Case of the Month

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Don’t You Forget About Me

Aug 21, 2018

The Case

The College received a complaint from a patient about the physiotherapy care she received at a family medical clinic. 

The patient indicated that the physiotherapist placed acupuncture needles in her neck and shoulders while she lay on a table in a private treatment room. The physio then left the room and closed the door.
Although she felt that significant time had passed, the patient initially assumed that the timing was part of the treatment plan. As she grew increasingly concerned that the physiotherapist had not yet returned, the patient yelled out for help, but nobody came.
After waiting for two and a half hours, the patient forced herself off the table while trying not to move her neck and shoulders. In the hallway she encountered another physiotherapist who removed the needles and told her that the physio who initially treated her had left the clinic. 

As a result of the incident the patient reported feeling “emotionally traumatized” as well as experiencing ongoing tenderness in her neck and shoulders and shooting pain in her arm.

The physiotherapist who had been treating the patient admitted that she forgot about the patient in the private treatment room when she learned of a family emergency and unexpectedly had to leave the clinic, neglecting to ask another PT to take over treatment. 

She acknowledged that the patient was left alone with the acupuncture needles in her neck and shoulders for approximately two hours. She said she called the patient on the same day of the incident to see if she needed to discuss any symptoms and implemented measures to prevent something similar from happening in the future. 

The Standards

The Essential Competency Profile for Physiotherapists in Canada says that physios are required to “perform physiotherapy interventions…in a safe and effective manner” and to “implement appropriate monitoring during specific physiotherapy interventions.” It further states that PTs are required to “maintain continuity of physiotherapy service delivery” via communication with other physiotherapists and health professionals by arranging substitute treatment as appropriate. 

The Decision

The Inquiries, Complaints and Reports Committee felt that the physiotherapist did not meet these professional expectations and, furthermore, left the patient in an unsafe situation for an extended period of time by forgetting that she was in the treatment room. 

While the Committee appreciated the fact that the physiotherapist left the clinic due to a family emergency, they did not believe it negated her responsibility to ensure that any patients undergoing care at the time were monitored by another health professional. 
As a result, the physiotherapist was required to appear before the Inquiries, Complaints and Reports Committee to be cautioned, the fact of which will permanently appear on the Public Register

The patient who made the complaint filed an appeal, but the decision was upheld.

Comments about this case? Please share them below. 
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  1. Mike Poling | Aug 29, 2018
    Just for the record, Robin McKenzie didn't forget about Mr. Smith (the patient).  He was working with another client and Mr. Smith came in early, so Robin asked him to lie down in the other treatment room.  Just wanted to clear up that.
  2. John Wright | Aug 28, 2018

    I am reminded of the story of an Australian PT who one day asked a patient to go into a treatment area and wait on the table. As the story goes the patient got prone on a plynth erroneously adjusted for extension.  Robin McKenzie, the therapist in question was promptly distracted and forgot the patient for some time. And thus was born one of the most commonly used treatment models in our profession. 


    I understand that you have no choice, but to place a permanent blemish on a member’s public record seems harsh. On another day or with a another patient this incident might well have had a very different outcome.

  3. sherif shafey | Aug 28, 2018

    As long as the patient is in a physio clinic that mean he/she in a safe environment because all the staff they know there work regarding the client safety.

    and regarding to the effective manner I think no body will obtain the license or even the acupuncture roasted unless he is a good physiotherapy

  4. Catherine Fuller | Aug 28, 2018

    If a client is left unattended they should have access to a call bell. This is protocol at my clinic whether the patient is receiving acupuncture or any other modality or treatment. 

    As well, the therapist can set his/her watch timmer which is a useful habit or protocol.

  5. Kishore PT | Aug 28, 2018
    There is nothing wrong in leaving out of clinic due to family emergency reasons. Having said that, transfer  of care and the communication to the patient is absolutely necessary. 
  6. Mike Poling | Aug 28, 2018
    This is one of the pitfalls to private office practice of acupuncture.  It is easily alleviated by performing acupuncture in an open bed/curtained area where other healthcare professionals can hear the patient and respond.  That being said, family emergencies, depending on how severe, could cause anyone to be quite out of sorts and not act rationally.  I think the Committee could have considered that a bit more seriously.  After all, if your child was dying in hospital, for example, would you seriously expect you would act logically after receiving such a phone call?  Perspective is reality, after all.

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