Charge

On 26 and 27 October 2022 and by audio visual link on 23 November 2022 the Health Practitioner’s Disciplinary Tribunal heard a charge laid by the Director of Proceedings of the Health and Disability Commissioner’s Office against Dr Nelson Nagoor a registered medical practitioner formerly of Invercargill and now of South Africa, (the doctor).

The charge alleged that the doctor between 5 April 2019 and 2 August 2019, whilst caring for his patient Mr Joshua Linder, acted in such a way that amounted to professional misconduct, in that:

1. On or around 17 April 2019 after receiving his patient’s histology report (in respect of a lesion he excised) which included the diagnosis “Primary melanoma, invasive. Subtype: Superficial spreading melanoma. Tumour thickness (Breslow): 8.9mm. Level of invasion (Clark): III. Dermal mitotic rate: 4 per mm2”, failed in his care of his patient, in that he did not take steps to contact his patient to advise him about the histology report and/or to arrange an in-person consultation with his patient to advise him about the histology report; and/or

2. On 30 April 2019, during and/or following an appointment with his patient and despite having received the histology report, failed in his care of his patient in that he:

1. failed to advise his patient about the diagnosis contained in the histology report and/or inform him that the lesion was cancerous and/or a melanoma; and/or
2. advised his patient that the lesion was not cancer; and/or
3. failed to advise his patient that a wider excision was recommended; and/or
4. documented in his patient’s clinical notes that “at this stage no further excision to be done” despite the histology report recording and/or the clinical guidelines recommending a wider excision; and/or
5. failed to refer and/or recommend referral of his patient for further specialist assessment, management and/or treatment in respect of his melanoma; and/or
6. in the alternative to e., failed to document any discussion of such a referral to a specialist and/or recommendation and/or any decline of a referral by his patient. and/or

3. On or around 17 April 2029 and up until and including 2 August 2019 the doctor failed to adequately communicate to his patient that he had an advanced aggressive form of melanoma cancer; and/or

4. On 2 August 2019 when the doctor reviewed his patient, he failed in his care of his patient in that he:

1. Failed to refer and/or recommend referral of his patient for further specialist assessment, management and/or treatment in respect of his melanoma; and/or
2. recorded six-monthly reviews when three-monthly reviews would have been more appropriate; and/or
3. failed to examine his patient’s lymph node basis; and/or
4. failed to perform or document performing a “top-to-toe” skin check of his patient.

The conduct alleged in the above four particulars separately or cumulatively amounts to professional misconduct.  The conduct is alleged to amount to malpractice and/or negligence and/or conduct that brings discredit to the medical profession under s.100(1)(a) and s.100(1)(b).

The doctor did not attend the hearing but was represented by counsel.  The doctor accepted that his conduct as described and that most of the particulars of the charge amounted to professional misconduct.  However, it was up to the Tribunal to consider whether professional misconduct was established.

Background

The patient presented at the clinic on 5 April 2019 with a mole on his back he was concerned about.  He was initially assessed by a nurse who noted the mole as very suspicious and that it might be melanoma.  She arranged for an urgent revision by the doctor that day.

On review the doctor noted the mole was large and dark in colour and had grown rapidly, his working diagnosis being keratoacanthoma, a skin tumour that can occur on sun-exposed areas.

On 12 April 2019, the doctor excised the mole and sent it to the laboratory for histology.

On 15 April 2019, the nurse reviewed the patient’s wound and redressed it.

On 17 April; 2019 the histology report was received by the doctor stating the diagnosis as primary melanoma, invasive, with a sub-type of superficial spreading melanoma.  The report recommended wider excision.

On 26 April 2019 the patient returned to the clinic for removal of alternate sutures which was undertaken by the nurse.  She asked the patient if he had heard from the doctor about his results.  The patient had not so the nurse arranged for him to see the doctor that day but was unable to get an appointment until 30 April.

The patient was seen by the doctor on 30 April.  In an affidavit to the Tribunal from the patient, the patient stated that at this consultation the doctor advised him that there was ‘no cancer’.

The patient saw the doctor again on 2 August for review of the wound.

On 27 September 2019 the patient attended the clinic for a review of a lump in his right armpit which had become painful.  He was seen by another doctor at the clinic.  That doctor noted the histology report in the patient’s notes and urgently referred the patient to the hospital for assessment of the lump.

Results of the assessment were that the lump was cancerous.  An ACC Treatment Injury Claim made on 11 November 2019 stated the patient had metastatic melanoma, potentially avoidable or more proactively managed with appropriate action.

Sadly, the patient died before the Tribunal was able to hear the charge.

Finding

The Tribunal found all particulars of the charge established and that separately and when taken together amounted to professional misconduct warranting disciplinary sanction.

The Tribunal accepted the evidence of the expert witness that it was possible the patient presented late with an already advanced lesion which in his opinion had almost certainly metastasised prior to the patient’s initial presentation and that earlier referral would not have altered the ultimate outcome.  Notwithstanding that, the Tribunal found the doctor failed to follow the widely accepted best practice clinical guidelines for diagnosis, treatment and care of patients with advanced melanoma.  This failure delayed any opportunity for early intervention and left the patient not knowing that he had potentially life-threatening cancer which required urgent referral to specialist care.

Penalty

The Tribunal ordered:

• Censure;
• Suspension of registration for three months;
• Conditions on practice up to three years should the doctor return to medical practice in New Zealand;
• Fine of $5,000;
• 35% contribution to of the costs of the Director of Proceedings and the Tribunal fixed at $26,000

The Tribunal directed publication of the decision and a summary.