordered that Dr Davies had behaved in a way that constitutes unsatisfactory professional performance, is reprimanded, and pay a fine of $2,500 plus the Board’s costs.

The decision is published on the tribunal’s website.