NHS Fife surgeon, Stuart Oglesby, 'failed to assess patient's fitness for surgery'
According to the General Medical Council, Mr Stuart Oglesby, an NHS Fife surgeon, made a catalogue of errors in his medical examination of the patient:
- ‘It is important, however, that any decisions made are with the full understanding of the patient and relatives, and it would appear that his consultations were deficient in this respect.’
- ‘It is my opinion, therefore, that Mr Oglesby’s assessment of the patient's fitness for surgery was inadequate.’
- ‘In my opinion, therefore, other more objective methods of assessment of fitness should have been used to assess the patient's fitness for surgery.’
- ‘Mr Oglesby had not made an adequate assessment of the patient's fitness for surgery, and therefore his decision that the patient was not fit for surgery was not appropriate… significantly more information should have been gathered about the patient's fitness… Furthermore, all these issues must be discussed with the patient and family, and particularly in borderline cases, their views taken into account. This clearly did not happen.’
- ‘In my opinion, therefore, Mr Oglesby failed to explain adequately the implications of the different management options to the patient and his family. Furthermore, it is likely that if these options had been explained properly, much of the confusion would have been prevented.’
- ‘It is clear, however, that this [assessment phase] was not explained properly to the patient and his family, and there is no evidence in the patient's records of any discussions about this.’
- ‘… it is clear that the multidisciplinary team did not discuss the issue as to whether or not the patient was fit enough for surgery… When there is doubt about someone’s fitness to withstand surgery, it is appropriate to discuss further with other colleagues, particularly surgical, anaesthetic or critical care colleagues. In this case it would appear that Mr Oglesby made this decision unilaterally without discussing it further with others. Although ultimately the responsibility for managing the patient (and therefore the decision as to whether surgery is appropriate) does rest with the Consultant in charge, it is considered good practice to discuss borderline cases with other colleagues, whether in the multidisciplinary team meeting or outside. This does not appear to have happened. The patient did, however, withdraw himself from further investigation and management under the care of Mr Oglesby, and clearly further discussions would have taken place at the multidisciplinary team if the patient had remained under the care of Mr Oglesby. It is conceivable that there may have been discussions about the possibility of surgery (and fitness for such surgery) at subsequent meetings, but on balance I think this is unlikely, as it would appear that Mr Oglesby had already made up his mind on that matter.’
- ‘Mr Oglesby… did not assess the patient's fitness for surgery properly… it is essential to discuss all treatment options fully with the patient and consider the patient’s views when deciding upon the appropriate treatment plan, and it is clear that Mr Oglesby did not do this. If he had done this properly, and these issues discussed fully in a multidisciplinary setting, it is possible that the patient would have had a more detailed assessment of his fitness for surgery, and other treatments options, including surgery, considered.’
- ‘Under the circumstances it really should have been possible to get a letter to the patient, if not in time for his departure, then at least to be given to his son for subsequent delivery to Hong Kong.’
- ‘Only a few brief notes were written relating to the outpatient consultation on 18th May, and nothing was written in the notes relating to the second consultation on 1st June. Thus, the standard and adequacy of Mr Oglesby’s note taking was very poor.’
- Conclusion: ‘Mr Oglesby… did not assess the patient's fitness for surgery adequately, and there was no multidisciplinary discussion or input into this aspect of the patient's assessment… there were significant deficiencies in Mr Oglesby’s communications with the patient and his family… It would appear in this case that Mr Oglesby was rather more conservative than others might have been, specifically with respect to consideration of surgery for his tumour… My main criticism is of the lack of objective assessment of the patient's fitness for surgery, and the lack of discussion of these issues with the patient and his family, thus preventing them taking part in the decision making process of this aspect of the patient's care.’
Failure to assess fitness for surgery
Mr Oglesby claimed he had based his decision to refuse surgery on four factors: alcohol, irregular heart rhythm, weight loss and reduced level of activity. However the General Medical Council found there was ‘minimal evidence’ to support Mr Oglesby’s claim:
- No evidence that weight loss was quantified.
- No evidence that the patient was weighed at either consultation [despite Mr Oglesby being a bariatric/weight-loss surgeon].
- No evidence of reduced activity levels being quantified in any ‘sensible and meaningful way’.
- Inconsistencies in Mr Oglesby’s notes: ‘he is reasonably fit’; ‘no past history of cardiovascular or respiratory disease’; ‘his exercise tolerance probably would not permit a surgical resection’.
- No reference to any impact of atrial fibrillation upon cardiac function.
- ‘Excess’ alcohol was not quantified in any way.
- No evidence that excess alcohol intake was a significant problem and that it had any impact on liver function.
- Other more objective methods of assessment of fitness should have been used to assess fitness for surgery.
- Significantly more information should have been gathered about the patient's fitness.
- Fitness for surgery issues were not discussed with the patient and family and as such their views were not taken into account.
Consistent with the General Medical Council's evidence above, the patient claims that the two consultations he had with Mr Oglesby lasted between 5 to 10 minutes only:
- The patient and another patient were booked into the same 10-minute slot for the final consultation, i.e. 5-minute appointment per patient (Freedom of Information request).
- The final consultation was also booked a week in advance (Freedom of Information request).
- The average consultation time for review consultations for Mr Oglesby is 10 minutes (Freedom of Information request).
Against good medical practice
- NHS Fife states: 'All decisions taken by clinicians in the exercise of their clinical judgement take account of a wide ra[n]ge of factors including input from colleagues at multi-disciplinary team meetings' (Freedom of Information request). But according to the General Medical Council, Mr Oglesby had failed to follow standard medical practice in discussing the treatment plan with the multidisciplinary team.
- The General Medical Council has reminded Mr Oglesby of paragraphs 2(a), 3(f), 22 and 23 of Good Medical Practice:
- '2 Good clinical care must include: (a) adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient
- 3 In providing care you must: (f) keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment
- 22 To communicate effectively you must: (a) listen to patients, ask for and respect their views about their health, and respond to their concerns and preferences (b) share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression, and the treatment options available to them, including associated risks and uncertainties (c) respond to patients’ questions and keep them informed about the progress of their care (d) make sure that patients are informed about how information is shared within teams and among those who will be providing their care.
- 23 You must make sure, wherever practical, that arrangements are made to meet patients’ language and communication needs.'
Failure to facilitate second opinion
Mr Oglesby failed to provide a letter to the patient or his family in time for the second opinion:
- Per General Medical Council: ‘Under the circumstances it really should have been possible to get a letter to the patient, if not in time for his departure, then at least to be given to his son for subsequent delivery to Hong Kong.’
- A statement by Mr Oglesby's secretary states that he was not prepared to do a 'To whom it may concern' letter (Freedom of Information request).
- The patient's family claims that the accompanying nurse had told them there was little chance in obtaining a second opinion in Scotland which would be different from Mr Oglesby's opinion. The nurse denies the claim.
- Mr Oglesby mentioned 'radiotherapy' in the consultations, but according to NHS Fife's management he should have discussed 'definitive chemo-radiotherapy' instead.
- NHS Fife admits to poor communication: 'What is acknowledged is that communications and the use of medical terms has confused matters...'
- The patient's family claims that the accompanying nurse told them that radiotherapy was for palliative treatment only as opposed to curative treatment. Despite the evidence, the nurse denies the claim.
Multidisciplinary team denies Mr Oglesby's claim
Statements obtained from a Freedom of Information request suggest that Mr Oglesby had made inconsistent statements on how he arrived at his medical opinion. Mr Oglesby suggested he consulted with the multidisciplinary team in his decision making:
- After discussing the sequence of the patient's clinical management with Mr Oglesby, Mr Barry O'Regan (Clinical Director) states: 'The clinical problem was discussed at the next available multidisciplinary team and Mr Oglesby communicated the consensus opinion to the patient and his family.' 'Mr Oglesby also noted that he had corroborated his opinion on the patients’ management on an ongoing basis with multidisciplinary team colleagues.'
- Mr Oglesby states: 'The patient had a number of factors associated with a poorer outcome from surgery... It was therefore my opinion, based on the investigations performed at the time, that radical oncological treatment offered the best balance of efficacy against risk of adverse events. This view was supported by the multi-disciplinary team when the patient was discussed at the multi-disciplinary team meeting.'
- Mr Oglesby further states: 'For patients with the same disease as the patient, 38% had the treatment I and the multidisciplinary team recommended (definitive chemoradiotherapy) and 58% surgery. It is likely that those who had the CRT [definitive chemoradiotherapy] had other health issues as did the patient.'
However, consistent with the General Medical Council's findings above, the multidisciplinary team have flatly denied Mr Oglesby's claim. Mr Oglesby had not discussed the patient's fitness for surgery with the multidisciplinary team and had not even attended any of the multidisciplinary team meetings. The multidisciplinary team states:
- The multidisciplinary team never made a decision that the patient was unfit for surgery. There was no consensus opinion that the patient was unfit for surgery.
- The multidisciplinary team was not given any information about the patient's fitness for surgery from Mr Oglesby. There was no discussion of fitness because no information was provided to the multidisciplinary team.
- The multidisciplinary team did not discuss Mr Oglesby’s fitness criteria: decreased exercise tolerance, significant weight loss, atrial fibrillation and excess alcohol consumption.
- The multidisciplinary team confirms the comment in the multidisciplinary team note of 14 May 2010: 'Past medical history; fit and active with good exercise tolerance'.
- The multidisciplinary team’s default position was always surgery, subject to fitness. They were still aiming for surgery at the multidisciplinary team meeting on 28 May 2010: 'At both multidisciplinary team meetings the plans were to continue the staging process with a view to potentially curative surgery (with neoadjuvant chemotherapy) if fit, or radical radiotherapy if unfit. No information as to his fitness was available on which to base any final decision.'
- The multidisciplinary team confirms the comment in the multidisciplinary team note of 28 May 2010: 'The patient's current level of fitness is not clear.'
- Mr Oglesby was not present at the multidisciplinary team meeting on 28 May 2010.
- The multidisciplinary team did not recommend definitive chemoradiotherapy as the patient's fitness level was unknown: 'The multidisciplinary team did not recommend any treatment at either multidisciplinary team meeting and would not do so without waiting for the full staging process to be completed.'
The multidisciplinary team completely refutes Mr Oglesby’s claims that: the 'clinical problem' was discussed at the multidisciplinary team; his opinion was 'corroborated' by the multidisciplinary team; there was a 'consensus opinion' at the multidisciplinary team; fitness criteria were discussed at the multidisciplinary team; 'radical oncological treatment' was supported by the multidisciplinary team i.e. a cancer treatment was recommended by the multidisciplinary team; and that 'definitive chemoradiotherapy' was specifically recommended by the multidisciplinary team.
Mr Oglesby changes his story
Mr Oglesby states that 'definitive chemoradiotherapy' was discussed with the patient and his family, which was subsequently repeated in an NHS Fife letter to the patient. However significant evidence presented by the patient's family, supported by a statement from the accompanying nurse, show that Mr Oglesby had only mentioned 'radiotherapy' in the consultations. In response, NHS Fife issued another letter stating that 'communications and the use of medical terms has confused matters' and Mr Oglesby admits that he did not use the term 'definitive chemoradiotherapy'. Mr Oglesby, however, then claims that 'radiotherapy and chemotherapy' was discussed instead and makes reference to the use of 'chemotherapeutic drugs'. There is however no evidence that 'chemotherapy' was ever discussed. Timeline:
- 27 June 2010: patient complains about the proposed 'radiotherapy' treatment.
- 19 August 2010: Mr Oglesby's internal statement mentions 'definitive chemoradiotherapy' only.
- 26 August 2010: NHS letter states '(definitive) chemoradiotherapy' three times.
- 13 September 2010: patient presents evidence that only 'radiotherapy' was discussed.
- 1 October 2010: nurse's statement states that only 'radiotherapy' was discussed.
- 11 October 2010: NHS letter states, 'communications and the use of medical terms has confused matters'.
- 8 November 2010: Mr Oglesby's internal statement - admits that he did not use the term 'definitive chemoradiotherapy'. But then states that 'radiotherapy and chemotherapy' was discussed and refers to the use of 'chemotherapeutic drugs' by the oncologist.
General Medical Council:
- 'Mr Oglesby's care was of a reasonable standard' but he is reminded of the terms of Good Medical Practice.
- General Medical Council report's full conclusion: click here.
- '...there is insufficient information to suggest that Mr Oglesby deliberately sought to mislead'.
Mr John Wilson, NHS Fife Chief Executive:
- 'All medical care that was provided was competent...'
- '...our intention is always to be open and honest...'
Mr Oglesby's solicitor, Graeme Watson, Simpson & Marwick:
- 'Having reviewed the article in detail, our concluded view is that it is defamatory of Mr Oglesby. We therefore invite you to remove it from the website of FifePatients.com, and from any other websites upon which either you or anyone on your behalf has posted it. We invite you to do so before 12 noon on 24th December 2012. Should you fail to do so, we shall take such further action as is necessary to protect the interests of Mr Oglesby.'
- 'We consider that the article in its entirety amounts to a defamation of Mr Oglesby, through the imputation of professional misconduct and incompetence. We again invite you to remove the whole article from the website by noon on Monday 24th December.'
- 'We again request that you simply remove it. The clear imputation remains one of professional misconduct and incompetence on the part of Mr Oglesby. The article wholly misrepresents the conclusions of the GMC.'
Mr Oglesby applies unsuccessfully for an injunction to remove this article.
FifePatients.com will not be bullied. Patients will not be silenced.