Panel hearing summary 2013.0166

Decision of the Medical Board of Australia

Performance and Professional Standards panel

Jurisdiction: Western Australia
Date of Hearing: 11 June 2013
Date of Decision: 11 June 2013

Classification of Notification:

Clinical Care: Missed, incorrect or delayed diagnosis
Clinical Care: Inadequate or inappropriate treatment
Clinical Care: Delayed or inadequate or inappropriate referral

Allegations

It was alleged that a medical practitioner behaved in a way that constituted unsatisfactory professional performance under s.191(1)(b)(i) of the National Law in that they:

1. failed to have a system in place to ensure that abnormal test results were brought to their attention in a timely manner
2. failed to take steps to urgently inform the patient of the abnormal results of a Glucose Tolerance Test 
3. failed to recognise that the results of the Glucose Tolerance Test were dangerously high and that the patient required immediate referral to hospital for urgent treatment and 
4. failed to recognise that the patient was likely to be suffering from Type 1 diabetes and that oral hypoglycaemic medication was therefore not an appropriate treatment.

Finding

The panel found that the allegations against the practitioner were substantiated.

Determination

The panel considered that, in light of the proactive steps taken by the practitioner to improve systems at the medical centre and to improve their skills in diabetes diagnosis, treatment and management, it was not necessary to impose any conditions on their registration.

It found the practitioner’s failure to recognise that the patient was suffering from acute onset Type 1 diabetes and to take urgent action to refer the patient for specialist treatment in hospital put the patient at significant risk of developing diabetic ketoacidosis, which in fact occurred.

The panel reprimanded the practitioner, to reflect the seriousness of the deficiencies in professional performance on this occasion.