Medical Protection provides support to a consultant psychiatrist through ten years of investigations. By Dr Andrew Stacey, Medicolegal Consultant, Medical Protection.
A consultant psychiatrist, together with a specialist early intervention in psychosis service (EIPS), had been treating a young man who had alcohol, drug abuse, and mental health issues. Those issues included a previous (first) psychotic episode, for which he received compulsory treatment in 2012.
Over the course of 2012, the patient was regularly seen by the services. His use of antipsychotic medication was tapered off (at his and his parents’ insistence) and he continued to be assessed by the medical team (psychiatrist and nurses). This included the team seeking out signs or symptoms of relapse and suicidality. The team’s extensive medical notes recorded repeated consideration as to whether the patient was suicidal, and found no such indications. In March 2013, the consultant psychiatrist and principal psychiatric district nurse conducted a home visit, and completed a comprehensive assessment of the patient, again finding no indications of suicidal intent or psychotic symptoms.
Unfortunately, three days later the patient died by suicide.
From the immediate aftermath of death, and onwards, the parents of the patient made serious allegations against those involved in their son’s care. In respect of the consultant psychiatrist, the parents’ allegations included that he was willing to lie and fabricate evidence. Medical Protection became involved at an early stage, defending the consultant psychiatrist in respect of all complaints made against him over the next decade.
In the first instance, the District Health Board (DHB) undertook an internal investigation into the patient’s death. It heard from those involved including the patient’s parents and the clinical team. The parents’ complaint, even at this early time, included allegations that the medical team had fabricated records of additional phone calls where the parents said they had conveyed their escalating concerns about their son in a way that was consistent with psychosis. The DHB’s investigation (as well as a subsequent investigation by the Health and Disability Commissioner) found no evidence supporting these allegations.
At an early stage, the parents made a police complaint, alleging the psychiatrist’s care of the patient was so deficient that he ought to be liable for manslaughter. While ultimately the police declined to further investigate or charge any person, the investigation of this complaint paused other processes (such as the coronial process) for a considerable period.
The parents also made a complaint to the Medical Council of New Zealand against the psychiatrist. No further action was taken by the Council.
A complaint to the Health and Disability Commissioner (HDC) was then made by the parents. This process spanned from 2013 to 2017. While the complaint was handled, the coronial process was again paused to enable the HDC to conclude its work.
The HDC’s focus was on quality of care, and appointed its own expert psychiatrist. They reviewed various documents, but had not been involved in the patient’s care and were not available for questioning or to test their opinions. The HDC was reliant on the expert psychiatrist finding grounds on which the DHB and doctor had failed to provide services to the patient with reasonable care and skill. In the doctor’s case, this was in one respect only – that the patient should have been made sufficiently aware of alternative treatments following his presentation to a different DHB in December 2012 during a holiday. It is notable that the coroner subsequently decided to place little weight on these findings, observing that the HDC’s expert had provided no reasoned response to further information provided via the HDC process by the doctor, and because the expert was not a witness at the coronial inquest, their evidence was untested.
The HDC’s Director of Proceedings elected not to take any action against either the DHB or the doctor from its findings. Despite this, following the HDC report, the parents commenced civil court proceedings against the DHB and the consultant doctor in the Human Rights Review Tribunal. They alleged breaches of the Code of Health and Disability Consumers’ Rights by the doctor and DHB, and sought a $100,000 award of damages.
The tribunal process was then halted to enable the coronial process to proceed. As the death appeared to have been self-inflicted, the matter had been referred to the coroner at an early stage. With police and HDC complaints dealt with, the coroner could commence his role.
A coronial inquest does not determine criminal, civil, or professional liability of any person. The purpose is to determine the causes and circumstances of death. A coroner may also make recommendations. In 2018, the coroner heard from the parties about whether he should convene an inquest, in light of the various investigations and complaints that had taken place to date. In 2019, the coroner decided to hold an inquest, on limited issues that he considered had not been determined fully by other processes. A key issue for inquest was whether the patient had been suffering a relapse by March 2013, or whether his behaviour and presentation was explicable instead by his ongoing alcohol and drug problems. Later, the coroner added, as an issue to be determined, the question of whether the psychiatrist’s last suicide risk assessment at the patient’s home in March 2013 was adequate.
Preparation for the inquest required a lot of , time, effort, and resources from multiple parties, including lawyers, medical experts, court staff, and others. The coroner made his own independent investigations, including ordering that the Institute of Environmental Science and Research (ESR) repeat the toxicology testing of the patient’s blood samples, some six years after death. Various witness statements were obtained, and the full written record of the patient’s file was put before the court. The bundle of documents was over 2,200 pages long. The DHB and the consultant had separate legal teams, both of whom were required to engage independent senior psychiatrists as expert witnesses. The role of the expert witness was to review the volume of material, in order to express their professional opinion at the inquest. The court also appointed its own expert psychiatrist, who attended court and provided his opinion.
Preparation was made more difficult by the fact that the patient’s parents were self-represented, and regularly made serious allegations about the clinicians, and other witnesses’, honesty and integrity. The parents were also witnesses, and although they were assisted by a support person who was a lawyer, conducted their own legal case. They sought to cross-examine other witnesses (and each other), and provided written and oral submissions to the court. The court also appointed a lawyer to assist the court. This lawyer was there to ensure the parents’ evidence was admissible for the benefit of the court, question witnesses, and present legal arguments.
The inquest hearing lasted for ten days in December 2020, and what was said at the hearing occupied over 930 pages of transcribed evidence. Early in 2021, the patient’s parents sought to reconvene the inquest in order to cross-examine the court’s appointed expert – an opportunity they had declined at the first hearing. The request was granted, over the objections of the other parties involved in the process, who demanded finality. The inquest was resumed in March 2021. Over six months later, in October 2021, the court discovered new information that had not been disclosed to the court or parties – communications between the parents of the patient and the ESR scientists, around the time of death. The parents sought to challenge or change the conclusions of the expert around the identification of drugs in the patient’s system at the time of death. The parties had to further address the coroner on this matter.
Several months later, in April 2022, the parents of the patient requested to add a new toxicology report they had obtained from an expert witness as evidence. This late request was granted, but further delayed the delivery of the coroner’s findings.
Outcome
In June 2022, the coroner released their 121-page decision. In summary, they concluded that the patient’s death was by suicide, that the patient had been intoxicated, and was not suffering a relapse of psychosis.
The coroner concluded that the psychiatrist’s suicide risk assessment of the patient had been appropriate. This followed the conclusions of all three expert psychiatrist witnesses, who had jointly agreed that the assessment was comprehensive and adequate, and assessed all relevant points of a suicide risk assessment appropriately.
The coroner remarked that there was a discrepancy in the evidence between the parents of the patient and the clinicians. On important factual disputes, he preferred the evidence of the clinicians and found the consultant psychiatrist to be an honest and reliable witness. The coroner observed that his evidence did not contain inconsistencies and that he was willing to make concessions or entertain alternative theories where appropriate. The coroner found his evidence was entirely consistent with the contemporaneous written record.
In September 2022, following the coroner’s findings being released and being made public in August 2022, all aspects of this long running dispute were resolved by the patient’s family, discontinuing their tribunal proceedings.
Learning points
This case shows the tension that can exist between meeting the needs and instructions of the patient and their caregivers – in this case the parents. Ultimately, it is the patient’s interests that must prevail for a medical practitioner, even though it can cause difficulty and leave a clinician open to criticism, however unfair, that others’ concerns are not being heard. This was exacerbated in the present case, by the parents’ increasing distrust of the treating clinicians, and their increasingly serious allegations about them, such as falsification of medical records.
The long history of this case also illustrates the point that even where a medical practitioner is eventually vindicated, it requires a lot of effort , resources, and time to ensure a just outcome. The passage of time also puts all witnesses and decision makers at a disadvantage. In the present case, many witnesses were the patient’s flatmates or friends and years had passed since the events in question. The coroner therefore placed reliance on written statements made by the witnesses when interviewed by police in 2013. It is important that any healthcare professional who is asked to provide a written statement take care to check it at the time it is given for completeness and accuracy.
Finally, the complex subject matter, and the vast number of communications and interactions between the patient, his parents, other medical staff, and the psychiatric clinicians, meant that the medical records assumed particular importance in this case.
We acknowledge the assistance of the doctor’s legal team in composing this report.