Wrong diagnosis lands doctor in jail

On June 5, 2009, a 42-year-old painter, living with his mother, died within a few hours after being attended to by a medical doctor at their home.
One week prior to his death, the patient had became restless and began drinking huge quantities of water. Both the patient and his mother thought the patient had caught a heat stroke.

However, on June 4, the patient’s condition worsened. He became confused and his speech was incoherent.

The patient went into a state of stupor and his mother noticed that her son’s breathing was erratic and his eyes were sunken and his breath had a queer smell.

Seeking medical help
At 5.50pm on June 4, 2009, the patient’s mother rang a health care provider who apparently knew that the patient had a history of anxiety and depression.

She described the patient’s condition to the triage nurse. The nurse asked her about the patient’s depression but she told the nurse that although the patient had had episodes of depression, the patient had never had a condition like this before.

In her own words, the patient’s mother told the nurse: “If this is depression, then l have never seen one as bad as this.”

The patient’s mother had expected her son to be taken to hospital and had even packed a bag for him. The healthcare provider sent a doctor to see the patient at home.
The doctor
The doctor she sent was a locum doctor, (a stand-by doctor, who worked when other doctors were on holiday). The patient’s mother was later to tell court that the doctor did not have any equipment on him and did not examine the patient.

The doctor diagnosed that the patient was depressed and advised that the patient’s general practitioner see him the following day to review his medication.

The patient’s mother even asked the doctor if her son had an infection and specifically if he might be diabetic. The doctor shook his head to all these questions.

After the doctor left, the patient’s mother gave him something to drink but he could not swallow. Later that night, the patient appeared so dehydrated to the mother that she gave him an ice cube at 1am.

She returned at 6am to find the patient dead in bed. An inquest into this death was instituted and the police were asked to carry out further investigations. Eventually the doctor appeared in a criminal court.

Expert opinion
A professor of medicine, who reviewed the case, told court that he considered the patient’s state of confusion, thirst, sunken eyes, peculiar breath, and inability to speak as classic symptoms of diabetic keto-acidosis
The professor told court the doctor should have checked sugar levels in the patient’s blood or urine and should have immediately had the patient admitted to hospital where he would have been treated and saved.

Another professor of clinical diabetes described the accused doctor’s records as grossly deficient and said the doctor could and should have measured the patient’s blood sugar which would have taken less than a minute. According to this professor, the failure to diagnose the patient’s condition was the main cause of death. The doctor even admitted before court that he had a blood-sugar testing kit in his car which he failed to use.
The doctor was sentenced to two-and–a half years for manslaughter.

Judge’s sentence
“The nature of your offence is too serious for anything other than a custodial sentence. You failed to recognise the patient’s condition despite the fact that all the classic signs of a diabetic condition were present. You opted for a diagnosis that was contrary to all the evidence. This was a gross breach of your duty of care. An expert called your diagnosis appalling. I agree. It was clearly criminally negligent and a wholly preventable death.”