(g) The fact that the symptoms referred to in (e) indicated that the plaintiff was depressed and very anxious and supported a diagnosis of "classical depression" .
183 Particular emphasis was placed by Dr. Bailey in making her diagnosis of a psychotic condition on 20 July upon the plaintiff's alleged statements referred to in (d) above. One issue is whether such statements, if made, in the context of the other five matters, entitled Dr. Bailey to conclude, as an aspect of the exercise of skill and judgment on her part according to the applicable standard, that the plaintiff had become psychotic on 20 July, Dr. Bailey having acknowledged in evidence that he had not exhibited psychotic symptoms prior to that date.
184 The significance of the statements which Dr. Bailey attributed to the plaintiff, are clearly central to the issue of breach. Dr. Fisher, who impressed as a balanced, experienced and knowledgeable general practitioner, was of the opinion that such statements did not in themselves provide sufficient evidence of a psychotic condition:-
"Q. A conviction in the light of that, a patient had the bowel cancer and was going to die, a conviction about which the patient couldn't be reassured, would be evidence of a psychotic, could be evidence of a psychotic depression, could it not?
A. I would need more evidence than that to conclude somebody was psychotic."
185 In determining the extent to which Dr. Bailey could rely upon the statements she attributed to the plaintiff as a basis for making the diagnosis of a psychosis, it is necessary to evaluate the level of significance that such statements carry in the overall context of the plaintiff's condition as assessed in July 2000.
186 Dr. Fisher's evidence was that a phobia is not a delusion (t.147), observing also that in some contexts "delusion" is used in its medical sense whilst in others it is used in a general sense. He did not consider that the defendant's notes nor the hospital notes established that the plaintiff was ever deluded (t.147). Phobia, he stated, is an actual fear of a fact. If he was delusional (being a fixed idea) then it would not come and go like anxiety.
187 However, it is also significant that, as Dr. Fisher explained it, "distorted thinking" can occur with both anxiety and psychosis. If it was "psychotic thinking", Melleril would be appropriate but not so if it was due to anxiety. In the event of "distorted thinking" being detected by a general practitioner, the key issue is whether it is due to or is in the nature of a marked or severe level of anxiety or whether it is due to a psychotic disorder. This is a distinction that may not always be an easy one to make. A matter relevant to the distinction in Dr. Fisher's opinion is that a delusional belief is not an extension or a greater degree of anxiety. He stated that it was "a totally different thing". A psychotic symptom is totally different to anxiety (t.162). A person may be very anxious and be quite firm in his or her belief about a matter and be unable to perceive the reality of it. However, the belief can be solved by dealing with the cause of the anxiety.
188 In examining the questions of breach of duty, I have given close attention to Dr. Bailey's failure on 20 July to record any psychotic symptoms and/or make reference to statements of conviction by the plaintiff that he was going to die of cancer and her failure to record her diagnosis of a psychotic condition. Such omissions are most important matters for consideration in making findings as to the symptoms that were presenting on 20 July and as to Dr. Bailey's diagnosis. This is especially so in light of the practice of Dr. Bailey to record matters of clinical significance as she herself said and as revealed by her notes generally.
189 However, the fact and significance of the omissions to which I have referred in the preceding paragraph must and should only be considered in the full context of the history of the plaintiff's treatment in July 2000.
190 It is apparent from the history recorded in this judgment that both leading up to and subsequent to 20 July 2000, the plaintiff exhibited a high level of anxiety that he had colon cancer. It will be recalled that on 7 August 2000, Dr. Hayes referred to the fact that he was still "petrified" that he had cancer. There is, as noted at [156], an entry in the St. Vincent's Hospital Progress Notes, following reference to his cousin's death, to "paranoid re colon ca". The note of the Psychiatric Registrar as to "pre-occupied fear of cancer" is consistent with obsessive thought processes. Up to 20 July, the plaintiff was plainly experiencing a rising sense of extreme anxiety and depression up to and including that day when he rang Dr. Bailey seeking help. Additionally, as noted earlier, the St. Vincent's Hospital record entries link the plaintiff's pre-occupation or concern with dying to colon cancer not to a deficiency in neutrophils.
191 I have considered at length the evidence of the plaintiff, Dr. Bailey, Mrs. Schultz, the references in the St. Vincent's Hospital Progress Notes and the observations made by Dr. Hayes in determining whether the evidence does establish, as a matter of probability, that the plaintiff made the statements to Dr. Bailey as she maintained in evidence to the effect that he believed he was going to die, was riddled with cancer etc., notwithstanding that Dr. Bailey did not record them in her notes. In that respect, I find that, as a matter of probability, the plaintiff did make such statements.
192 I should record that I found both Mr. Schultz and Dr. Bailey to be impressive witnesses and my finding is one largely based upon the objective facts and circumstances to which I have referred. The explanation for the discrepancy in their evidence as to what was said on 20 July 2000 is probably related to inadequacies in the plaintiff's recollection.
193 The progress notes in themselves record the history as given by Mrs. Schultz including the specific statements in italics as well as the note "paranoid re colon ca" given as part of the plaintiff's history.
194 The surrounding facts as to the plaintiff's increasing or rising level of anxiety as to cancer and the observations of Dr. Hayes that he was as at 7 August 2000 "petrified" all tend to corroborate Dr. Bailey's assessment, which I accept she made, that Mr. Schultz was in effect in a very fragile, fearful state as at 20 July 2000 and exhibiting distorted and obsessive thinking.
195 I accept that Dr. Bailey prescribed Melleril by reason of an assessment which she did in fact make that the plaintiff was manifesting distorted thinking of a psychotic nature.
196 The purpose in adding Melleril was to provide relief from what she described as the plaintiff's extremely distressed condition and the delay before Cipramil would take effect. She added, that she was concerned about his risk of suicide and felt that benzodiazepines, whilst they would reduce some of his anxiety and distress, would not in any way address his distorted thinking, his delusional belief that he had cancer. She stated that she accordingly felt that a more powerful medication was warranted.
197 The defendant said that she was aware of the risk of the agranulocytosis. She was not sure if she was aware of the rarer risk of pancytopenia. Whilst she could not remember whether she had expressly discussed the risk of agranulocytosis with the plaintiff, she stated that it was her normal custom to refer to known side effects when prescribing drugs.
198 It is at this point that it is necessary to apply the standard of care to which I have earlier referred. Dr. Bailey was not exercising the specialist medical skill of a consultant psychiatrist. As an experienced general practitioner, she was in a position where she was required to make a judgment as to what to do for a patient who had become highly anxious and distressed.
199 Many, if not most, psychiatric conditions are not as susceptible to as ready or precise diagnosis as many illnesses of a physical nature. In this case, on 20 July, Dr. Bailey was required to make a judgment on the plaintiff's mental or psychological condition based, in part, on his presenting symptoms and their severity as well as on what he was saying to her. The judgment, in essence, which she was required to make as a general practitioner was whether the plaintiff was experiencing or suffering from a "phobia" or a psychotic conviction or delusion. That was not a matter which lent itself to simple clear-cut diagnosis. That fact is underlined by what was said by Dr. Fisher, as earlier noted, namely, that "distorted thinking" can occur with either anxiety and/or with a psychotic condition. The distinction may call for fine judgment. Is a general practitioner practising in a country region without ready access to specialist opinion, necessarily both wrong and negligent if the judgment as to "distorted thinking" is considered psychotic rather than the product of extreme anxiety?
200 Even Dr. Phillips, in his report of 10 October 2005 (p.4), stated that criticism of a moderate order only should be directed at Dr. Bailey for prescribing and continuing to prescribe Melleril for the plaintiff where there was, on his assessment, inadequate evidence of a more intense depressive disorder or accompanying delusional beliefs.
201 The plaintiff's case was that the defendant had treatment options open to her and that, given the diagnosis of classical depression and anxiety, the appropriate course would have been to trial the plaintiff on a benzodiazepine such as Valium (diazepam) which had no adverse side effects apart from the possible risk of psychological or physical addiction with prolonged use. There was evidence that benzodiazepines are a very safe and anxiolytic.
202 It was submitted on behalf of the plaintiff that the defendant was negligent in her treatment of the plaintiff and that findings should be made in respect of the following matters:-