Keeping records regarding informed consent: Unsatisfactory professional conduct

In Woollard v The Medical Board of Australia [2015] WASC 332, the Supreme Court of Western Australia considered an application for judicial review of a finding of unsatisfactory professional conduct. The background was of a patient who suffered a stroke during coronary angioplasty. The Board had made a finding of unsatisfactory professional conduct on the basis that the doctor had not kept adequate records, with no recorded informed consent discussion. The patient had signed a consent form on a letter posted to him with certain risk warnings, which the doctor asserted formed part of his clinical records and documented the discussion with the patient in a formal manner: [32]. It appears not to have been disputed that there were no written notes of the consultation where the doctor asserted that he discussed the procedure and its risks with the patient: [28]. The doctor’s letter to the patient’s general practitioner contained no record of any discussions with or advice to the patient: [30].

The substantive ground of the appeal was that the finding adverse to the doctor was not open to the Board, given the materials before it: [67]. At [69] the Court said:

The submission on behalf of Dr Woollard was, in effect, that once the panel had found the patient gave informed consent, the finding that Dr Woollard had failed to maintain proper clinical notes could not follow. The submission, however, confuses two matters. Whether Dr Woollard properly recorded his discussions with the patient is an independent issue.

On the undisputed evidence that the notes did not record any relevant discussions with the patient, the only possible record was the consent form. At [70] the court concluded that having regard to the limited content of the form and when it was created, the unsatisfactory professional conduct finding of the Board was open to it.

With thanks to Karina Hafford for drawing this decision to my attention.

One Reply to “Keeping records regarding informed consent: Unsatisfactory professional conduct”

Comments are closed.