ROYAL COLLEGE OF VETERINARY SURGEONS MR AMIR KASHIV MRCVS FINDINGS OF FACT AND ON DISGRACEFUL CONDUCT IN A PROFESSIONAL RESPECT

Transcription

1 ROYAL COLLEGE OF VETERINARY SURGEONS v MR AMIR KASHIV MRCVS FINDINGS OF FACT AND ON DISGRACEFUL CONDUCT IN A PROFESSIONAL RESPECT 1. Mr Kashiv appears before the Disciplinary Committee to answer four heads of charge relating to his management of a 10 or 11 year old Scottish Terrier, Tanzy, who belonged to Mrs Greenhill. A copy of the heads of charge is attached to this decision. 2. At the outset of the hearing Mr Kashiv denied all heads of charge, however, at the conclusion of the College s case, the College indicated that it did not intend to pursue heads of charge 1 (a) and 2 (b), and, at the conclusion of Mr Kashiv s case, Mr Kashiv admitted heads of charge 1 (b), 2 (d) (in relation to 23 rd March 2015), and 4. The heads of charge left outstanding for the Committee to determine are heads of charge 1 (c) (d) c, 2 (a) (c) and The Committee has given detailed consideration to all the evidence in this case, the submissions of Counsel, and the advice of the Legal Assessor. It has applied the law on the burden and standard of proof, namely that the burden of proof is on the College and that the standard of proof required is that it has to be sure before it finds any allegation of fact contained in the heads of charge proven. The Committee has exercised its judgment in deciding whether the facts admitted, or found proved, amount to disgraceful conduct in a professional respect. 4. Mr Kashiv qualified as a veterinary surgeon from Liverpool University in 1993, and was employed by Vets & Pets, Broxbourne, Hertfordshire, a practice owned by Mrs Taverner and Mrs Buchan. The owners worked at reception and in the office at the practice. The majority of the surgery at the practice was undertaken by Mr Viviani, who had qualified as a veterinary surgeon in Italy. It would appear to be the case that there were no registered veterinary

2 nurses at the practice. The clinical records system in use at the practice was not computerised. 5. Mrs Greenhill is an elderly lady who lived at the time with her disabled partner now deceased. Mrs Greenhill had been a client of Mr Kashiv at the practice for some years. She had previously owned another Scottish Terrier which was registered at the RSPCA Harmsworth Animal Hospital where the dog had received treatment. 6. As the evidence emerged it became clear that there were only limited areas of disagreement between Mr Kashiv and Mrs Greenhill. The Committee found Mrs Greenhill to be a straightforward and honest witness who did her best to assist the hearing, as indeed did Mr Kashiv and the other factual witnesses. The Committee also heard expert evidence from two veterinary surgeons, Mr Maltman and Mr Jessop. Again the issues between the experts narrowed during the course of the hearing, where their views finally differed, the Committee generally preferred the evidence of Mr Maltman, as representing the standard of a reasonably competent veterinary surgeon. 7. The Committee also carefully considered the clinical records and correspondence with the College. The hand-written clinical records produced during the hearing contained later additions made by Mr Kashiv. Sometime in late March 2015, as Mr Kashiv explained in evidence, he attempted to collate the information from various sources onto the hand-written cards without signing and dating the alterations, however, an unaltered version of the clinical records was available from the copy sent to the RSPCA Harmsworth Hospital on 23 rd March The narrative of events as found by the Committee is set out below. 9. Mrs Greenhill brought Tanzy to the practice on 5 th March 2015 when she saw Mr Kashiv. She was concerned about blood in Tanzy s urine and swellings in Tanzy s mammary glands. Mr Kashiv examined Tanzy and carried out a fine needle aspiration for a cytopathology test. He advised Mrs Greenhill that Tanzy would require surgery to remove the mammary glands. The following day he received a cytopathology report which identified mixed mammary tumours. On 7 th March 2015 he spoke to Mrs Greenhill on the telephone and recommended surgery. It is apparent that at that stage he did not offer Mrs Greenhill any further tests, including radiography. 10. At the outset of the hearing there was an issue as to the extent to which Mr Kashiv gave a full explanation to Mrs Greenhill about the proposed surgery, either on 5 th or 7 th March Initially Mr Kashiv denied the heads of charge 1 (b) and (d), however, following the conclusion of his case, he admitted that he had failed to discuss radiography and had given inadequate information about the surgery as set out in the heads of charge. After he had spoken to Mrs Greenhill she spoke to one of the owners of the practice and booked the surgery for Tanzy. Mr Kashiv believes that cost was an issue and that the practice owner gave Mrs Greenhill a discount. It is clear from his evidence that he was not aware of this information until after Mrs Greenhill had booked the surgery. Although Mr Kashiv s recommendation that Tanzy should undergo a mammary strip is not criticised, it is clear that none of the alternatives to surgery

3 was explored with Mrs Greenhill, including not undertaking any treatment and monitoring an elderly dog. 11. On 13 th March 2015 Mr Viviani undertook a right side mammary strip, which involved removal of all the mammary glands and inguinal lymph node and Tanzy was discharged by him the following day. The surgery involved an extensive incision from the axilla to the groin of the dog. On 17 th March 2015 Mrs Greenhill brought Tanzy back to the practice for a postoperative check and saw Ms Kostadinova, a locum veterinary surgeon. Ms Kostadinova described the dog as bright, alert and responsive, which she clarified in evidence as being in the context of a dog that had recently undergone an operation. Mrs Greenhill became concerned about Tanzy s condition on 20 th March 2015 when Tanzy became unable to walk properly and squealed in pain. Her back legs appeared to have lost their function and she was pulling herself along with her front legs and was generally unwell. There had been one episode, or perhaps more, of vomiting and diarrhoea. 12. Mrs Greenhill took Tanzy in to see Mr Kashiv on 20 th March He admitted the dog for observation over the weekend. He considered that Tanzy was suffering from a spinal problem. He did not undertake any further investigations at that time. Mrs Greenhill and her partner visited Tanzy every day. The hospitalisation records are of a poor quality and are substantially incomplete. The main entries were made by Mr Kashiv who was in the practice over the weekend. There are two entries by the animal care assistants but the record card is left substantially blank. The record does show that Tanzy was being syringe fed, drinking moderately, defecating and producing urine over the weekend. Mr Kashiv describes on 21 st March 2015 that Tanzy was taken out of her cage and a towel was used to enable her to walk on her front legs. He does not believe that there were signs of urinary retention or an inability to pass urine voluntarily whilst she was hospitalised. It is clear that Mr Kashiv made no specific assessment of Tanzy s ability to urinate voluntarily other than the observation that Tanzy was not leaking urine nor had wet hind quarters. No episodes of vomiting and diarrhoea were recorded. Although Tanzy s weight is recorded, no consideration would appear to have been given by Mr Kashiv to any weight loss that Tanzy may have been sustained since she was seen by him on first presentation on 5 th March 2015 and 23 rd March On 23 rd March 2015 Mr Kashiv informed Mrs Greenhill that Tanzy could be discharged. There was a discussion between them either on 20 th or 23 rd March 2015 about obtaining an MRI scan to assist in diagnosis, however, Mrs Greenhill said that she had spent her savings on the surgery and did not have sufficient money for a costly MRI scan. Mr Kashiv had carried out radiography on 22 nd March 2015 for which he had not charged. They show a moderately full bladder and probably an enlarged kidney. These findings were not noted in the records. Mr Kashiv did not explain clearly to Mrs Greenhill that her dog was in a poor condition and that the future was bleak. He also did not give any adequate explanation as to how Mrs Greenhill should care for the dog at home either as to hydration, feeding or urination or defecation. On 23 rd March 2015 his record indicates that he carried out a pinch test on Tanzy s front legs without withdrawal being elicited, which indicates that he was also concerned about the front legs at that time. He carried the dog to the car. Mrs Greenhill took a photograph of the dog either the same day or the following day which shows her in lateral recumbency.

4 14. Tanzy deteriorated rapidly following her discharge from the practice with episodes of vomiting and diarrhoea and the following day Mrs Greenhill took the dog to the RSPCA Harmsworth Hospital, where Mrs Favy, veterinary surgeon, considered that Tanzy needed urgent attention. She undertook further tests, which showed that Tanzy was in renal failure. She telephoned Mrs Greenhill and recommended that Tanzy was put to sleep, which was performed in Mrs Greenhill s presence. 15. The Committee has concluded that head of charge 1 (c) is not proved. Mr Kashiv accepts that he did not refer to palliative care and monitoring and/or euthanasia at the consultation on 5 th March 2015 and has told the Committee that he did not consider that it was appropriate for him to do so at that time. The Committee is satisfied that Mr Kashiv should have provided a menu of treatment options, in order to obtain informed consent, which would have included a recommendation of surgery to the mammary glands. He should also have included an option not to undertake any treatment and to monitor Tanzy s condition, however, the Committee does not consider that it was mandatory on 5 th March 2015 for Mr Kashiv to have discussed palliative care and/or euthanasia. At that time Tanzy was not close to death. The head of charge is dismissed. 16. The Committee has also concluded that head of charge 1 (d) c. is not proved. The Committee has concluded that it was not mandatory for Mr Kashiv to have explained to Mrs Greenhill the identity of the veterinary surgeon who was going to undertake the surgery. Whilst veterinary surgeons at many practices would have done so, the Committee accepts that there are others where the clients will not be informed in advance of the name of the veterinary surgeon carrying out surgery on their animals. The head of charge is dismissed. 17. The Committee is satisfied that head of charge 2 (a) is proved. It acknowledges that Mr Kashiv did offer further investigation, an MRI scan which was refused on the grounds of cost, and that he also carried out radiography of Tanzy, for which he did not charge. Whilst some veterinary surgeons would have carried out a blood test on admission on 20 th March 2015, others would not have done so. The Committee is satisfied, however, that by the time Tanzy had been hospitalised for a period of three days it was mandatory for a blood test to have been performed, given her marked deterioration. Mr Kashiv should have undertaken a blood test before he discharged the dog on 23 rd March 2015 in circumstances where the dog was anorexic and where he had become concerned about the dog s front legs. If Mr Kashiv was unsure as to what to do, he should have considered referral to, or sought further advice from another veterinary surgeon, or obtained a second opinion, however, he appears to have concluded that Tanzy had suffered an FCE ( fibro-cartilaginous embolism ) and taken no further action. 18. The Committee is satisfied that head of charge 2 (c) is proved. The Committee considers that it is incumbent on the treating veterinary surgeon to make his professional opinion understood to a client. It is satisfied Mr Kashiv did express his opinion that the prognosis was poor or guarded but it is also satisfied that he did not give the full explanation that was required in the circumstances of this case to enable Mrs Greenhill to understand fully the prognosis. It is stated in the original clinical records that the prognosis was guarded and that Tanzy required

5 nursing for three weeks. The Committee is satisfied that at the time Mrs Greenhill saw Mrs Favy at the RSPCA Harmsworth Hospital she did not have proper understanding of the very poor condition of the dog. 19. The Committee is satisfied that head of charge 3 is proved. By 23 rd March 2015 Tanzy s condition had been deteriorating for at least three days. Mr Kashiv was clearly concerned about Tanzy s front legs, which was why he undertook the pinch test. Whether or not he performed the test correctly, the fact that he undertook the test indicates that he was concerned. He already knew that there was no deep pain response in the rear legs. Although it is unclear whether Tanzy was quadriplegic, it is likely that the dog was profoundly depressed. The radiographs taken were at best equivocal with a moderately full bladder and the presence of a probable enlarged kidney. The Committee is satisfied that a blood test should have been performed and that there should have been a full assessment to see if Tanzy could voluntary control her urination. The evidence does not indicate that there was any particular pressure from Mrs Greenhill to take the dog home. The Committee is satisfied that Mr Kashiv should not have discharged Tanzy home in these circumstances. There was a further issue as to whether Mr Kashiv made any assessment as to whether Mrs Greenhill and her partner were capable of looking after the dog. The Committee is satisfied that no proper assessment was made or the actions required were communicated to Mrs Greenhill. 20. For the reasons set out above, the Committee considered whether Mr Kashiv s actions amounted to disgraceful conduct in a professional respect. It is satisfied that Mr Kashiv s actions fell far short of the conduct to be expected of a reasonably competent veterinary surgeon in respect of heads of charge 1, 2 and 3 but not 4. The individual and cumulative effect of the admissions and findings, as recognised on behalf of Mr Kashiv, amount to disgraceful conduct in a professional respect. The Committee has concluded that Mr Kashiv s inadequate recordkeeping, as he acknowledged, fell short of the standards to be expected, but not so far short so as to amount to disgraceful conduct. It considers, however, that where alterations are made to records after the event, the alterations should always be signed and dated. DISCIPLINARY COMMITTEE 12 December 2016