Today, the Judicial Committee of the Privy Council has quashed the decision of the Royal College of Veterinary Surgeons to remove Dr Gary Samuel from the register of veterinary surgeons.
Vet Juris has yet to critically analyse the Privy Council's judgment. But, in his conclusion Lord Toulson said that the Committee's (RCVS) finding that Dr Samuel was unfit to practise "cannot fairly stand".
Vet Juris
The thoughts of a veterinary law researcher - VetJuris@ymail.com
Wednesday, 16 April 2014
Monday, 2 December 2013
Jude Dawson prompts rabies questions in Parliament
Jude Dawson’s article, published on this site in September
and also in the Veterinary Record (Oct. 2013 vol. 173:14 pp.348-349), on the
risk posed to vets by the emergence of rabies, has sparked a wealth of
interest.
Most surprising, however, was a communication from the
offices of Professor the Lord Trees. Lord Trees is interested to take the
matter further and to that end has tabled two questions in Parliament, relating
to the article, for written answers from Her Majesty’s government.
Also, following the article's publication, the British Small Animal Veterinary Association (BSAVA) has written to Public Health England, pointing out many of the issues that were raised in the article. The letter, signed by BSAVA President Professor Michael Day, urges Public Health England to consider including veterinary staff on the list of those entitled to receive pre-exposure rabies vaccinations.
You read it here first.
You read it here first.
Sunday, 1 September 2013
Vets' risk from rabies will increase
In July of this year a client presented a pipistrelle bat at
my practice. My professional obligations required that I administer to the
welfare needs of the animal. My statutory obligations[i]
required, that as a protected species, the bat should be tended to and released
when no longer disabled; or humanely destroyed if it had no reasonable chance
of survival.
I double gloved with heavy, latex examination gloves before
performing a preliminary examination. Other than identifying several small
perforations to the membranes of both wings the animal appeared to be free of
any obvious injuries.
The first priorities were to attend to the bat’s hydration
status and to reduce the stress of it being captive; later focusing on its
nutritional needs. I contacted the Bat Conservation Trust so that I could pass
the bat into the care of one of their representatives. It was during one of the
feeding sessions that I was bitten twice on the finger through the doubled
gloves.
On hearing of the incident a member of the Trust contacted
me at my practice. He was anxious that I seek medical attention and receive a
rabies post-exposure prophylaxis course. After several phone calls to various
NHS facilities I was finally directed to the virology department of Leeds
General Infirmary. The unit could not have been more helpful. They prepared a
rabies immunoglobulin – tailored to my body weight – and a course of vaccines.
The urgency of treatment was explained to me; the immunoglobulin
was heat labile and, despite being on ice, would be inactivated in a few hours.
The virology unit liaised with my GP surgery and arranged for a doctor to
administer the injections. The immunoglobulin was administered intramuscularly
in four sites; I was also given a vaccination intramuscularly. The vaccines are
to be repeated on days three, seven, fourteen and twenty-eight.
As a veterinary legal researcher I was naturally curious as
to the health and safety implications to the practicing veterinary surgeon that
emanate from the double obligations imposed by the RCVS and Parliament.
Section 2 of the Health and Safety Act[ii]
outlines the general duties of the employer towards their employees. In
particular, section 2(2)(b) relates to the making of reasonable and practical
arrangements that ensure the absence of
risks to health in the handling of articles. My interpretation of this section
leads me to the conclusion that veterinary staff should be protected from the
risk of rabies by means of routine, pre-exposure vaccination.
Pet travel, to and from Europe is becoming more popular;
over one million pets have already travelled by Eurotunnel[iii] and
this only accounts for 65% of the animals entering the U.K. With the relaxation
in the previous safety checks that were necessary for the issuing of a
pet-passport, there are undoubtedly many animals entering the U.K. without
protective titres of rabies antibodies. In my own practice, when blood testing
was required prior to the issuing of a passport, between five and ten percent
of animals failed to achieve the required antibody levels after the first
inoculation.
With this in mind I wanted to ascertain the diagnosed
incidence of rabies in the whole of the European Union. The figures[iv] reveal
that between 2002 and 2012 there have been 27,974 confirmed cases of rabies in
the E.U. recorded across all species. When restricted to just domestic animals
the numbers fall to 4,791 reported cases. When further restricted to just cats
and dogs, the species that veterinary surgeons in this country could potential
come into contact with, the number of reported cases is 2,990.
The annual reported incidence of canine and feline rabies in
the E.U. has diminished gradually from 420 cases in 2002 (with a high of 482 in
2003) to 127 cases in 2012 (with a low of 92 in 2011).
A worrying aspect is that, in Romania, this trend is being
reversed. In 2002 there were 28 cases of rabies in cats and dogs and in 2012
there were 82 confirmed cases. In the first six years of the last decade Romania
reported 327 cases; in the last five years there were 406 cases. In the last
five years Romania, alone, has accounted for 55% of the E.U.’s rabies in cats
and dogs. It should be borne in mind that Romania becomes a full member of the
E.U. on the January 1st 2014; many Romanians will want to come to
the U.K. and many of those will want to bring their pets with them.
Arranging to be vaccinated against rabies is a simple
process[v]. Contact
your GP’s surgery and tell them you are a veterinary surgeon. Advise the doctor
that you are obligated, as a matter of professional and legislative duty, to
administer to the welfare needs of any bat that is presented to you. Also
advise the doctor that due to changes in the U.K. quarantine laws and the
relaxation in monitoring the efficacy of canine and feline rabies inoculations,
rabies is becoming an emergent disease. The doctor will then instruct a nurse
to administer the course of vaccination; she/he will then ask you for £120-£150
for the service (it is not available on the NHS).
It is ethically wrong for a State to single out a group in
society and compel them to be placed in the front line of vigilance against a
potentially lethal disease; remove the safeguards that have been in place for
more than a century; multiply the risk factor by extending free movement of
people and their pets, and then tell them that the State will not offer any
protection – you must pay for it yourselves. I would call on the bodies that
represent the veterinary profession in this country to unite and have this
issue raised in Parliament.
RCVS v Chikosi - Racist and illogical?
Much has been written over the past few weeks about the
judgment of the Disciplinary Committee of the RCVS in the case of Munhuwepasi
Chikosi. A great deal of the discussion has little or no relevance to facts
that lead to the outcome of the case; instead
focusing on issues such as – should a blanket be used to move an injured
animal?
Mr Chikosi had been charged with unreasonably delaying in
attending to Mitzi (the injured dog) and/or allowing Mitzi to remain in pain
and/or suffering for longer than was reasonably necessary.
Unfortunately, Mr Chikosi was unrepresented at the hearing
and what factors, if any, he had considered, which may have explained his delay
before attending to Mitzi at the farm were unexplored. However, at paragraph 31
of their judgment the Committee concluded that Mr Chikosi’s conduct may have
been the result of his being an “overseas veterinary surgeon”.
In recent months it has been suggested in the veterinary
press that the racial origin of a veterinary surgeon may have been an
influencing factor in some of the decisions that have been handed down by the
RCVS’ Disciplinary Committee. Had Mr Chikosi chosen to take his case to the
Privy Council, this reference to his race would probably have constituted
grounds for appeal.
For Mr Chikosi to be guilty of allowing Mitzi to remain in
pain and/or suffering for longer than was reasonably necessary two questions
have to be answered. The first, was Mitzi in pain? If this were answered in the
affirmative the second question would be, how long was Mitzi in pain? Neither
of these questions has been satisfactorily addressed in the Committee’s written
judgment.
Mr Mathews (Mitzi’s owner) phoned Vets Now and said that he
had run over his dog and it was in considerable pain. It would be reasonable to
conclude that Mr Mathews’ assessment was honest, but one cannot determine if it
was accurate, not to the standard of proof required: “to be sure”. An injured
animal thrashing involuntarily in the immediate aftermath of an accident may
suggest it is in pain to a lay person but as any medically trained person knows
this is often not the case.
At paragraph 28 of their judgment the Committee states that
the evidence that Mitzi was in pain was that she uncharacteristically bit Mr
Mathews’ son. This “proof” is less than rational. There are many reasons why a
severely injured animal might uncharacteristically bite, pain is one of them;
other reasons include fear, seizure, shock, hypoglycaemia and confusion.
It is possible that Mitzi suffered pain when moving her was
attempted and it is possible that this induced her to bite Mr Mathews’ son.
But, if this were the case, the question that has to be asked is, was the pain
inflicted, in this instance, unnecessary? By direct analogy, a severely injured
person in the road may be totally pain free but on moving the patient from the
road surface to a stretcher may cause considerable, but necessary, pain. If the
infliction of pain is not unnecessary it is not unlawful.
As suggested above, even if Mitzi were in pain at the time
the owners attempted to lift her it is not evidence that she was in pain whilst
on the ground. If it is not proved that Mitzi was in pain Mr Chikosi would have
no charge to answer.
At paragraph 19 Mr Chikosi is quoted as diagnosing Mitzi’s
status as hypothermic and in hypovoleamic shock. The Committee’s own,
unsubstantiated, opinion at paragraph 28, that Mitzi probably had major
internal organ damage. This, added to Mr Chikosi’s own clinical assessment, suggests that Mitzi would probably have lapsed into insensibility reasonably
quickly. One has to ask, how did the Committee come to the conclusion at
paragraph 28 that, if Mitzi were in pain it would have been for at least one
hour?
A second ground for appeal to the Privy Council, had Mr
Chikosi chosen to pursue the matter would have been that the Disciplinary
Committee had not discharged their burden of proving the charge to the required
standard.
The right to appeal the Disciplinary Committee’s decision to
the Privy Council is Mr Chikosi’s alone. This fact was also voiced by Mr
Richard Dixon, group managing director of Vets Now, in a recently published
article. Mr Dixon was responding to the question “will you/Vets Now be
appealing?” Mr Dixon said “It is a shame that the RCVS doesn't have an internal
process that would enable them to review their decision.”
The process which will enable the RCVS to look again at its
decision is judicial review. Judicial review can test the lawfulness of the
decisions of public bodies (including the RCVS’ Disciplinary Committee). The
procedural rules are complex and are set out in section 31 of the Senior Courts
Act 1981 and the Civil Procedure Rules. In short, the right person must seek
the right remedy in the right proceedings; engaging a lawyer who specialises in
constitutional law would be recommended.
The right person, unlike appealing the case to the Privy
Council, is any one with locus standi
– a person or body with sufficient interest. In theory, this could be any
veterinary surgeon, but more practically it could be the BVA, the VDS or Vets
Now. If anyone or group wanted to pursue this avenue the most pressing issue at
present is time; Part 54 of the Civil Procedure Rules stipulate that a claim
must be brought “promptly and in any event, within three months” of the
decision complained of; this makes the cut off date for judicial review 18th
September.
© VJ 2013
Sunday, 17 March 2013
The RCVS and the myth of "informed consent"
Quoting from the RCVS Code of Professional Conduct at paragraph
11.1 - that “Informed consent, which
is an essential part of any contract, can only be given by a client who has had
the opportunity to consider a range of reasonable treatment options, with
associated fee estimates, and had the significance and main risks explained to
them.” Unfortunately, the RCVS is
wrong in the assertion that informed consent constitutes any part of a contract.
A contract is comprised of four component parts: an
offer, an acceptance, consideration and an intention to create legal relations.
The offer and acceptance together constitute the agreement. The consideration
has a specific legal definition, but simply put, it is the exchange of
promises; the veterinary surgeon promises to perform an operation and the
client promises to pay for the work that is done. The intention to create legal
relations is a rebuttable presumption in any commercial undertaking.
As was stated
in the case of Chatterton
v Gerson, [1981] 1 All ER 257, a lack
of informed consent as to the risks
inherent in a medical procedure does not vitiate the patient's consent to it,
provided he knows its nature in broad terms. Additionally, as per Lord Diplock, Lord Keith and Lord Bridge
in the case of Sidaway v Governors of
Bethlem Hospital [1985] 1 AC 871, English law does not recognise the
doctrine of informed consent.
This does not mean that there is not a legal (and moral) obligation
to inform the client so that they are able to make a balanced judgment. But,
failure to do so would not invalidate the contract. Any liability would not lie
in surgical trespass but in the tort of negligence. Negligence in the duty to
inform would only be an issue if it were shown that the client would not have
consented had they had fuller information.
The law on the duty to warn is not controversial, Lord
Bridge of Harwich in the Sidaway case
said “when questioned by a patient
of apparently sound mind about risks involved in a particular treatment
proposed, the doctor's duty must be to answer both as truthfully and as fully
as the questioner requires.” In the same case it was made clear that this was
primarily a matter of clinical judgment. Lord Templeman said, “…it was for the
doctor to decide what information should be given to the patient and the terms
in which that information should be couched.”
It is
important to be empathetic with the client; to be open and accommodating in
answering any questions that the client may have. That is not the same as
burdening the client with information that they either do not need or, in many
cases, do not want to know about. The vet/client relationship is one that is
based on trust and understanding that, in many cases, would have been built
over a number of years. The vet’s role is to guide the client through the
process of their pet’s illness and to, benignly, use their Aesclepian
authority.
Empathy requires that one should be responding to the
client’s needs and not just passing over a prescribed list of possible adverse
consequences. “The decision on what risks should be disclosed for the
particular patient to be able to make a rational choice whether to undergo the
particular treatment recommended by a doctor was primarily a matter of clinical
judgment” (Lord Templeman). In Bolam v Friern Hospital
Management Committee [1957] 2 All EWR 118 it was held that, “the doctor could not be criticised if, believing
the dangers involved in the treatment to be minimal, he did not stress them to
the patient.”
Of course, I agree with the tenor of the RCVS statement; after all effective communication is an essential ingredient to the "art" of veterinary medicine. Most veterinary surgeons and, indeed, veterinary nurses do a superb job of informing clients of the treatment options and consequences of such treatments that their pets may have to undergo. This is done at a time when the client is usually under some stress and feeling anxious. They will often be relying on the veterinary team for some emotional support. The veterinary surgeon or nurse should not feel compelled or constrained as to what information is passed onto the client on the basis of a legal doctrinal fallacy.
VJ(c)2013
VJ(c)2013
Sunday, 8 July 2012
Dog trapped in car
I was in the middle of my Saturday morning clinic yesterday when
the practice received a phone call from a concerned client. She was concerned
about a dog, a white German shepherd that had been locked in a car since 2 a.m.
and was now, at 12 p.m. on a warm and muggy day, apparently in distress. The
lady had phoned the police, but according to the caller, they were not very
interested in the matter. She wanted my advice as to what she could do. I told
her to smash one of the car windows so that the dog could at least get some air
and possibly be released from the car’s confines.
2012 (C) VJ
So, what is the legal position when one deliberately smashes
a window of someone else’s car? The
offence of criminal damage in section 1 (1) of The Criminal Damage Act 1971
reads: “A person who, without lawful excuse destroys or damages any property
belonging to another intending to destroy or damage any such property or being
reckless as to whether any such property would be destroyed or damaged shall be
guilty of an offence”.
The defence to the action that I advised are contained in
the phrase “without lawful excuse”. This defence is given in section 5(2)(b) of
the Act:
A person charged with an offence to which this section
applies shall… be treated for those purposes as having a lawful excuse…
if he destroyed or damaged… property in question… in order to protect property
belonging to himself or another… and at the time of the act…he believed: (i)
that the property… was in immediate need of protection; and (ii) that the means
of protection adopted…would be reasonable having regard to all the
circumstances.
In addition to the advice above that I gave, I also
recommended that she should notify the police of her proposed actions;
primarily as I thought that it might motivate them into action. Unbeknownst to
me, my conversation was overheard by a retired police officer. Her comments
were that that was exactly the advice she would have given. In fact, she said,
that was the primary use she made of her truncheon whilst she was serving as an
officer.
It appears then that the
advice is good.2012 (C) VJ
Thursday, 14 June 2012
Veterinary prescription fraud
The British Veterinary Association have been cited as calling on the Veterinary Medicines Directorate to introduce more robust measures to stop prescription fraud. Unfortunately Vet Juris thinks it is going to be a very long wait.
The problem with veterinary prescriptions is that there is no mechanism in place to cancel prescriptions once they have been filled by a pharmacist. Unlike human scripts, our prescriptions are not serial numbered and they do not have to be forwarded on to a central body, for the pharmacist to receive payment and the script to be cancelled. Because of this difference, a major problem in prescription fraud has been the duplication of the document by scanning multiple times or faxing the same document to several internet pharmacies.
At The Vet we have started embossing the practice details over the signature of the prescribing vet and adding a line: “Invalid if not embossed”; thereby preventing faxing or scanning . Unfortunately, this does add a level of difficulty for the client wishing to purchase their medicines via prescription, but it is a step forward in preventing prescription fraud.
Time will tell if this system works or not; perhaps pharmacies could be mystery shopped with invalid prescriptions. What is really needed is for the VMB to stop sitting on the fence and suggesting voluntary schemes, that will never be fully complied with, and introduce a standardised and serial numbered prescription pad that can be used on a national basis.
VJ(C)2012
The problem with veterinary prescriptions is that there is no mechanism in place to cancel prescriptions once they have been filled by a pharmacist. Unlike human scripts, our prescriptions are not serial numbered and they do not have to be forwarded on to a central body, for the pharmacist to receive payment and the script to be cancelled. Because of this difference, a major problem in prescription fraud has been the duplication of the document by scanning multiple times or faxing the same document to several internet pharmacies.
At The Vet we have started embossing the practice details over the signature of the prescribing vet and adding a line: “Invalid if not embossed”; thereby preventing faxing or scanning . Unfortunately, this does add a level of difficulty for the client wishing to purchase their medicines via prescription, but it is a step forward in preventing prescription fraud.
Time will tell if this system works or not; perhaps pharmacies could be mystery shopped with invalid prescriptions. What is really needed is for the VMB to stop sitting on the fence and suggesting voluntary schemes, that will never be fully complied with, and introduce a standardised and serial numbered prescription pad that can be used on a national basis.
VJ(C)2012
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