DECLARATION OF GENEVA

1. DECLARATION OF GENEVA I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practice my profession with conscience and dignity; I will respect the secrets, which are confided in me, even after the patient has died; I will maintain by all the means in my power, the honour of the noble traditions of the medical profession; My colleagues will be my brothers; I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patients; I will maintain the utmost respect for human life from its beginning even under threat, and I will not use my medical knowledge contrary to the laws of humanity; I will make these promises solemnly, freely and upon honour.

2. MEDICAL NEGLIGENCE - A REVIEW Dr. R. GOORDOYAL Chairman MEDICAL COUNCIL OF MAURITIUS

3. Medical Council Act 1988 1999 2002 December 2007 • Functions of the Medical Council • ………. • Exercise and maintain discipline in the practice of medicine with the assistance of its Medical Disciplinary Tribunal • Establish a code of practice for the medical profession on standards of professional conduct and medical ethics and monitor compliance with such a code

4. Discipline 13.1-PRELIMINARY INVESTGATION BY COUNCIL “Subject to section18, the Council may investigate any complaint of - -professional misconduct, -Malpractice, -Dishonesty or -Negligence or -A breach of the code of practice against a registered person including a public officer in respect of whom it holds a delegated power.

5. COMPLAINT RECEIVED AT COUNCIL COMPLAINT RECEIVED AT COUNCIL Possible fault on the part of M.P • Medical practitioner not concerned • No obvious fault of doctor Preliminary Investigation (I.C)(Section 13) Council informed Notify Doctor of the nature of the complaint Set aside Summon and hear doctor +/-complainant Summon and hear witness Complainant informed Call for documents Judge in chambers(if refusal by a person to give evidence or communicate document on ground of confidentiality

6. Presentation of Report of Preliminary Investigation to Council Evidence of fault of doctor No prima facie evidence of fault of doctor • Section 14(1) • Breach of code of practice • Act of fraud, dishonesty, negligence • Act of professional misconduct or malpractice • Any other act likely to bring the medical profession into disrepute Set aside • Section 14(2) • Prima facie evidence of negligence, incompetence or grave misconduct • Public interest requires that the registered person should instantly cease to practice medicine Charges drafted Inform doctor & complainant MDT Report to Council not >14 days after completion of proceedings Suspend for not >6 mths Cont/d Private Public officer (+delegation of power) • Disciplinary Proceedings • Show cause • Warning/severe warning Report to PSC for decision on suspension D Proceedings cont/d Inform doctor & complainant

7. MDT Report:Council's Opinion • 17(3) • Charges proven • Aggravating/alleviating circumstance Charges not proven Set Aside Inform doctor & complainant 17(4)a Public Officer (+delegated power) • 17(4) b • Every Other Case • Warning/severe warning • Reprimand/severe reprimand • Suspension from medical practice for not>12 months • Removal of name from register Report to PSC

8. 17(5) Punishment (Dismissal or Retirement) by PSC Removal of name from the Register COUNCIL • Decision under 17(4) or (5): inform doctor within 14 days

9. Section 18 CONVICTION OF REGISTERED PERSON Show Cause Punishment as per 17(4) (b) Section 19 Summary Proceedings (Minor Fault) Show Cause Warning/Severe Warning

10. Objectivity/independence of Decision • Preliminary Investigation – Evidence based -Accepted practice • - Literature • - Expert opinion • - Written explanations/interview of defendant doctor • - Interview of complainant party • - Documents: patient file, Investigations • Deliberations at Council - Views of full board • - Composition of Council • -Nominated members (non-medical) • -1 Rep. each from PMO,MOH,SLO • -vote ± casting vote of Chairman • Sanction- Show cause • Judicial review – aggrieved parties. -Doctors :public/private :General practitioner/specialist

11. DECISION OF COUNCIL • Presided by Judge + 2 senior medical practitioners • Evidence based • Hearing of parties + witnesses • Defence lawyers No fault of doctor Doctor at fault Set aside Show cause MDT Doctor+complainant informed Sanction COUNCIL Deliberations + determination Charge proven Charge not proven MOH/PSC (Public officer) Show cause Set aside Sanction Parties informed Parties Informed

12. Definition of Faults • Malpractice • Medical Council Act:“includes a failure to exercise due professional skill or care, which results in injury to or loss of life of a person”.

13. Definition of Faults • Medical Negligence • Medical Council Act: “includes failure on the part of a registered person to exercise the proper and timely care expected from a registered person”. • Act of Omission • Act of Commission

14. To succeed in a claim for negligence, a plaintiff patient must prove, on a balance of probabilities, • The following: • The defendant doctor owed him a duty of care • The defendant doctor breached that duty by failing to exercise the necessary level of care • Harm and injury was caused by that breach and • He suffered damages which was not too remote ( i.e. it was foreseeable by the doctor) “But for” testfor proving causation.

15. BOLAM TEST • “ A doctor is not negligent if he has conformed with responsible professional practices”. • A G.P must meet the standards of a competent G.P • A Consultant Gynaecologist must meet the standard of a competent consultant in that speciality

16. A common practice might be declared not to be rightlyaccepted: (common professional practices might be wrong) • The judiciary find it acceptable to challenge medical opinion, but only when the latter has no rational basis. • There may be circumstances where the provision of information will be “ so obviously necessary to an informed choice that no prudent medical men would fail to make it”.

17. Res Ipsa Loquitor “the facts speak for themselves” can help a patient in situations where he cannot specify what exactly caused the injury. the doctor has to establish his innocence, rather than the patient having to prove the doctor’s guilt.

18. The egg shell skull rule • “take your victim as you find him” the doctor is liable for all damages even if the damages are more serious because of the patient’s pre-existing illness orcondition.

19. Civil Negligence (Malpractice) • Failure in regard to the contractual obligations by a doctor when he agreed to treat a person. • Burden of proving negligence and damage on a balance of probabilities lies with the patient plaintiff. • A medical accident can be compensated but not the natural development of an illness. • Claims for compensation may be based on: - the tort of negligence - tresspass to the person and battery; or - breach of contract

20. Criminal Negligence • Arises in case of death or serious injury to a patient. • The degree of negligence must be so grave as to go beyond a matter of compensation. • The doctor may be prosecuted by police or charged in a criminal court for culpable homicide.

21. Contributory Negligence • Concurrent negligence by the patient and the doctor, resulting in delayed recovery or harm to the patient. • Defence for the doctor in civil cases. • Burden of proof on doctor.

22. Vicarious Responsibility • Liability of the master (employer) inspite of absence of blame worthy conduct on his part. • Negligence • Employer responsible for negligent acts of his servants. • Within the scope of his employment/range of services. • Tort of occupier’s liability (e.g. visitor injured on hospital grounds).

23. NOVUS ACTUS INTERVENIENS • The assailant is responsible for all the consequences of his assault – the immediate and remote – which link the injury to death. • !Breach in continuity of events by entirely new and unexpected happening (not reasonably foreseeable).

24. Liability in Medical Negligence Doctor Non- medical staffInstitution (Employer) Patient

25. : :Time factor, workload (no. of patients) Fatigue – lack of concentration Experience / competence Referral to specialists (specialized centres) Medical certificate Easy money – illegal abortions Doctor Financial

26. Communication Monitoring &Follow up Other Doctors Reports-Histopath,X-ray Withholding information Not following doctors’instruction CONTRIBUTORY NEGLIGENCE Patient Institution (Employer) Vicarious Responsibility • Understaffing Nursing X-Monitoring Others X-Execution of doctor’s orders • Equipment Unavailability/Faulty • Essential/Emergency drugs Non Medical Staff Laboratory technician-lab. Errors, delays

27. ETHICAL ISSUES • Professional relationship between colleagues • Making disparaging comments about colleagues( in front of other colleagues, staff, patient party). • Taking over a patient under care of another colleague without prior information to the latter. • Proper referral of patients to other colleagues. • Sharing of medical knowledge/new technologies + assistance to colleagues. • “Overcharging” of patients.

28. FOLLOW UP OF PATIENTS • During surgery/anesthesia, e.g. monitoring • Esp. after surgery/intervention • Instructions/orders not executed properly • Availability of treating doctor Postoperative complications Anaphylactic shock • Handing over to other colleagues in case of unavailability • Deficiencies in nursing care-monitoring of head injured patient -delay in executing instructions • Patient smelling alcohol: May mask certain signs in head-injured patient • Wrongly tagging as alcoholic without excluding other diagnosis • Follow up, monitoring + management of critically ill-patient especially in ICU • Too many patients in casualty

29. REQUEST FOR INVESTIGATION • Rationale for request • Not seeing results of URGENT INVESTIGATIONS • Unnecessary delay in requesting special investigations, e.g. CT scan

30. Prescription Form • Use of decorative letter head • Over description of doctor’s qualities /competence (publicity) • Handwriting – wrong dispensing • Explaining to patient • Perception of indiscriminate prescription / over prescription of certain drugs (e.g. steroids) in chikungunya Gastric perforation (in patient of chikungunya)

31. Conviction for drug abuse

32. Medical Certificates • Death certificate issue • Without examining corpse • Cause of death (true?) • Use of abbreviations • Time of death

33. Medical certificate of sickness • Requirements of Medical Council Act • Date of examination • Full name and address of the patient • Registered name and address of the RMP • Signature of the RMP • Cases:Backdating and postdating • diagnosis (?confidentiality) • Not confirming identity of patient (patient in police custody)

34. Improper filling of other forms e.g.. Blood transfusion form –Identity of patient - Degree of urgency/when needed - X-match/type & screening - type of products and quantity

35. COMMUNICATION Doctor-Doctor Patient Non Medical Staff

36. DOCUMENTATION & RECORD-KEEPING • Scanty/ no clinical notes • Name of doctor • Date and time of examination, diagnosis/D.D • Pre operative status • Treatment/Operation notes • Progress • Investigations/Monitoring • Handwriting-wrong dispensing • Use of Abbreviations (CST,ISQ, ADS)

37. “If it isn’t written, it wasn’t done” Four most frequent themes in case of a bad outcome: • Believe your monitors! • Recordkeeping • Surgical team agreeing as to what occured • (Avoid rushing to condemn) • 4. Communicate with patient before and after

38. Flow Chest ( common surgical accidents leading to Medical malpractice Suits Blood Transfusion Mistakes Wrong Patient Paralysis from Splints Medical Practitioner Wrong Side of the Body Surgery on wrong Digits Failure to X-ray Fractures Tight Plaster Casts Retained Objects Anaesthetic Mishaps Surgical Errors (e.g. ligation of ducts) Removal of Wrong Organ

39. COMMUNICATION-DICLOSURE OF INFORMATION Good-Proper-Adequate……? Questioning-Listening-Responding-Explaining • Precautions to comply with: • Disclose information only to the proper person or authority • Preserve confidences as far as possible (avoid idle conversation about patients, use “aliases”) • Do not disclose beyond what is required by the law and the situation • Document in patient’s record the reasons for and circumstances of the disclosure.

40. Situations where it is ethically and legally required to reveal information: • When the patient consents • To medical colleagues • As a statutory duty (Re: Infectious diseases) • As information to relatives • In the interest of research projects • In disclosure to court • In the discovery of documents in court proceedings • In the public’s interest

41. INFORMED CONSENT1(BRAND) • Benefits of treatment • Risks of treatment • Alternatives (other treatment options) • No treatment (risks of) • Documentation + signature(patient, doctor, independent witness) • Material Risk • The “Prudent Patient” Test • Therapeutic Priviledge • Battery/Tresspass

42. INFORMED CONSENT2based on information about: • The name of the operation • The nature of the proposed treatment • What the operation involves • The potential complications • The special precautions required postoperatively • The limitations of treatment • The success rate of the operation • How the patient will feel after treatment • What happens on admission

43. Fundamental ethical and guiding principles • Respect for patient’s autonomy (self determination) • Non-maleficence (the duty to do no harm) • Beneficence (contribute to patient’s welfare). • Justice (equitable distribution of benefits and burden). • Fidelity (truthfulness and medical confidentiality). • Veracity (honesty).

44. MEDICAL ETIQUETTE Concerned with the conventional laws and customs of courtesy which are generally followed between members of the same profession. A doctor should behave with his colleagues as he would like to have them behave with him.

45. MEDICAL ETHICS • Concerned with moral principles for members of the medical profession in their dealings with each other, their patients, and the state. AIM:to honour and maintain the noble traditions of the medical profession

46. THANK YOU