Panel hearing summary 2013.0172

Decision of the Medical Board of Australia

Performance and Professional Standards panel

Jurisdiction: Western Australia
Date of Hearing: 9 October 2013
Date of Decision: 9 October 2013

Classification of Notification:

Clinical Care - Inadequate or inappropriate treatment

The matter concerned the alleged unsatisfactory professional performance and/or unprofessional conduct in relation to the care provided by the practitioner to the patient on 10 August 2008.

Allegations

The Medical Board of Australia alleged that the practitioner behaved in a way that constituted unsatisfactory professional performance under s.191(1)(b)(i) of the National Law and/or unprofessional conduct under s.191(1)(b)(ii) of the National Law, in that they:

1. failed to connect a carbon dioxide probe when intubating the patient 
2. relied solely on clinical observations and failed to observe an end-tidal carbon dioxide waveform flat trace to confirm placement of the endotracheal tube in the oesophagus and 
3. failed to consider and/or identify that the endotracheal tube was in the oesophagus rather than the trachea, in circumstances when oxygen saturations were critically low for an extended period of time.

Finding

The panel found allegations 1 and 2 proven, and that the practitioner had behaved in a way that constituted unsatisfactory professional performance under s.191(1)(b)(i) of the National Law.

Determination

The panel noted that the practitioner had shown deep remorse and insight after the incident that triggered the notification. Since then, the practitioner had taken courses and further education. They teach, train and supervise other practitioners, and is an active member of the college.

The panel concluded that the practitioner had already undertaken the further training and education that it would have recommended as part of its determination. The panel cautioned the practitioner.