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.

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

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 practiceagainst a registered person including a public officer in respect of whom it holds a delegated power.

COMPLAINT RECEIVED AT COUNCILCOMPLAINT RECEIVED AT COUNCIL

Possible fault on the part of M.P •Medical practitioner not concerned

•No obvious fault of doctor

Council informed

Set aside

Complainant informed

Preliminary Investigation (I.C)(Section 13)

Notify Doctor of the nature of the complaint

Summon and hear doctor +/-complainant

Summon and hear witness

Call for documents

Judge in chambers(if refusal by a person to give evidence or communicate document on ground of confidentiality

Evidence of fault of doctor No prima facie evidence of fault of doctor

Set aside

Inform doctor & complainant

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

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

MDT

Report to Council not >14 days after completion of proceedings

Cont/d

Suspend for not > 6

mths

Private Public officer (+delegation of power)

Report to PSC for decision on suspension

Disciplinary Proceedings

•Show cause

•Warning/severe warning

Inform doctor & complainantD Proceedings cont/d

17(3)

•Charges proven

•Aggravating/alleviating circumstance

Charges not proven

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

Set Aside

Inform doctor & complainant

17(5)

Punishment (Dismissal or Retirement) by PSC

•Decision under 17(4) or (5): inform doctor within 14 days

Removal of name from the Register

COUNCIL

Section 18

CONVICTION OF REGISTERED PERSON

Show Cause

Section 19

Summary Proceedings (Minor Fault)

Show Cause

Warning/Severe Warning

Punishment as per 17(4) (b)

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

•Presided by Judge + 2 senior medical practitioners

•Evidence based

•Hearing of parties + witnesses

•Defence lawyers

Show cause

Doctor at fault

Sanction

MDT

COUNCIL

Deliberations + determination

Charge provenCharge not proven

MOH/PSC (Public officer)

Show cause

Sanction

Set aside

Parties informed

No fault of doctor

Set aside

Doctor+complainant informed

Parties Informed

• 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”.

•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

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” test for proving causation.

“ 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

A common practice might be declared not to be rightly accepted: (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”.

“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.

“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 or condition.

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

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.

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.

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).

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).

Doctor

Non- medical staff Institution (Employer)

Patient

: :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

Monitoring &Follow up

Other Doctors

Reports-Histopath,X-ray

PatientWithholding information

Not following doctors’instruction

CONTRIBUTORY NEGLIGENCE

Institution (Employer) Vicarious Responsibility

Understaffing NursingX-Monitoring

Others X-Execution of doctor’s orders

Equipment Unavailability/Faulty

Essential/Emergency drugs

Non Medical Staff Laboratory technician-lab. Errors, delays

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.

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

Rationale for request

Not seeing results of URGENT INVESTIGATIONS

Unnecessary delay in requesting special investigations, e.g. CT scan

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)

Death certificate issue

Without examining corpse

Cause of death (true?)

Use of abbreviations

Time of death

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)

e.g.. Blood transfusion form –Identity of patient

- Degree of urgency/when needed

- X-match/type & screening

- type of products and quantity

Doctor-Doctor

Patient Non Medical Staff

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)

1. Believe your monitors!

2. Record keeping

3. Surgical team agreeing as to what occured

(Avoid rushing to condemn)

4. Communicate with patient before and after

Four most frequent themes in case of a bad outcome:

“If it isn’t written, it wasn’t done”

Flow Chest ( common surgical accidents leading to Medical malpractice Suits

Blood Transfusion Mistakes

Wrong Patient Paralysis from Splints

Medical

PractitionerSurgery on wrong Digits

Tight Plaster Casts

Retained Objects

Removal of Wrong Organ

Surgical Errors (e.g. ligation of ducts)

Anaesthetic Mishaps

Failure to X-ray Fractures

Wrong Side of the Body

Good-Proper-Adequate……?

Questioning-Listening-Responding-ExplainingPrecautions 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.

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

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 PriviledgeBattery/Tresspass

INFORMED CONSENT2 based 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

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).

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.

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