NEGLIGENCE

By Dr Kadiyali M Srivatsa

Ethical duty of a doctor is to protect human rights and dignity of the patient Physician’s must “Disobey Law” that demand “Un-Ethical Behavior”

ACT OF COMMISION

To Do Something Which A Prudent

Man In Similar

Situation“Will NOT DO”

- Alderson 1843 -

ACT OF OMISSION

Not Do Something Which A Prudent Man In Similar Situation

“WILL DO”

DILIGENCEDiligent Behavior Is Indicative Of “WORK ETHICS”You must understand “Diligence” before you can understand all about ethics

A Belief That “Work Is Worship”Ref: Keith E. Thurley, Sek Hong Ng (1996), "The Concept of the Work Ethic",

DILIGENCESteady, earnest, conscientious application of one’s energy to accomplish what have been undertaken

Exercise of investing all energy to

complete the assigned

tasks.

DILIGENCEContinue to work hard and vigilantAvoid errors and stay focused on the taskPays careful attention to details Dedicated to achieving quality results. Committed to transform vision into reality.Work hard towards goal.

My Vision: “Bring Tears Of Happiness”

DILIGENCE”The Seventh Heavenly Virtues”A zealous and careful nature in one's actions

and work.Decisive work ethic, steadfastness in belief,

fortitude, and the capability of not giving up. Budgeting one's timeMonitoring one's own activitiesUpholding one's convictions at all times -

especially when no one else is watching “This is called Integrity”

FACTORS THAT INFLUENCE DILIGENCE

Discipline Motivation Concentration Responsibility Devotedness

Ref: H Bernard, DD Drake, JJ Pace (1996)

DILIGENCE IN BUDDHISM Strive on with Diligence Diligence is an integral part of Buddhism The Fourth of paramita (wisdom) “Diligence is the third paramita that lead

to Liberation Diligence will bring an increases of

quality

Je Gampopa (1994), Gems of Dharma, Jewels of Freedom, Altea Publishing, p. 163

EIGHT FOLD PATH

DILIGENCE IN CHRISTIANITY

Diligence and Faith are two sides of a mystery

DILIGENCE IN CHRISTIANITY Effort to do one's part Diligence and faith are two sides of a mystery. One doesn’t know how, despite one's effort, it all

works out. When combined with faith assures spiritual

success. One of seven virtues describes thoroughness,

completeness and persistence of an action, particularly in matters of faith.

1. How do we live the Christian Life? David Sper (2002)2. Andreas J. Kšstenberger (2011), Excellence: The Character of God and the Pursuit of

Scholarly Virtue.

DILIGENCE IN BIBLE Show this same diligence to the

very end to make your hope sure. Do not become lazy Imitate those who through faith and

patience inherit what has been promised”.

The Holy Bible: New International Version. International Bible Society, (1973), THE LETTER OF PAUL TO THE HEBREWS 6:11-12

SEVEN HEAVENLY VIRTUES To oppose the seven deadly sins Psychomachia or Battle of the soul or the Battle

between Good Virtues & Evil Vices Work in middle ages helped to spread the

concept in Europe. The Virtues are chastity, temperance, charity,

diligence, patience, kind ness and humanity Practicing these seven virtues is said to protect

one against temptation from seven deadly sins.Ref: Aurelius Clemens Prudentius, a Christian governor who died around 410 A.D.,

DILIGENCE IN ISLAM

DILIGENCE IN ISLAMThat man can have nothing but what he strives for; the fruit of his striving will soon come in sight.

He will he be rewarded with a reward complete.

The Quran; An-Najm 53:39-41

DILIGENCE IN HINDUISM

Discover and live a “Dharmic life”. Live with right intention and diligenceHave “Concern for well being of others”

1. Brian Hatcher (2008), Bourgeois Hinduism or Faith of the Modern Vedantists, Oxford University Press.2. Hatcher, B. A. (2007). Bourgeois Vedānta: The Colonial Roots of Middle-class Hinduism. Journal of the

American Academy of Religion, 75(2), 298-323.

DUTY OF A HINDUEvery Hindu Will

1.Jnana Yogi : Acquire Knowledge2.Bhakti Yogi : Dedication3.Karma Yogi: Work is Worship4.Raja Yogi: Universal Self.

Hindu who acquire knowledge and dedicate his life is “Karma Yogi” He will transcend the limits of the finite self will embrace universe as the King “Raja Yogi” before Mohksha

BRAHMAN AND MAYA• Brahman is the key metaphysical concept in various

schools of Hindu philosophy. • It is the theme in its diverse discussions.• METAPHYSICS: What is ultimately real, and are there

principles applying to everything that is real?• Brahman is the ultimate “Eternally constant reality”• Observed “Universe is constantly changing”. • Maya pre-exists and co-exists with Brahman • Ultimate reality, Highest Universal and Cosmic Principle

MAYA & BRAHMAN• Maya is “perceived reality”, one that does not reveal the

hidden principles, the true reality is – The Brahman. • Maya is unconscious, Brahman-Atman is conscious. • Maya is the literal and the effect, Brahman – the principle and

the cause.• Maya is born, changes, evolves, dies with time• Brahman-Atman is eternal, unchanging, invisible principle,

unaffected absolute and resplendent consciousness. • Maya concept is "the indifferent aggregate of all the

possibilities of emanatory or derived existences, pre-existing with Brahman", just like future tree pre-exists in the seed of the tree.

HUMAN RIGHT (1948)• Started with United Nations in 1945• The Universal Declaration of Human Rights

1948 define human rights. • Ethical duty of a doctor is to protect the

human rights and dignity of the patient • Document that defines human rights has had

its effect on medical ethics.

ETHICS & MORALITY

ETHICS•Ethics is the study of morality•Systemic reflection on and analysis of moral decisions and behavior whether past, present or future.

MORALITY•NOUN: Rights, Responsibility, Virtues•ADJECTIVE: Good, Bad, Right, Wrong, Just & Un Just

MEDICAL ETHICSEthics is a Matter of KNOWINGMorality is a matter of DOINGRational criteria to DECIDE or BEHAVEHigher standards of behavior than LAWEthics Require Physicians DISOBEY LAW

that demand UN-ETHICAL BEHAVIOUS

MEDICAL ETHICS Moral Principles that apply values and

judgments to the practice of medicine. Practical application in clinical settings as

well as work on its history, philosophy, and sociology.

“ If I have to or forced to “Do Something” a prudent man will not do or “Do Not Do Something” a Prudent man in similar situation “Will Do”, I feel very uncomfortable and so must be “Un-Ethical.”

HINDU MEDICAL ETHICS (600 BC)Study of science to attaining virtue, wealth and

pleasure.Help relief pain and suffering inflicted upon fellow

human who walk in the path of “Righteousness”.Duty to defend & protect “Righteousness” Gain knowledge of truth, acquire spiritual merit to

help humanity.“Knowledge of Health is Knowledge of Life”Ref: Medical ethics - as prescribed by Caraka, Susruta and other ancient Indian physicians. HANDBOOK ON

MEDICAL ETHICS

HINDUISM & MEDICINEMedicine is a life long study of life with no limits.Must apply thyself to it with diligence. Learn the skill of practice from another without carping. The entire world is the teacher to the intelligent and foe to

the unintelligent. You should listen and act according to the words of

instruction of even an unfriendly person, when they are worthy.

“Good physician should always persevere to do his best in the acquisition of the true qualities of a physician so that he may be a real giver of life to people’

ETHICS & RELEGIOUS TEACHING

“Hippocratic Oath” – A Promise“Formula Comitis Archiatorum”

Code of ethics 5th CenturyIslamic scholors wrote the Conduct of a

Physician, 1st Book Of Medical Ethics.Jewish and Christian thinkers describe

case-oriented analysis Catholic moral theology.

EUROPEAN MEDICAL ETHICS 1800-1900Moral self-conscious discourse. Thomas Percival

Modern code of medical ethics in UKPamphlet with the code in 1794Expanded version “Medical Ethics” 1803.

CAVEAT EMPTORLet the buyer, purchaser or

receiver (patient) make diligent survey or assessment.

The duty of seller or provider of service (doctor) must be honest and share information

NURSE DRUG PRESCRIBINGA

pril

2006

NURSES FAILED BOLAM TESTNurses I identified to have inflicted pain and suffering to

fellow human failed “BolamTest”, It is “My Duty” to raise concern about wrong doings as a

prudent doctor in a similar situation will do.

NURSE DO NOT NEED DOCTORS BACKUP

CRIMINAL ACT

NURSE ON CALL - 2006Ju

ly 2

006

NURSE ON CALL - 2013

UN-ETHICAL BEHAVIOUR

SEPTICEMIA - 37,000 DIE

SUB-STANDERD CARE

BREACH OF DUTYNexus Between Damage & Negligence

NEGLIGENT CAREUn-Ethical Medical Practice Community nurses in UK were trained for six months

to clinically examine patients by senior nurses NO Formal Medical School Training or experience 7000 Independent Nurse Practitioners were employed

by the NHS to work as doctors and prescribe drugs. Nurses with no formal emergency care training

diagnose, triage patients with medical emergency The number of patients referred to A&E, specialist has

doubled since 2006. Wrong diagnosis – treatment result in delay,

prolonged pain, suffering and complications.

UNETHICAL “SUBSTANDARD CARE” Independent Nurse Practitioners: Not trained or supervised. Nurses are used in A&E / ER in hospitals to perform initial

assessment and discharge, admit or refer to doctors “Walk In Clinics” managed by “Nurse Practitioners since 2006. Clinical errors, complications, deaths, hospital admissions has

doubled since 2006. Avoidable death has increased. Majority of hospitals are bankrupted by escalating cost. Compensation payment has increased to £1.5 Billions The best health care system in the world is now crumbling

BOLAM TEST A doctor need not possess the

highest expert skill. It is sufficient if the doctor exercise

the ordinary skill of a competent doctor exercising that particular art

Must use knowledge, clinical examination, diagnosis, treatment or advice as another doctors in similar situation” Will Do”

UNETHICAL

Medical School Year 1: Acquire in-depth knowledge of Anatomy (human

body), Physiology (How body works), Biochemistry (chemical changes in body)

Year 2-3: Pathology (abnormal functions), Microbiology (bacteria and infections), Pharmacology, Forensic, Orthopedics, Ophthalmology and dermatology

Year 3-5: Clinical Skill training (How to examine patients and diagnose illness and how to treat using drugs.

Pass Final Examination before they can work as doctors under supervision in hospital

Junior Doctor In Hospital Year 1: Pre-registration house officer (PRHO) - 1 year Year 2: Senior house officer a minimum of 2 years Year 4: Specialty Registrar in general practice: 3 years Year 5: General practitioner: total time in training: 5 years Years 6-8: General practitioner after passing Examination Year 9: Consultant total time in training: 7-9 years

After completing they are expected to pass examination to prove they are safe to work independently as a consultant and not under supervision

Nurse Training• Theoretical and practical training to nurse • No formal training to clinically examine and diagnose• No in-depth knowledge of pathology or drugs• Learn to take care of patients personal, physical and

psychological wellbeing • Trained to offer treatment as advised by doctor• Educated by senior nurses and NOT BY DOCTORS• Registration as typical nurse is four years• Specialist Nurse Prescriber: Six months course to

learn what doctors spend 10-12 Years!!!

DOCTOR & NURSEDUTY OF NURSENurses job is to look after people who are ill. Hospitals are full of sick people who need social care to help them get better. These sick people are called patients. Many nurses work in hospitals taking care of patients

DUTY OF A DOCTORDoctor in the hospitals find out about patients illness and then the doctor tell the nurse what to do to help the patient get better. The nurse carry out doctors order and care for the patient until they are well enough to go home

Early Diagnosis, Treatment & Referral To Specialist Care

1. WEEKNURSEInitial Diagnosis and Treatment is wrong – Delay

2. WEEKDOCTORDoctor start from assessment, investigation, diagnose and treat – Failure

3. WEEKProcess to Refer to Specialist start.

WHY DISOBEY LAW?• Antibiotics resistant bacteria is threatening our very existence. • Knowing abusing this drug by allowing people who are not

trained to clinically examine, perform tests and diagnose infections is helping bacteria develop resistance

• Prescribing antibiotics claiming to be based on evidence based medicine is not safe and not in the interest of our profession

• Wrong dose result in helping resistant strains colonisation• Excessive use result in antibiotics pollute environment• Ignoring and allowing people in power to continue “Un-Ethical

Medical Practice” is immoral and unethical• Physician’s duty is to “Disobey Law” that demand “Un-Ethical

Behavior”

STANDARD OF CARE DIFFER• Primary care physician and Consultant• Physician and Surgeon• Junior doctor and Consultant• Nurses and Doctors• Place the Treatment is given (Primary

care and Hospital care)

When Medical Errors Are Committed, The Court Has To Decide Whether The Injury Caused Was Accidental Or Non-Accidental Injury

ACCIDENTAL INJURY• Accidental injury or misfortune

without criminal intent is not an offence.

• Accidental injury is not an offence or neglect.

• Doing a lawful act in a lawful manner by lawful means with proper care and caution is not neglect

MODE OF TREATMENT

Two School of Thoughts for given situationIf doctor adopts one of them, he/she is justified and Not Negligent

ACCIDENTAL INJURY

•Who did it?•Whom it was done?•Where was it done?•When was it done?•How was it done?

ACCIDENTAL INJURY• If the answers to all the questions

are satisfactory then you can plead the injury as accidental injury and not neglect

• If Answers to all the questions are favorable and still something goes wrong then it can be regarded as an accident

REO Vs. MINISTER OF HEALTH (1954) Anesthetist used spinal anesthesia (Procaine) which was

stored in a solution of phenol. The incidence took place in a hospital in 1947. Patient developed diplegia (paralysed below waist) In 1951, the hospital discovered cracks in the ampules

that were stored in phenol.

Doctor was not found to be negligent because he had adopted standard practice recommended in 1947.

The standard of practice is to be judged at the time and date of the incidence and not the date of trial.

BOLAM Vs. FRIERN HOSPITAL (1957)

Mental health patient advised ECTHe was not given anesthesiaPatient sustained fractured hip and claimed

compensation

Court Ruled sufficient skill exercised accordance with accepted practice by “Reasonable body of medical men defending”.

Doctor was not negligent, because other skilled in the particular art have opinion adverse to it.

DUTY OF CARE

DAMAGE• When DAMAGE is not direct but

REMOTE and the REMOTNESS of the consequence could be FORESEEN or PRE-RECOGNISED

• The Doctors will be held RESPOSIBLE even for REMOTE CONSEQUENCE

CONTRIBUTORY NEGLIGENCE

DOCTOR’S RESPONSABILITY• Duty of doctors is to raise concern if patients suffer pain,

demeaning treatment, torture or harm inflicted by others.• If a doctors does not raise concern, he or she can be held

responsible for contributing to negligent care.• Doctor or nurse performing procedure, committed error in

diagnosis or prescribed a drugs that I in a similar situation would not have - Then this is Commission “Negligent care”

• Doctors or nurse did not act, prescribe or refer patients to hospital when I in similar situation would have – This is Omission and so could be labeled “Medical Negligence”

WHY NURSE FAILED BOLAM TESTNurses Working As Doctors

• Nurse need not possess the highest expert skills.

• Nurse did not exercise the ordinary skill of an ordinary competent doctor exercising that particular art and so inflicted pain and suffering to fellow human.

ACT OF COMMISION

Nurses Did Something which a General Practitioner in similar situation Will Not Do.

“MEDICAL NEGLIGENCE”

ACT OF COMMISIONLabeling Infections Or Illness As URTI, LRTI, Cough, Cold, GE And Antibiotic Prescribed Is An Act Of Commission Because These Are Not Accepted As Illness or Disease By Doctors All Over The World. Patients Can Take Legal Action

ACT OF OMMISIONPrescribing Antibiotic For Viral Infection Result In Patient Colonizing With Antibiotic Resistant Bacteria. If The Patient Develops Septicemia Due To Resistant Strain And Die, Relatives Can Take Legal Action Against The Doctor because “Doctors Did Not make the correct Diagnosis”

ACT OF OMMISSIONDoctor or Nurse who Does NOT DO what another doctors in similar situation “WILL DO”

ACT OF OMMISSIONDoctor or Nurse who Does NOT DO what another doctors in similar situation “WILL DO”

ACT OF OMMISSIONDoctor or Nurse who Did NOT DO what another doctors in similar situation “WILL DO”

This 18 Years old girl presented with history of Anxiety and Hoarse voiceDoctors and nurses failed to undress and examineHer chest for almost 2 years but refered her toSpeech therepist

ACT OF OMMISION Wrong Diagnosis And Treatment

25 years man with rash on his cheek and neck went to local walk in clinic and consulted a nurse.

Diagnosis: “Shingles and advised acyclovir cream and paracetamol

Two days later, he was seen by doctors in surgeryDiagnosis “Septic Shock” with low Blood pressure

Doctors in similar situation would have diagnosed “Imedigo” and prescribed the right Antibioitc and advised isolation. This is “Act of Omission” resulted in complication and almost death and so “Negligence”

ACT OF OMISSION

Wrong Diagnosis & Treatment resulted in spreading infection to others in the family

ACT OF OMISSIONDiagnosed But Treatment Not Given

2 years old child taken to local walk-in-clinic on Saturday. Seen by a nurse and told the child has chest infection. No treatment given but asked to consult doctor in the surgery on Monday morning.

Child seen on Monday morning as an emergency. The child was unwell, grunting and breathless with mild fever.Clinically “Serious lobar pneumonia” due to delay and not

offering antibiotics early.

The nurse should have offered antibiotic or refer to hospital care. The nurses are not allowed to treat children less than 2 years in the walk in clinic, so the nurse did not do what a prudent doctor in a similar situation would do (Ref to refer to specialist care in a hospital). This is an “Act of Omission” and so “Medical Negligence

ACT OF OMMISIONCorrect Diagnosis But Not Managed Well District nurse visit terminally ill patient at home. He is on high dose of

codeine phosphate and opioids for pain relief. This patient complaints about pain in supra-pubic area and unable to pass

urine and severe constipation. District nurse diagnose “Constipation and Retention of urine” She tried to catheterize bladder but fails to empty bladder She calls “Nurse-led practice” and came to know I am on holiday. She speaks

to “Independent Nurse Consultant” No Action taken, patient left at home to suffer for 15 days. They wait for me

to return from holiday.

This is “Act of Omission” because a doctor would have tried to catheterize, if he failed, he would have performed “Supra-pubic cystectomy” to reduce pain by emptying bladder or referred him to hospital care, and so “Negligence”

COMMISSION OR OMMISSION?

Girl aged 23 years consulted a Nurse as emergency Nurse-led Practice.

She complained of vomiting, high fever, passing dark urine and thought she has jaundice.

The Consultant Nurse Practitioner, Did not think the girl has jaundice Prescribed paracetamol and advised to drink lots of fluid. Did not advice isolation Not reported to Infectious disease team

2 days later, the girl returns to consults locum doctor. The doctors request LFT (Liver function test)Result of Blood Test (LFT) were abnormal. Locum doctor accused her of abusing paracetamol.

COMMISSON OR OMMISSION?

PRUDENT DOCTOR WILLDiagnose Jaundice and asked about the travel and the

color of her stool to differentiate obstructive from non-obstructive jaundice.

She was passing pale stool with dark urine & No h/o travel so refer to hospital “?Obstructive Jaundice”.

Will not routinely prescribe paracetamol Refer to specialist care or admit in hospitalPrevent her getting dehydratedInform “Infectious Disease Surveillance Team” to prevent

spread of infection in community.Investigate to make the correct diagnosis to prevent

complication (Obstructive jaundice is serious illness).

NEGLIGENT CARE BY NURSE

“Act of Omission” because the nurse “Did not Do” what a prudent doctor in a similar situation would have done

“Act of Commission” because the nurse “Did” what a prudent doctor in a similar situation would “Not have Done”

NEGLIGENT CARE BY LOCUM DOCTOR“Act of Ommission”

Locum doctor diagnosed an illness, investigated but “Did Not Do” as another Prudent Doctor in similar situation would have done.

“Act of Commission” Patient is seen regularly with the same proble Doctors requested blood tests, noticed abnormality but accused

of abusing paracetamol Did not refer, isolate, inform infectious disease survelence team Assess patients physical and prevent dehydration Not differentiated obstructive from un-obstructive jaundice Fail to take “Do” what a prudulent doctor in similar situation will

do

ACT OF COMMISION & OMMISIONWrong Diagnosis, Treatment, Interpretation of Result and Management

• Girl Aged 12 years with tiredness was seen by Nurse & later by Doctor. Both diagnosed Anemia but DID NOT Clinically Examined her.

• Blood test result was seen but filed in as normal when it was obviously abnormal and not acted upon.

• 2 years later she was seen and examined by another doctors.

• On examination, this girl had huge kidney and was on kidney failure.

• Now she has lost one kidney and is hypertensive drugs

ACT OF COMMISSON & OMMISSIONMissed Pregnancy & Prescribed CI Drug in Pregnancy

52 years old Pakistani married women consult a nurse practitioner with history of tummy pain and vomiting. Diagnosed as gastritis she was advised antacid.

Two days later, she returns to consult a locum doctor. Diagnosis gastritis and prescribed anti-emetics.

A week later she consulted another doctor. Based on history, he asked her if she was sexually active. The

women was embarrassed but told him she was. After clinically examining her abdomen, the performed

Pregnancy test which was positive. She terminated pregnancy (against her religious belief)

because of fear of congenital abnormality in the fetus.

“Act of Ommission” Prudent Doctor would have ruled out “Pregnency”Clinically examined the abdomen before diagnosis

“Act of Comission” Did what a prudent doctors would not have done

in a similar situation. Prescribing toxic drugs that affect fetus

VICARIOUS LIABILITYHealthcare Providers Are Said To Be Vicariously Responsible but The Nurse will be held responsible if the patient takes legal action. The nurse will have to relay on his/her notes and documented information

VICASIOUS LIABILITYDifficult To Prove Who Is Responsible, “BE PREPARED”

• Liability instead of another person• Each person is liable for his own deeds but there are

circumstances when acts are committed by one person and liability comes on to another

• Two Principles• He who does an act through another is, in law deem to

have done it himself• Let the superior be responsible (they will always say NO)

If a Doctors allows a nurse to diagnose, advice and treat a patient, the Doctor is Held Responsible for the injury caused by the nurse.

LISTEN TO PATIENTS AND ACT

PEOPLE WHO OFFER MEDICAL ADVICE WITHOUT PROPER TRAINING IN MEDICAL SCHOOL OR LICENCED TO PRACTICE COULD BE SUMMENED TO COURT

FINAL THOUGHT• Always listen to patients they know what is wrong with them• Majority of patients know what to expect.• Think of hidden agenda but offer treatment only if necessary• Mentally ill patients do not have insight and can mislead you• Common symptoms are common but rare ones are rare• Patients with serious illness present with common symptoms• Think and DO NOT ASSUME• As a doctor you acquire knowledge from patients• Doctors are not GOD who save lives but mastered the art of

postponing death

“The world will not be destroyed by those who do evil, but by those who watch them without doing anything”

Albert Einstein

We Bring Tears Of Happiness

THANK YOU

Dr. Kadiyali Srivatsa