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DP v Bhatia
Health Practitioners Disciplinary Tribunal,
12 February 2007
On 30 January 2007 the Health Practitioners Disciplinary
Tribunal upheld one charge of professional misconduct against
urologist Dr Sajan Bhatia, who admitted that performing a partial
cysectomy (bladder removal) instead of a total one on his patient,
was an inadequate and appropriate response to a woman who had
squamous cell carcinoma in the bladder and a large tumour.
In August 2003, Mrs Sheila Pearce, then aged 53, was urgently
referred by her general practitioner to Dr Bhatia. She had
been passing clots of blood, mucous and debris. She had a
15-year history of urine infections and difficulties with her
bladder and had had to practise intermittent self-catheterization
for some of this time. She had been seeing Dr Bhatia as an
outpatient at Southland Hospital since July 1991.
On 3 September 2003, Dr Bhatia undertook a cystoscopy (an
examination of the bladder), urethral dilation and bladder washout
under general anaesthetic. A 2-3 cm x 2-3 cm tumour involving
the anterior wall of the bladder was noted and biopsied by Dr
Bhatia. Histological examination revealed an invasive
keratinising (high grade) squamous cell carcinoma with muscle
invasion. This meant that Mrs Pearce had an aggressive
bladder cancer with a very high likelihood of similar changes in
other parts of the bladder, and extremely poor prognosis.
On 9 September Dr Bhatia advised Mrs Pearce of the histological
findings. A CT scan of Mrs Pearce's chest, abdomen and
pelvis, on 12 September 2003 revealed no evidence of pelvic
lymphadenopathy or extravesical disease (that is disease outside
the bladder), but it showed a thick walled bladder and bulky
uterus, secondary to fibroids.
On 7 November 2003 Mrs Pearse underwent a partial
cystectomy. The tumour was seen to be occupying three
quarters of the bladder wall. The removed tissue contained a
6 x 9cm portion of bladder wall. This contained a 6cm area of
ulceration in the centre with a necrotic base. The resection
of the tumour left 25% of the bladder. This meant that the
chance of Mrs Pearce ever having a good functional bladder again
was unlikely.
Histology confirmed a poorly differentiated squamous cell
carcinoma with squamous metaplasia of the remaining bladder
mucosa. The margins of the removed bladder tissue were
positive for tumour indicating that the tumour removal had been
incomplete.
Mrs Pearce made an uneventful post-operative recovery, and was
followed up with radiation and chemotherapy from 5 January 2004 to
19 February 2004 at Dunedin Public Hospital.
Mrs Pearce subsequently saw Mr Bhatia complaining of lower
abdominal pain and had a CT scan in March 2004, when she was found
to have a fistula. Mr Bhatia subsequently operated on Mrs
Pearce to explore the fistula.
The patient's condition progressively declined and she died on
27 August 2004.
The Tribunal referred to the expert opinions of urologists
Professor John Nacey and Dr Michael Rice, including the expert
evidence that transitional cell carcinoma of the bladder is more
common than squamous cell carcinoma and that the only acceptable
treatment option was a totally cystectomy. It concluded that all of
the expert evidence shows that there was no other option for Mrs
Pearce by to have a total cystectomy and that the failure to
perform this constituted conduct which falls far short of that to
be expected of a reasonably competent urologist and that it was
malpractice (neglect of a professional duty) and negligence (a
breach of duty in a professional setting). It considered that
a finding of professional misconduct was needed to protect the
public, maintain professional standards and punishing the
practitioner.
Dr Bhatia was censured, fined $5000.00 and ordered to pay 30% of
the costs of the investigation and prosecution. He was also
ordered to practise under conditions that he join a peer review
group, undergo a clinical audit and practise under the supervision
of a urologist. Interim name suppression was lifted.