Exempt from public disclosure pursuant to offline a. § 13 cf. PAA. § 13, first paragraph. 1
Decisions warning
Norwegian Board of Health has decided to give you a warning under the Health § 56 first paragraph. We have concluded that you have violated the acceptability requirements of the same Act § 4 and § 7 in that you evening the xxxxxx not ensured that xxxxxx was seen by a doctor that night. Furthermore, we have determined that you have violated the Health §§ 4 and 7 morning xxxxxx when you are not ensured that the patient was taken by ambulance to the doctor’s office.
You can appeal the decision within three – 3 – weeks of receiving this letter.
Procedural process
Norwegian Board of Health received the letter from the County xxxxxx xxxxxx in submitted a supervision about your business as a doctor. Attached the transmission followed obtained documents from you, xxxxxx municipality xxxxxx HF as well as documents from xxxxxx police district’s investigation.
Supervision case concerns the health care that was given xxxxxx (hereinafter the patient) in the period xxxxxx until she died xxxxxx.
Norwegian Board of Health has obtained expert declaration drawn up for Norwegian pasientskadeerstatning (NPE).
We oriented you by letter xxxxxx that we would consider giving you an warning. You stated you to this by letter dated xxxxxx with attachments.
Norwegian Board of Health has xxxxxx received new evidence from xxxxxx police. Following a review, we have not found data in the new documentation will affect our assessment of your business as a doctor. This is therefore not sent to you for further information.
We apologize for the long processing times.
The subject matter
You are educated in xxxxxx and got xxxxxx authorization as a doctor in xxxxxx. You received authorization as a doctor in Norway the xxxxxx, HPR no. Xxxxxx. You have stated that you worked as emergency doctor at xxxxxx xxxxxx in before you completed internship in xxxxxx, and that you have undergone ATLS courses in xxxxxx. At the time of the incident you work in Norway through their agency xxxxxx. You was a substitute physician in xxxxxx municipality and you worked as emergency doctor.
Norwegian Board has considered the matter on the basis of the documents you’ve got submitted earlier in the proceedings. Below is a discussion of the factors that have had an impact on our rating.
The patient, one xxxxxx year-old woman from xxxxxx, was Friday xxxxxx operated by xxxxxx for hemorrhoids, in that it was conducted knit treating patient internal hemorrhoids. Sunday xxxxxx patient began to experience pain. The patient met at work Monday xxxxxx, but called for a few hours their spouse and asked to be picked up, as it hurt so much. The pain increased, and Tuesday xxxxxx xxxxxx contacted patient. It was agreed that she would receive a certificate. Same Tonight pain have increased further, according to the explanation of the spouse, and he contacted then the emergency room.
The sequence of events starting xxxxxx even xxxxxx
Norwegian Board assumes the following sequence of events, from what is described in Printing from audio log and Emergency Medical Information System (AMIS), a report prepared by the municipality, complaint from the patient’s spouse as well as your statements of xxxxxx, xxxxxx and your statement in questioning by the police.
The xxxxxx kl. 6:26 p.m. contacted the patient’s spouse LEMC (LV-center) for xxxxxx municipality. LV-center is collocated with the emergency center (AMK-center) in xxxxxx, and the two telephone lines operated by the same operator. In this case, called the patient’s spouse phone number of the LV center because of concern for the patient’s condition. The operator relayed the request to you as the duty doctor.
LV-operator stated that the patient had been operated for haemorrhoids and that she had severe pain. You took then contact with the patient and her spouse. According to your description you gave advice on painkillers, Codeine, which the patient could take for abdominal pain. You must have agreed that the patient should come to the doctor’s office the following day and that the patient should take new contact if there was worsening. The patient felt better the next day, and did not show up at the doctor’s office.
In the evening xxxxxx kl. 6:52 p.m., contacted the patient’s spouse LV-center again and informed that the patient had been better on the day, but felt now worse again. LV-center contacted you 20 minutes later, notified that the patient felt very bad and asked you to contact the patient. You contacted when the patient and was informed that she had been better in the morning, but was now sick and had not been able to eat. However, she had drunk anything and you should have gotten the impression that the patient’s breathing was normal with respect to frequency and that she had a fever. It was agreed that the patient should come to the doctor’s office the following day.
Later that night approached the patient’s spouse xxxxxx their switchboard and was put over regional EMC kl. 7:54 p.m.. Your spouse gave opposite AMK operator indicated that he was not relying on emergency doctor’s decision. AMK operator asked for changes in the patient’s condition, and was informed that the patient was bedridden and that she was sick. Her husband also told that the patient was about to faint three times when she was showering. AMK operator asked spouse what number he had called, whereupon the spouse replied that he had called the hospital switchboard because he thought it was a bit drastic to call 113. After some discussion agreed AMK operator that he should notify emergency doctor again, so you could call back to the patient.
AMK-center contacted immediately and notified that the patient was about to faint several times, and that the patient’s spouse was not comfortable with waiting until the morning after. You agreed that you would contact the patient. When you contacted the patient should have been informed that the patient had felt dizzy when she stood up to shower so that she had to lie down again, and that she was nauseous and had bleated out. You also learned that the patient was clammy. You got spouse to measure the patient’s temperature showed 34.7 measured forearm. Her husband told me that he had a blood pressure monitor, and you got him to measure the patient’s blood pressure. However, he succeeded not even after several attempts. You must have perceived that it was because of the failure of the blood pressure monitor. You should also have talked with the patient, and you assessed that the patient’s condition was stable, the patient was dizzy as a result of that she had been to bed all day without anything to eat and that the pain was not aggravated. You asked again the patient to come to the doctor’s office the next day, regardless of whether she was better or not, and that she should take new contact if her condition deteriorated during the night.
In the morning xxxxxx kl. 7:13 contacted spouse again LV-center. He referred to conversations with LV-center and out on the two preceding days. The spouse also referred to the agreement with you from the night before, that the patient should attend the clinic at. 8:30. Her husband explained that he was unable to get the patient into the car and insisted that the patient had to have an ambulance. He believed that hemoroideoperasjonen could not be the direct cause, then the patient fainted, failed to eat and keep food and was sick and lay writhing. The spouse stated that it was now acute. LV-operator would not promise that any ambulance be sent to the patient. The operator explained that it was shift change and that he would talk to those who came on duty on this. It was agreed with the spouse that LV-center should call back.
You were contacted at. 7:28. LV-operator informed that the patient’s spouse had called and said that they were unable to get to the doctor’s office without an ambulance. LV-operator expressed doubts whether it was necessary. You enlightened first emergency operator that you had talked with the patient and spouse in two days and that the patient had pain, a little hypothermia and some bad blood pressure. You also believed that the man was upset that it was easier to talk to the patient than with the man and that you could talk to the patient if she was “resonabel”. You agreed with LV operator that they should talk to the patient to ask if she could take a taxi. LV-exchange followed this, and talked with the patient and agreed that she should take a taxi. After this conversation decided spouse, according to his own statement that he would drive the patient to the doctor’s office.
When the patient arrived at the doctor’s office, she was, according to printing AMIS audio log kl. 9:14, nauseous, dizzy, clammy, poorly circulated, with blood pressure 100/80 and difficult contactable. It was notified to the AMK-center on the need for an ambulance with red response for transport to hospital. According to your statement of xxxxxx assessed that the patient was in hypovolemic shock. Patient stabilizing treatment including administration of the fluid at the doctor’s office, and it was also requested ambulance for transport to hospital. Transport by helicopter ambulance was initiated at. 10:40.
When the patient arrived at the hospital she was awake, alert and oriented. The clinical picture showed suspected sepsis. Antibiotic therapy was initiated. After it was made CT and rektoskopiundersøkelse were patient’s clinical condition more and more critical despite intensive treatment. Kl. 4:15 p.m. she lost consciousness, it was connected to defibrillator and ECG now showed asystole. Resuscitation was attempted, but with persistent asystole patient was pronounced dead at xxxxxx. 16:45 CET.
Information from AMIS registration
According to AMIS’s inquiries the xxxxxx kl. 6:52 p.m. and 7:54 p.m. both registered a communications pathway “emergency” and the events prioritized by urgency V (typical), which corresponds to “green response” according to NI. It was not given criteria. It was registered as a problem: “ hemoroideopr. Friday started m. Codeine occasion. Pains. Nausea and dank. Rings on again- had nærsyncoper when she was in the shower. Not comfortable with waiting until tomorrow . “
The next day, the xxxxxx kl. 7:13 when the spouse contacted LV-center, it is recorded V – Green response – with the criteria “ 3.6, unresolved problem “. It is recorded that the patient has pain, feel sick, unwell and relatives say that the patient can not get off at the appointed doctor’s appointment without ambulance.
Statement from the Department of Forensic
xxxxxx, Department of forensic medicine, xxxxxx, writes in his conclusion of xxxxxx that it is reasonable to assume that the cause of death was blood poisoning occurred as a complication to knit the treatment of hemorrhoids.
Statement from expert
xxxxxx, specialist in general has given his statement to the Norwegian pasientskadeerstatning xxxxxx. She notes that a patient and their relatives who call repeatedly to emergency and says that the patient can not get out of bed without collapsed, is dank and body temperature of 34.7, shall be examined. She concludes that the patient should be seen by a doctor on xxxxxx, the diagnosis sepsis as could have been completed and the patient could have been placed on the same day.
Statement from xxxxxx Municipality
Ass. Councilman in xxxxxx municipality xxxxxx In a letter xxxxxx stated that emergency room in xxxxxx municipality is well secured with on-call and telephone access to a doctor with a longer practice.
Your statement to the case
You describe in your note of xxxxxx to your spouse complain that you reviewed the patient’s temperature was measured at 34.7 ° C was an error value as a result of the measurement method forearm. You asked spouse measuring patient’s blood pressure with a blood pressure device he had at home, and he tried several times without getting a result. You spots blood pressure device that the spouse used was not working when he should have suggested that it was possible that the battery failed. You also write that you afterwards with blueprint in hand made a misjudgment, and that it is easy to say that this was due to a low blood pressure. That night you considered the reason why the patient became dizzy when she stood up, to be sure she had been bedridden all day and had not eaten. You write that it is normal in such cases that patients receive blood pressure which gives dizziness and similar symptoms. You Rated on the basis that you perceived the situation as stable, the patient could get to the doctor’s office in xxxxxx next day, but had to take new contact if she got worse during the night. You noted further that the patient had a difficult illness. That the patient arrived too late to the doctor’s office due to the assessments you made and that the patient and the patient’s spouse during communicated symptoms by phone.
You have emphasized that in talks xxxxxx was not a discussion about whether you should go and assess the patient in the home. The discussion focused on whether the patient should go to the doctor’s office the same evening or the next day. The choice about securing the availability of emergency care physician for other residents of the municipality, and that the municipal doctor’s office identified more and better medical equipment enabling a correct diagnosis. Moreover, data for record keeping, and if referral to hospital applicable done it much better from the doctor’s office.
In the minutes of a police interview the xxxxxx is it so Norwegian Board understands, no distinction between EMCC and LV -central. Both features seem to be referred to as AMK. You are in the interrogation explained that you have perceived that it is your responsibility as a doctor on duty to take the medical assessment, both when speaking with AMK and patient. You could also requisition ambulance by contacting AMK if you found it necessary and you would not then have been overruled. If the ambulance is in another mission, it will be a priority issue in dialogue with AMK. You explained in the interview that the visit by the patient is possible, but the main rule is to take the patient to the doctor’s office where there are facilities for making surveys. It can then be used ambulance to fetch the patient.
Regarding the incident stated that you assumed that the patient had undergone elastic treatment of external hemorrhoids and that you were not aware that knit processing was the patient’s internal hemorrhoids. You also stated that this was a field that was a little on the outside of your field. The current day xxxxxx did you first contacted by the spouse of the patient after business hours. You understood then that the patient was sick and no appetite and had unchanged symptoms. Later in the evening received a new inquiry about the patient. You got when illuminated by the spouse of the patient that the patient was dank, the temperature measurement you were given was measured forearm and let therefore not measure the performance of reason. You got it after your statement stated that the patient taking down liquid, but was sick and did not eat. The patient had been giddy, but attempts at blood pressure measurement device spouse had at home, did not result when the spouse did not get the appliance to work. You found it not unreasonable that the patient was dizzy during the shower, and the reason it meant you were the patient had not eaten, was bedridden and had taken Codeine and Ibux.
You clarified during the interrogation that there Something about the patient’s general condition seemed worse, or that there was something new. On this basis, you agree with the patient and the spouse that they should come at noon the following day. You explained that you did not hear anything more before the patient came to the doctor’s office the day after noon. 9:05. When the patient arrived at the doctor’s office so you immediately that she was seriously ill, and you initiated investigation and lifesaving. You got when deploying two venous cannulas and fluids under pressure. You summoned ambulance, but due to delays it took 60 minutes compared to the normal 20 minutes before the ambulance helicopter arrived.
You have given a new statement to the matter in a letter of xxxxxx. There is no distinction between EMCC and LV-central statement said. Here commenting that you continually have obtained the necessary information from the patient and spouse with the aim of providing an accurate picture of the patient’s health condition. In your opinion has the work been carried out in accordance with expected requirements to professional responsibility and diligent care and have thus been no violation of § 4 in Health.
You also believe that the cases presented to the experts wrong, and you state that LV / AMK have not forwarded the necessary information to you.
Regarding expert witness statement you have several notices:
In an expert assessment describes the spouse on the phone the xxxxxx should have stated that the patient was “ cold and clammy “. Of your medical record stated that the patient was “ dank and pain affected .”
In the evening you shall according to experts’ preparation have given patient is instructed to take painkillers on the evening xxxxxx when spouse requested the patient had inflows of doctor. You believe that important information is omitted and manufacture is therefore incorrect.
When AMK contacted emergency on the evening xxxxxx kl. 8:02 p.m. claims that AMK not relayed information from the conversation with your spouse at. 7:55 p.m.. In this conversation has spouse said that the patient is “ not the one who shouts and is such a type that would rather not bother anyone “. You think that such expert portrays case it might seem as if that duty doctor received this information, which you did. This information would in your opinion have influenced the decision to not consider the patient that same evening.
Where expert refers to symptoms of SIRS, commenting that you have questioned whether the patient’s respiration in each phone. You have demonstrated that RF is normal which means respiration rate was lower than 20 breaths per minute. This finding speaks against severe disease in your opinion. You also notes that her husband measured blood pressure and pulse with a sphygmomanometer, but because of what you perceived as a machine error / battery shortcoming is failing the test.
You also refuted experts’ conclusion that there was a failure that patient was not seen by a doctor on xxxxxx, and the patient should not have been told to wait until the day after. You mean that the patient was denied assessment that evening and the decision to postpone consideration until the next morning was taken with the patient himself, and was based on the current available information at that time. You mean it was asked adequate questions to assess the patient’s condition and vital parameters.
You also shows that when AMK clinic, xxxxxx kl. 7:28 and conveyed that her husband said that the patient could not get to the doctor’s office without ambulance, added that AMK “ I do not know, I think it’s a bit like that on the edge of ambulance “. Noticing that her husband then had just testified that the patient was unable to sit. AMK has not forwarded information that the spouse gave about your spouse’s statement that the patient felt icy. Selecting cab instead of an ambulance must in your opinion considered in relation to this information was not known and that otherwise would ambulance obviously been ordered to ensure prompt and adequate transportation of the patient to the municipal clinic.
You show also points out that you have previously given your statement to the County in which you have commented spouse’s complaint.
Legal basis for assessment
Information in supervision by the case to consider whether you have acted in contrary to the requirement of proper business in Health § 4, which reads:
health professionals must perform their work in accordance with the requirements of professional responsibility and diligent care that can be expected based on their qualifications, the nature of work and the situation in general.
Health professionals should abide by their professional qualifications, and shall obtain assistance or refer patients further where necessary and possible. If the patient needs dictate, the profession shall be by collaboration and cooperation with other qualified personnel. Health professionals have an obligation to participate in developing individual plans, when a patient or user is entitled to such a plan for patient and user Rights Act § 2-5.
In collaboration with other health care professionals , the physician and dentist decisions respectively medical and dental issues relating examination and treatment of the individual patient.
The Health § 4 is a central provision. The provision requires professional responsibility and diligent care and health professionals’ professional practice.
What is justifiable is determined by an assessment of each case, and how health workers ideally should have acted.
In situations requiring immediate assistance set in the Health § 7 additional requirements to clinician profession:
Health personnel shall immediately provide the medical care they are capable of when it must be assumed that aid is urgently needed. With the limitations imposed by patients and User Rights Act 3 § 4-9 , necessary health care is provided even if the patient is unable to consent, and even if the patient objects such care.
If doubts about health care is of vital importance, health personnel carry out the necessary investigations.
The obligation does not apply in the extent other qualified health provider undertakes responsibility for providing health care .
In the specific assessment of whether the way you act in the matter is justifiable taking Norwegian Board of Health based on the general description of what should be expected, so-called “good practices”. Emphasis is placed on current professional guidelines, where they are prepared.
In order to set the framework for prudent operations emphasized how healthcare should have acted in the specific situation in the light of their own qualifications and experience, not how health workers ideally should behaved . By proper proportionality assessment is taken further into account the action alternatives in the current situation, as well as health care professionals’ duty to keep up to date.
It also emphasizes on the activities are organized such that the health are able to fulfill their statutory duties. Which specific procedures or established procedures to ensure proper health care, we assess whether the health personnel acted in accordance with these.
Not any deviation from “good practices” considered unjustifiable. There must be a relatively clear deviation from good practice before the action is unjustifiable under Health § 4. The soundness are emphasized on the degree of risk of injury a deviation will be associated with. This declaration tightened if there is great risk of serious injury if done incorrectly.
Norwegian Board of Health review
The central issue to be assessed is whether you acted contrary to the requirement of professional responsibility and / or duty of immediate assistance cf Health Personnel § 4 and § 7. The central Government Health has been your handling of the incident at the following times:
- the evening of xxxxxx when you first time that night agreed that patient should come to the doctor’s office the day after,
- the evening of xxxxxx when you again asked the patient to come to the doctor’s office the day after,
- the morning of xxxxxx when you agreed with LV-center that the patient could use taxi.
Regulations and statement of good practice as a basis
AMK-center in xxxxxx has function as emergency telephone xxxxxx municipality. Casualty doctor cooperates with the emergency call center operated by AMK-center with its own operators. Responsibility for emergency doctor, LV-central and EMCC, and conditions at the emergency medical prehospital services are regulated in Regulation for emergency medical services outside the hospital of 18 March 2005 no. 252.
The regulations § 7 and § 9, ref. § 14, that the regional health authorities are responsible for the AMK centers and ambulance services. It’s EMCC conferred authority and expertise to evaluate and implement emergency medical response, including the dispatch of an ambulance.
The municipality has claimed Regulations §§ 7 and 10, responsible for the establishment and operation of LV-central who will receive and handle inquiries and prioritize, implement and follow up inquiries to the doctor. LV-centers, according to the regulation § 11 “ consider requests for emergency assistance, including carrying out the follow-up as deemed necessary”. Tasks that fall under this, according to the regulation § 12 be, inter alia, to diagnose and treat acute medical conditions and to provide for referral to a specialist if needed.
In order to fulfill this responsibility, it is essential that the operator obtain necessary information on the incident, and whether the patient’s condition. Decision support use all AMK centers and a range LV exchanges Norwegian index for medical emergencies (NI). NI is a key decision-making tool in emergency situations where urgency to get given proper assistance. It will, together with other procedures and routines constitute a dynamic decision-making tools for the collection of relevant patient information, assessing the degree of urgency, and implementation of emergency medical response. NI is a reference work that helps to bind together the Emergency service and other emergency services.
According to internal procedures for emergency services in xxxxxx municipality shall LV operators use NI by obtaining information about the patient’s condition and using the appropriate additional questions that NI specify.
All inquiries Norwegian Emergency Medical / LV-exchange registered in AMIS, a system for business registration and communication of information about the event / patient. In AMIS registration includes the registration of each event with time for handsets, activation and status of resources, such as ambulance, criteria for patient’s problem and urgency of treatment needed. Criteria chosen from postings in NI. NI recommends the following assessments of priority:
- green response if medical supervision can be done in the doctor’s office the day after,
- yellow response to possible serious conditions where emergency physician must be contacted and possible. get to emergency in taxi or ambulance for examination at doctor’s office, and
- red response where ambulances and emergency doctor always alerted for immediate response.
Health professionals have a responsibility actively to obtain the necessary information to assess the degree of urgency. This follows from the Health § 4, first paragraph. § 7 second paragraph that imposes the obligation to conduct the necessary investigations by doubts.
At the yellow and red response shall LV-operators always contact emergency physician to make necessary arrangements . If in doubt about the inquiry concern needs immediate help, ie whether it is green or yellow / red response, the emergency physician who is responsible for taking a decision, ref. The Health § 4 third paragraph that gives doctors a special responsibility to take decisions in medical questions, by cooperation with other health professionals. In the contact between LV-panel operator and emergency physician, it is therefore always emergency doctor who is responsible for deciding on the response.
This division of responsibilities is also stipulated in LV xxxxxxs systembok indicating the medical guidelines for cooperation between the municipality and health authority . It describes that
“ After notification has emergency doctor xxxxxx situational responsibility to anna agreed.
AMK xxxxxx is responsible for notifying the local doctor in xxxxxx in emergency medical situations .
… If doubts about the urgency should emergency medical attention utan galvanizing. “
Patients who are not examined by a doctor has under NI always an unresolved issue. In such a case there is a central task for emergency care physician to determine whether the patient’s symptoms indicative of red or yellow response.
At the unresolved problem and by repeated inquiries from patients with suspected acute / serious problem, recommends NI that triggered red response. The same is recommended when the patient has symptoms that suddenly pale and nauseous and still awake, but faint.
In this case, all requests from the patient’s spouse, apart from the inquiry xxxxxx kl. 7:54 p.m., gone to LV-center. Norwegian Board of Health has considered the matter from that municipality and you as emergency physician who mainly received inquiries from patient / spouse and thus had the professional responsibility to handle the requests.
The inquiry into LV-central xxxxxx kl. 18: 52
From LV-center received information and that the patient was now very poor and the operator asked you to contact the patient. In your conversation with patient / spouse did you find out that the patient was sick and could not eat, and when she tried, it came up again. You did, however, know that the patient had ingested a drink and you spots patient’s breathing was normal and that she had a fever.
Norwegian Board of Health finds that you already at this inquiry had access to information about the patient condition that can match the symptoms of a serious condition. You however, concluded that the patient’s condition was so severe that you have to examine the patient in accordance with the degree of urgency yellow.
Norwegian Board would point out that the patient’s condition, after your interrogation over the phone, was still unclear. You had not ruled out that the patient’s condition was not serious. We therefore consider that it was not in compliance with NI to deal with the patient to wait until the next day of examination. The patient had symptoms that gave suspected acute / serious problem that should have led the patient was examined.
