DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE: CAC15-08

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1 DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE: CAC15-08 Dr A (Section 39 referral/complaint) Dr A B Dr C Veterinarian Clinic where Dr A works Former staff member at B, who raised the concerns about Dr A Names and locations have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person s actual name. Summary 1. A Complaints Assessment Committee (CAC) of the Veterinary Council of New Zealand (VCNZ) has investigated the above referral. Under section 43 of the Veterinarians Act 2005 (the Act), the CAC has reached a decision as set out below. Background 2. Dr A is a senior veterinarian at B. 3. This decision statement follows the investigation of matters raised by a former employee of B, Dr C, veterinarian, which were referred to the CAC by Council. 4. Dr C raised concerns about various aspects of Dr A s current practice and her belief that lack of continuing education means that his treatment methods and advice are out of date. Information considered 5. The CAC considered the following information. The original letter of concern from Dr C (6 February 2015). A letter of referral from Council s Notification Review Group (13 April 2015). Dr A s response of 4 May Dr C s comments of 18 June 2015 on Dr A s response. Clinical records for cases specified by the CAC. Random clinical records as requested by the CAC. Brief case summary 6. Dr C worked as a locum at B from May 2014 to November In a letter dated 6 February 2015, Dr C advised Council of her concerns. This was considered by Council s Notification Review Group who referred the matter, under its delegated s39 authority, to a CAC to investigate under s40 of the Act. Issues raised in the complaint 8. Dr C advised concerns about Dr A s usual practice in relation to anaesthesia of animals. As well as this, she questioned his decision making, use of pain relief, bandaging skills, record keeping and engagement in continuing education. 1

2 9. According to Dr C, Dr A s standard regime for anaesthesia in dogs is xylazine premed followed by thiopentone induction. She reported that cats receive a single injection of xylazine/ketamine (cat speys and some other procedures are not intubated). The recoveries are extremely long. This protocol also applies to all patients regardless of age and health status. Dr C reported that: she believed that the drug dosages are not very weight specific drug dosages given to patients are not recorded anywhere. Dr C raised concerns about apparent failure to keep animals warm during anaesthesia. She noted that the clinic is very cold and draughty in the winter yet no blankets, heat pads or other heating devices are used on patients during or after anaesthesia. 10. Dr C wrote that no pain relief is given pre or post-op to any surgical patients, with the exception of oral NSAIDS sent home for orthopaedic surgeries and that, in these instances owners were not instructed to give the medication until the following day. 11. In terms of record-keeping, Dr C wrote that computer records often have no age and/or weight recorded for patients and medication (especially repeats) were often dispensed by handwriting the instructions on the dispense packaging but making no note whatsoever of any of this on the computer records. In her view, Dr A s record entries were especially short and lacking in detail. 12. Dr C was particularly concerned about Dr A s bandaging techniques, writing that he routinely uses Elastoplast wound tightly and directly over wounds without a protective non-stick dressing and leaves bandages on from surgery until stitch removal (10 14 days) without any rechecks of the wound in between. 13. Dr C noted that she has concerns about what she believed to be a lack of continuing education for Dr A. She considered treatment methods employed and advice given to be out of date and that there is generally a lack of diagnostic investigations offered as well as a lack of advice given to clients regarding preventative/maintenance care. 14. In response to the issues raised by Dr C about anaesthesia, Dr A stated that xylazine and thiopentone are both registered for use in the anaesthesia of animals and using these drugs provides a calm, safe anaesthetic which can be easily continued with gaseous anaesthesia. Drug doses for all anaesthetics are not fixed but are to effect and this is judged by the anaesthetist (me). Further, he wrote, we use analgesics regularly and temgesic, codeine, tramadol, butorphanol and NSAIDs are all used in this clinic. We have reviewed our use of these drugs. 15. Regarding the matter of temperature control, Dr A wrote, that all operations are carried out on an insulated table. Blankets are used for every recovering animal. Electric heat pads are commonly used, as are hot water bottles The clinic has two heat pumps, electric heaters and a fireplace. All this is used as necessary. Heating in the winter, cooling in the summer. 16. Dr A wrote that he always writes down the abnormalities but not necessarily all the normal things about an animal and doses of which drugs are given are recorded in all prescription drugs handed out. While he uses abbreviations on the white board for the day s surgical list, he writes in full in the client record. 17. In explaining his bandaging techniques, he advised that he dries the area, puts sulphadimidine powder on the wound and bandages with about two layers of Elastoplast (Tenoplast). His rationale for this is that Tenoplast will never stick to the wound or anything else wet, only the dry skin and hair around the wound, where there is no powder. If he thinks the wound will leak he commonly cuts holes in the Tenoplast for 2

3 extra drainage. He acknowledged that it takes a level of skill and care to remove these dressing and this is why veterinarians and not lay people do it. 18. Dr A wrote I take an active interest in my profession and always have done. I am always talking to colleagues about diagnosis and treatments. I attend many meetings. I read a lot. 19. The CAC requested and received copies of the clinical records for the cases referred to in Dr C s notification as well as the clinical records for a selection of random cases seen by Dr A. The Code of Professional Conduct for Veterinarians 20. The CAC referred to the requirements of the Code of Professional Conduct for Veterinarians (the Code). The following sections of the Veterinary Services section of the Code is relevant to this complaint: Section 1 Veterinarians must keep their skills and knowledge up to date by taking part in relevant continuing professional development activities that maintain and develop their competence and performance. b The public has the right to expect that veterinary services are provided in a competent and contemporary manner and that veterinarians will maintain and enhance their professional skills and knowledge. c. Clinical standards change over time. Methods of treatment which may be considered acceptable at one time may not be considered acceptable at a later date. Clients have the right to expect that veterinarians will keep their knowledge in their field of practice up to date. d. Veterinarians must comply with VCNZ's requirements for continuing professional development. Section 3 All veterinarians must take reasonable care to ensure that the practice that they are working in is operated to the standard expected in this Code. e. Veterinarians who believe that premises, equipment or other resources/systems in a practice are below the standard expected should raise those concerns with the practice owners or principals. Where such concerns are not appropriately resolved they should be brought to the attention of VCNZ. Section 4 Veterinarians must maintain clear and accurate clinical records. The records must: a. Be of such detail that another veterinarian could take over the management of the case at any time; f. Veterinarians have an obligation to maintain medical records which contain enough information to allow another veterinarian to easily take over the case. The medical history should be able to be organised and retrieved efficiently, and documented in a legible form. The medical record facilitates communication between veterinarians providing treatment. g. Records should contain relevant clinical history and findings, decisions made, treatments provided and information provided to clients. The record should document 3

4 relevant communication between veterinarian and client that directly relates to the patient. 21. The CAC also referred to the Competency Standards and Performance Indicators for Veterinarians (the Competency Standards), including: 5. Implement safe and effective veterinary procedures and therapeutic strategies - Safely induces, maintains and monitors analgesia and anaesthesia and takes steps to ensure safe and humane recovery - Carries out surgical procedures using appropriate techniques and procedures before, during and after surgery that minimise the risk to the animal and maximise the likelihood of a successful outcome. CAC considerations 22. Anaesthesia and patient warming While the anaesthetic drugs being routinely used by Dr A, as cited by Dr C, were first used many years ago, this alone does not make their use today inappropriate. Likewise, if something has always been done a certain way, that in itself is not a reason to continue to do it that way e.g. if new anaesthetic drugs and techniques are more appropriate. With regard to patient warming Dr A advised that B has a variety of methods available to maintain patient temperatures during surgery and hospitalisation. (This was confirmed by a senior colleague at the practice.) There are however differences in opinion between Drs C and A about how frequently and effectively these methods are used. 23. Pain Relief Peri-operative pain control has moved a long way in the past decade(s). What was acceptable to the veterinary profession, and the public, prior to these developments is no longer acceptable to either party now. The public expects that pets will not experience any discomfort if treatments are available to alleviate this discomfort. In his response Dr A has reported that there has been a review of their use of post-operative pain relief drugs. 24. Continuing Education Dr A lists sources of continuing education in his response that would appear to meet the requirements of the Code. 25. Record Keeping Five surgical records for August and September 2014 that involved Dr A were provided to the CAC. Of these, three are very brief and it is the CAC s opinion that these three records do not meet the requirements of Section 4 of the Veterinary Services principle of the Code (listed in 20 above) as they lack sufficient detail. In all five records it would be appropriate to include notes relating to the pre-surgical assessment of the animal, the name and dose for the drugs given, the length of the anaesthetic, notes about the procedure carried out as well as the post-operative instructions given. The recent clinical records, from June 2015, for consultations provided by Dr A do meet the requirements of the Code. 26. Bandaging Techniques Dr C and Dr A have differing opinions on appropriate bandaging techniques. Dr A provided his rationale for the bandaging techniques he uses. While the CAC does not consider the bandaging techniques used by Dr A to be consistent with those used by the majority of veterinarians; it does not find them unacceptable. 4

5 27. General The CAC thanks Dr C for raising her concerns. Her action was consistent with Section 3 of the Veterinary Services principle of the Code (listed in 20 above). The New Zealand veterinary profession is committed to a culture of continuous improvement. Sharing of experience and best practice, both within and between veterinary practices, through collegial discussion is to be encouraged as it is a major contributor to maintaining and improving standards. CAC recommendations and suggestions 28. The CAC recommends that Dr A: target some of his continuing education to the areas of anaesthesia, pain relief and bandaging but not at the exclusion of other topics relevant to his area of practice. It would be appropriate for Dr A to discuss with companion animal veterinarians, outside of B, how they are managing their patients review the Code with particular reference to paragraph 4 of the Veterinary Services section on clinical records. Dr A then needs to amend his protocols and practice as needed to ensure that the Codes requirements are met. 29. The CAC suggests that Dr A regularly re-evaluate all clinic protocols, in light of current knowledge and recommendations by appropriate veterinary advisory groups. While this may not result in changes to these, the practice needs to be able to show that they regularly review these and can demonstrate that these are informed by the current scientific evidence. The CAC suggests that the first protocols to be re- evaluated be those concerned with anaesthesia, pain relief and patient warming. Decision 30. The CAC considers that this case can be closed and no further action 1 needs to be taken. Reasons The reasons for the CAC s decision are: further education in anaesthesia, analgesia, and bandaging will ensure that Dr A is aware of recent developments and current practice in these areas regular reviews of clinic protocols, in the light of current knowledge and recommendations by appropriate veterinary advisory groups will help B and Dr A comply with the Code s requirements Dr A has demonstrated insight by reviewing the use of pain relief protocols in recent months Dr C s stated intention (in raising the concerns) was not to judge or criticise but rather to suggest more effective and modern methods of veterinary practice as a means of helping both the clinic, the clients and the animals. Dr C stated I do not seek any legal or formal action to be taken against [the] veterinarian. 4 September 2015 Dr Mark Simpson Chair Complaints Assessment Committee Date 1 Pursuant to s43(1)(f) of the Act 5