Standard for prescribing typical v. atypical antipsychotics remitted by board for reconsideration

The Health Professions Review Board of B.C. remitted a matter for reconsideration and disposition of the allegation that a geriatric psychiatrist fell short of regulatory standards by prescribing typical as opposed to atypical antipsychotics for patients admitted to the hospital and certified under the Mental Health Act.

In Complainant v. College of Physicians and Surgeons of British Columbia (No. 1), 2020 BCHPRB 96, the complaint, filed in March 2018, questioned the adequacy of the healthcare provided by the registrant, a geriatric psychiatrist, to the complainant’s grandparents, who had both been involuntarily admitted to the hospital for a number of months and certified under the Mental Health Act, RSBC 1996, c 288, which states under s. 31(1) that the treatment ordered will be deemed given with the patient’s consent.

In 2017, while the grandparents were admitted and certified, the registrant prescribed the complainant’s grandmother, who experienced delusions, with the typical antipsychotic medication Haldol, which is also known as haloperidol, and the complainant’s grandfather, who had assaulted a neighbour, with the typical antipsychotic medication Loxapine. In September 2017, the grandfather died after being diagnosed with neuroleptic malignant syndrome (NMS), a severe side effect of Loxapine.

The complainant alleged that the registrant chose medications that went against best practices and dismissed the family’s concerns about the medications’ impacts on the grandparents. In June 2017, during a family conference call, the registrant allegedly took offense to the complainant’s questioning of the scientific basis of her decision to prescribe a particular medication, while in August 2017 the registrant allegedly brushed off the family’s worries about the grandfather’s steep decline and the possibility that his symptoms might be neuroleptic malignant syndrome.

The deputy registrar investigated the complaint and found no basis to be critical of the registrant’s treatment of the complainant’s grandparents, stating that the registrant took a proper history, performed an adequate examination, made a diagnosis and advised appropriate treatment options.

The Health Professions Review Board remitted the matter, directing the Inquiry Committee to investigate and issue a new disposition of the conduct complaint. The HPRBBC recommended that the committee seek evidence relating to the regulatory standards of care for a geriatric specialist in the use of typical antipsychotics in elderly patients, including those with dementia, who are certified under the Mental Health Act.

The HPRBBC found that, while the deputy registrar’s investigation of the registrant’s clinical care had been adequate and thorough, the investigation of the registrant’s conduct when she interacted with the family had been unreasonable. The deputy registrar did not take the minimum steps needed to adequately investigate the conduct complaint and did not reach a provisional assessment of the registrant’s conduct, said the board.

In particular, the deputy registrar stated that he was not present at the time of the interactions during which the registrant allegedly behaved in a dismissive and unprofessional manner, so he could not comment on what had occurred. “To state the obvious, the College is never ‘present’ at the time of the interaction giving rise to a complaint,” wrote Kent Woodruff, panel chairperson for the board. “Its job is to investigate.”

The HPRBBC pointed out that certain staff members were present during the August 2017 meeting and were named in the record. The deputy registrar could have involved them in the investigation, the board said.

The HPRBBC also found that the disposition of the complaint lacked justification, transparency and intelligibility as regards the key issue of whether the registrant failed to comply with the regulatory standard of care when she prescribed typical antipsychotics instead of atypical antipsychotics for the grandparents.

The HPRBBC stressed that the deputy registrar did not need to offer a detailed analysis of the guidelines and literature cited by the parties, but he should have at least directly disposed of the key issue while considering the literature cited, instead of glossing over the key issue.