[164] Congress now has a computerised system which is able to pick up patients who fail to attend appointments. However, at the relevant time, Congress essentially relied on picking up a patient who missed an appointment when that patient next attended Congress.
[165] I have concluded that the first defendant had a responsibility to put administrative procedures in place for the situation that arose in this case where a patient fails to attend for a fasting cholesterol test which is part of the treatment plan for a potentially serious condition.
[166] I have concluded that because of the administrative system that existed at that time within Congress, Dr Boffa was not responsible for following up the deceased's failure to attend for a fasting cholesterol test.
[167] In addition to failing to attend an appointment for the fasting cholesterol test, the deceased did not attend the appointment that had been arranged for him at the Specialist Physician Clinic on 21 March 2000. Had he attended the Clinic it would have been picked up by the doctor in charge of the Clinic that he had not attended for the fasting cholesterol test and arrangements could have been made for this to be done.
[168] The doctor in charge of the clinic was Dr Janusic. Dr Janusic was appointed as the Medical Officer Co-ordinator a position she still held in March 2000. Her job was to determine where the medical practitioners worked, the jobs they did and how much time was allocated to their medical duties (tp 450). In addition to her work as a medical co-ordinator, Dr Janusic was predominantly a medical worker. She performed two administrative functions. The first was to meet with doctors and then relay their concerns to management. Her second administrative role was rostering medical staff and dealing with correspondence.
[169] The specialist clinic included a Physician Clinic and occurred on a Tuesday morning. There was an appointment book with appointments for each of the clinics. This contained the appointment time, the name and address of the referred patient, the medical record number and a column for whether or not transport was needed. To refer a patient to the clinic, the practitioner completed an internal pink referral form and wrote down the details of why they wanted an opinion from the specialist clinic. The pink form was left in the file. Either the doctor, health worker or, at their request, a receptionist would fill in the appointment book. There was no record kept of who made the entry in the appointment book. One of the jobs allocated to Dr Janusic was to do the follow up of any patients who failed to attend. On the evidence of Dr Janusic, failure to attend ranged from 30-50 percent of all appointments to the Clinic. Prior to the start of the Clinic a receptionist would retrieve the files for the patients scheduled to attend the Clinic that morning. The receptionist would then deliver the files to the clinic. On arrival at Congress, patients were advised by reception to go to the southern wing where the Clinic was held. Their file would be there already. When the patient arrived at the Clinic, the health worker would highlight the patients' name in the appointment book. As the morning progressed, all patients who attended would have their names highlighted. The names not highlighted were the ones who had failed to attend. Dr Janusic stated she would process the files from the physicians clinic and the health worker would process the failures to attend the other clinics, being the podiatry, ophthalmology and diabetic clinics. Dr Janusic stated she would take the files and check she had the right ones from the remaining names in the appointment book. It is Dr Janusic's evidence that if a person failed to attend and it was their first referral to the physician, it would be an automatic booking for a second appointment at the next available clinic. An appointment card would be written and dropped off to the patient by bus or mailed to them if they had a town address. If they failed to attend a second appointment, they would be given a third appointment and the same process followed. If a patient was a regular attendee to the Physician Clinic or had seen the physician previously and missed an appointment, then there would be an entry in the file to discuss with the patient on his next visit to Congress to make a new appointment.
[170] Dr Janusic gave evidence that it was the receptionist's job to get the files out before the Clinic started at 9.00am and deliver the files to the southern wing of the building. The files and appointment book were placed on top of a metal cabinet in the corridor.
[171] The file for Clive Impu Snr was one of the files remaining at the end of the clinic as having not attended. Dr Janusic gave evidence that the appointment book had the name Clive Impu with no other details. It matched the file that had been retrieved. There was nothing on the file to indicate that there were two patients with the same name. If the deceased had attended the clinic, a health worker would have seen him first, ascertained that he did not have the correct file and obtained the correct file. It would have been drawn to the attention of the senior receptionist who would do what is normally done when this situation arises and marked on the front cover of both files in Texta or thick ink and in large print "Note: Two files with the same name". This would be an alert to subsequent practitioners accessing those files. Whoever had filled out the appointment book had not given the file number. Two persons with the same name would have different file numbers. Dr Janusic gave evidence she did not know why the receptionist would have chosen the particular file that was extracted.
[172] Dr Janusic stated she wrote in the file that Clive Impu had not attended the clinic for his appointment. Dr Janusic stated she could not remember if a pink slip accompanied the file. This did not cause alarm because some practitioners forgot to fill in the pink slip and would write a note in the file itself. Dr Janusic stated she was comfortable with stating that this matter should be looked at again next time the patient attended because Clive Impu Snr was attending within two weeks for his medication.
[173] Dr Janusic gave evidence that on 21 March 2000 there was nothing to alert her to the fact that she had the wrong file. It is Dr Janusic's evidence that she did not have the authority to change any of the administrative procedures although she could make recommendations. Any changes would have to be made at a meeting of senior managers.
[174] Under cross examination (tp 460) Dr Janusic agreed that aboriginal patients had special needs. Diseases such as coronary disease and diabetes are more prevalent amongst aboriginals than the rest of society. Dr Janusic agreed that Congress had tried to develop simple processes for aboriginal people who did not deal well with the paper work. She also agreed aboriginal people had a great many distractions, such as obligations to attend ceremonies, that could take them away from Alice Springs. She stated that social problems, including living conditions and pressure from relatives in town camps, were a source of considerable stress for many aboriginal patients. Congress had aboriginal health workers, counsellors and transport to assist their patients. The dispensary at Congress was a way of ensuring patients received only their prescribed medication. Dr Janusic stated that each doctor could decide whether to personally follow up with a patient or allow the system to do the follow up. This required clear communication from the doctor referring a patient for treatment. The referring doctor must write clear and unambiguous notes on the patients file for the benefit of any subsequent doctor. Dr Janusic agreed that matters of concern could be written on the Health Summary Sheet just inside the file to alert subsequent health workers about the current progress. They could then look back into the file to see what had been referred and what had been actioned. Dr Janusic gave evidence about the red sticker system which was used up to the year 2000. A red sticker was an alert to a serious matter such as suspected ischaemic heart disease that needed significant action. Dr Janusic gave evidence about the confusion this system caused when the red stickers were not removed after the warning had been actioned and, as a consequence of that, became less frequently used. Dr Janusic stated that there was a meeting of doctors at Congress on Wednesday mornings where there was general discussion as part of the quality assurance program about aspects of their practices and any inadequacies in the system (tp 471). Dr Janusic gave evidence the appointment book had been lost. She had not seen this book since late 2000 or early 2001. She had asked for the relevant page to be extracted after the death of Mr Impu. The appointment time was noted on the page Dr Janusic sighted. The name Clive Impu was there. There was no patient number, known as the COOC number, and no address noted. She stated that she only saw this page on one occasion and that it was her guess that it was Dr Boffa's writing. Dr Boffa was the referring doctor. She stated she could have been wrong about it being his writing. She agreed his writing was messy. The evidence of Dr Janusic about who had written in the appointment book is ambivalent. It appears that when she gave evidence to this Court it was in fact the first time she had ever suggested it was Dr Boffa's handwriting on the relevant page in the appointment book. Unfortunately, it appears the appointment book is missing. It was not available for tender in these proceedings. Searches that have been made by staff at Congress to locate the appointment book have not been successful. I am not prepared to make a finding that, on the balance of probabilities, it was Dr Boffa who wrote in the appointment book.
[175] Dr Janusic gave evidence that she knew, following the deceased's death, that the wrong file, i.e. the file of Clive Impu Snr, had been retrieved. For that reason, she wanted to look to see what she had written on the file (tp 475). Dr Janusic stated she is certain there was no patient number recorded in the appointment book. It was not unusual not to have the patient number there and the receptionist would have been used to that. Dr Janusic concluded the receptionist must have chosen the file of Clive Impu Snr to deliver to the clinic because there was only one file delivered to the clinic in the name of Clive Impu. It is Dr Janusic's evidence that sometimes in that situation, where there were two patients with the same name, the receptionist would send both files to the Clinic. It was then left to the general practitioner in charge to identify which of the particular two files was being referred to. Dr Janusic gave evidence her role was to see the diabetic patients and to follow up the non-attendance for the Physician Clinic and the diabetes clinic. Dr Janusic stated that with respect to the files for the non-attendees at the Physician Clinic she would write new appointments or an action plan in the notes. On 21 March 2000, one of the non-attendees whose file had been delivered to the Physician Clinic was Clive Impu. The file that had been delivered was for Clive Impu Snr instead of the Clive Impu for whom the appointment had been made. The Physician Clinic was cancelled that day, i.e. for 21 March 2000. Dr Janusic stated she would normally see patients who did attend a clinic which had been cancelled as a regular consultation. Dr Janusic was shown the Congress file for Clive Impu Snr (Exhibit 35). Inside was a note that read "21/3 Physician Clinic cancelled. Why was he referred? Sort this out at the next visit". Dr Janusic gave evidence this note was written in her handwriting and she had initialled the note. No Clive Impu had attended the clinic. Dr Janusic stated she looked back through the file to identify a specialist referral. She stated it was not unusual to have appointments with no referral, although, to have a referral was the best medical practice and had been raised as an issue at their meetings.
[176] Dr Janusic stated the Clive Impu, whose file she had, was on medication. He had been attending for blood tests to monitor his diabetes and she was confused about why he had been referred to the Physician Clinic. Dr Janusic said she had no reason to raise the matter with her medical colleagues at the meeting the following Wednesday morning as there was always a 30-50 percent non-attendance rate of patients at the clinic. She stated it was not possible in the time they had for a meeting to make reference to the non-attendees at the Physician Clinic.
[177] Dr Janusic gave evidence that if the file number had been put into the appointment book or if the file cover had noted there were two patients with the same name then she would have picked up the fact that she had been given the wrong file. However, her evidence is there was no file number in the appointment book and the file cover did not make mention of there being two patients by the same name. She agreed that the percentage of Congress patients with the same name was about 9 or 10 per cent and a higher number who had a similar name. Dr Janusic was shown the original file for Clive Impu Snr and confirmed that she wrote her note of 21 March 2000 in red ink as a prompt to subsequent practitioners because it had a more urgent look than blue or black ink. She agreed that she was disappointed that whoever had seen Clive Impu Snr on the next occasion did not follow up the red alert. A copy of Clive Impu Snr's file is Exhibit P35. The page with the notation made by Dr Janusic is flagged and a copy of her note highlighted in yellow texta.
[178] Dr Janusic gave evidence that after the death of Clive Impu Jnr in early 2001, Congress recruited a new senior receptionist in an upgraded position. A receptionist was also employed to organise the files and put them in order. She gave evidence that doctors had complained about the way the reception area functioned. Dr Janusic agreed that the failure to bring the correct file to the clinic on 21 March was a serious administrative error because it meant that the specialist referral for the deceased was never actioned. Dr Janusic gave further evidence that, as at March 2000, notes in patient's files were not bound or in any way clipped together so that the files could be kept in order. She stated this was now one of the duties for the file maintenance receptionist.
[179] Dr Janusic gave evidence that on the Monday following the death of the deceased she had attended Congress and looked at the deceased's file (Exhibit P13). Dr Janusic says she would have seen the pink referral form that is in the file because she went through every page. She stated it was her task to examine the file following Mr Impu's death. This was because she was the clinical co-ordinator for the medical officers and the person required to report the matter to the insurer. Dr Janusic stated she was aware there was a likely possibility an Inquest would be held. She had not previously had to prepare for a Coronial Inquest. She sought some advice from Dr Boffa and together they sat down and tried to piece together what had happened. They were puzzled as to why the deceased, who was so young, had died suddenly. They thought there may be a possibility that there was a connection between his death and his attendance on 2 March 2000. Their focus initially was on the brevity of the notes that Dr Morrison wrote on Friday, 26 January 2001, when the patient attended shortly before he died. Dr Janusic gave evidence they did not then, or at any subsequent time, discuss the deceased's consultation with Dr Boffa on 2 March 2000. The report prepared by Dr Janusic for the insurer was done on behalf of Congress not with respect to an individual doctor. It was decided that Dr Janusic would do an internal investigation into the matter. Dr Janusic wrote a report setting out her opinion after she had reviewed the file for the deceased and the file for Clive Impu Snr. In compiling her report she did not speak with Dr Boffa or any of the other practitioners who had seen the deceased. Dr Janusic stated the report she prepared was done for the senior management at Congress and had nothing to do with Dr Boffa (tp 491). Dr Janusic gave evidence that although the pink referral form was on the deceased's file it was not possible to know where it was on the deceased's file at the relevant time. Dr Janusic was taken to a note on the file entered by Dr Yazdani who attended upon the deceased on 23 April 2000 when the deceased presented complaining of boils. She stated it was possible that Dr Yazdani did not detect the presence of a pink referral form on the file. Similarly, with respect to the attendance by the deceased on 28 April 2000, when the deceased again presented complaining of boils and was seen by the health worker Mr Braun, Dr Janusic suggested that Mr Braun may not have detected the presence of the referral form. The deceased further presented on 29 December 2000, complaining of a dog bite and was seen by a health worker and again no one adverted to the presence of a pink referral form.
[180] Dr Janusic gave evidence it was the responsibility of the receptionist to maintain the files in order. She agreed a doctor may need to organise the papers in the file to ascertain what had occurred on past attendances as this may shed light on the presenting symptoms of the patient. Dr Janusic was taken to a document which was described as an "Emergency Department Discharge Facsimile" from the Alice Springs Hospital to Congress. Dr Janusic thought it more appropriate that she have sole responsibility for reviewing these facsimiles in case there were matters that Congress needed to follow through with, however, the Clinic Manager decided to delegate this task to other practitioners. Dr Janusic agreed that the receipt of this facsimile was a further opportunity for the deceased's file to be retrieved and for the information on the facsimile to be married up with the information on his file. She stated, however, that there were a great many of these facsimiles received from the hospital each day and that this may have been the reason the task of follow up was delegated to a number of practitioners at Congress.
[181] Dr Janusic also agreed that the system at Congress was a multi practitioner practice and that many practitioners relied on the follow up system at Congress rather than following up their referral personally. Dr Janusic said that if she were the person doing the referring, she would write in her diary everyone she referred and then check it in a few months to ensure things had happened. This was for her own development to find out about the more complicated and diagnostically difficult cases. She considered this would also be in the patients best interest.
[182] Dr Janusic said she would do the immediate follow up for the non-attendees at the Physician Clinic and on this particular occasion, she had written an action plan. This would have worked if the right file had been retrieved. Dr Janusic stated that, under the Congress system after a physician to whom a patient was referred had done an assessment, a copy of the report would go into the pigeon hole for that practitioner (tp 502).
[183] Dr Janusic was shown the hand written report that she prepared, being the report from her findings after reading the file of Clive Impu Snr, and the file of the deceased for the purpose of trying to see where Congress could improve. Dr Janusic confirmed that her reading of the attendance of the deceased on 2 March 2000 was that, when he consulted the doctor, the deceased no longer had chest pain but chest discomfort. She stated that she read it this way and that the fact the word discomfort was underlined was to emphasise the fact that the pain had receded into a state of discomfort. Dr Janusic stated in this report that, in her view, the incorrect file was retrieved on two occasions. She had also identified the fact that there had been a failure by practitioners and aboriginal health workers. This was to emphasise the lack of follow up with the patient. She had also pointed out that correspondence on the deceased's file was not dated and the only way she could infer the ECG referred to was carried out on 31 December 1999, was because this was the only ECG reference in the file.
[184] Dr Janusic had noted some positives which included the fact that there was now a system in place to document the fact that patients had failed to attend for an appointment or that they had attended but left before they were seen by a doctor. There was also a reference to the fact that there were options for placing red stickers onto the file as a prompt to alert the practitioner that action was required.
[185] A copy of the report prepared by Dr Janusic dated 11 May 2001 was tendered and marked Exhibit P36.
[186] Under cross examination by counsel for the second defendant, Mr Abbott, Dr Janusic agreed that as at March 2000 the system in place at Congress was a shared patient system. There were no patients who were exclusively one practitioners, although patients could express a preference to see a particular practitioner. Dr Janusic said that because it was a shared system it was important for doctors who saw patients on subsequent consultations to be aware of what had occurred before and that they ought to have done that by reading the previous progress notes on the file and anything else in the file that may be significant. She said that if there was no apparent result from the previous notes then the practitioner ought to enquire why from the patient or make any other reasonable enquiry.
[187] Dr Janusic stated the system of using red stickers as a prompt to subsequent practitioners was not in place in 2000 in the sense that red stickers were not at that time used in cases of an urgent condition which might prove fatal if not dealt with in the next few days. It is her evidence that in 2000 everything, including progress notes and test results, worked on a paper based system. A doctor would not record a diagnosis based on suspicion but would have the patient investigated. The diagnosis would only be recorded if the doctor could make such diagnosis clinically. She would not expect the doctor to record suspected ischemic heart disease in the notes until the patient had been investigated.
[188] Dr Janusic stated it was the receptionist's job to complete the Health Summary Sheet with details of the patient's address and Medicare number. This is all provided for in the manual (Exhibit D22 p 4.1), including the fact that it is the receptionist's duty to get out and put away files as needed by Congress staff and file pathology test results.
[189] Dr Janusic gave evidence under cross examination that she came to work on the Monday following the death of Clive Impu Jnr. She was asked by the service branch manager to investigate the circumstances leading up to his death. She discussed the death with Dr Boffa. They looked at the file and focused on the few lines and lack of information that appeared in the entry for the day of the deceased's death. They discussed how management was to be told about the incident. Dr Janusic consulted with Dr Boffa because he was the more experienced practitioner at Congress at that time. It was clear that the wrong file had been brought for Dr Morrison on the date of the deceased's death. It was then obvious there were two Clive Impu's. The deceased's file was subsequently locked away so that it could be preserved for the inquest and whatever else occurred. This directive came from the services branch manager.
[190] At a later time, Dr Janusic went through both files and wrote her report. She did not consult with Dr Boffa about this. She observed from reading the report of the deceased's file that on 2 March 2000, Dr Boffa had referred the deceased to the specialist clinic. Dr Janusic saw a pink referral form on the file and observed the pink form had the name of the patient, his birthday and a Congress file number. She made a note on page 2 of her report that there was no entry on the deceased's file about the appointment date nor any indication of whether he attended the appointment. There was an entry for 21 March 2000 in the file of Clive Impu Snr indicating the patient had not turned up on that date (tp 518).
[191] Dr Janusic gave evidence that at one time she did have the relevant page from the appointment book. She told senior management that the appointment was not completely written in but she could not remember what happened subsequently. She stated she knew the deceased's file was kept locked up in the safe. Dr Janusic gave evidence that she had been shown the page from the appointment book prior to the Inquest in 2001. Still under cross examination by counsel for the second defendant, Dr Janusic said there was no way she could have known that the file she made a note in at the clinic on 21 March 2000, was the wrong file. She gave evidence that she had not done anything wrong with respect to her medical duties. She was concerned that she might be caught up in the administrative process on the issue of the insurer. The evidence of Dr Janusic is that the file she was given was the file of a person who was a regular attendee, who was already on medical treatment and had already had blood tests. She said there was no reason to think he was inappropriately there. An examination of the file of Clive Impu Snr in which Dr Janusic had made a note on 21 March 2000, does not support her evidence that he was a regular attendee. Dr Janusic gave evidence she had received a letter from Congress stating that they could not indemnify her because she had worked both as a medical practitioner and as an administrative manager. When she was writing the report (Exhibit P36), Dr Janusic said she knew she had written in the wrong file on 21 March and wanted to find out how this mistake had occurred. She stated "there were no alarm bells to indicate it was the wrong file at the time". She said the person to whom the file referred had multiple medical problems and could have been referred to the specialist clinic for any number of reasons (tp 530). It is her evidence that, even though there was no referral form in the file and no apparent reason for it written in the notes, this was quite a common occurrence. She said there was adequate information on the file to indicate this was a person with chronic problems whom the physician was likely to be seeing and that it was likely someone would make such an appointment. She stated there was no reason, as at 2 March 2000, to check the appointment book. Dr Janusic was referred to the medical file of Clive Impu Snr and taken to the various entries in the file as to his previous attendances. Dr Janusic said she had to make a decision whether to rebook the appointment or just make a note that he was to be reviewed on his next visit. Dr Janusic did not agree that she should have drawn the inference, when she read the file of Clive Impu Snr on 21 March 2000, that in fact he was not the person who had been referred to the specialist clinic. She agreed the receptionist could have obtained the two files in the name of Clive Impu and checked for a referral form to be sure which of the two patients had been referred to the clinic. Dr Janusic was asked about the doctors meeting at Congress when Dr Boffa had identified the systemic failures that had occurred being, (1) Dr Morrison's failure to examine the deceased before prescribing medication on 26 January 2001; (2) the wrong file being produced on 21 March 2000; and (3) the wrong file being produced on 26 January 2001.
[192] Dr Janusic agreed she had never previously asserted that Dr Boffa had written in the appointment book or that he had failed to put in the file number. Her evidence is that she presumed it was his writing in the appointment book but she was not certain. She agreed the first time she had ever made such an assertion was in giving evidence to this Court. I have already stated that I do not accept, on this evidence, that it was Dr Boffa who wrote in the appointment book.
[193] Dr Boffa was recalled to give evidence. He stated that he had never received the report which Dr Janusic had prepared for the health services branch manager in relation to this matter. It is Dr Boffa's evidence that he had never seen the page in the appointment book referring to the appointment of Clive Impu on 21 March 2000. It is his evidence that Dr Janusic never asked him if he had written the deceased's name in the appointment book and that she had never told him that whoever had written the deceased's name in the appointment book had failed to note the date of birth and the Congress patient number. He said if Dr Janusic had identified him as the writer in the appointment book with vital information missing, he would have expected that in her capacity as medical officer co-ordinator, she would have approached him and counselled him. He said this did not occur. It is his evidence that the first time he became aware of a suggestion or attempt to place the relevant page from the appointment book in the safe, was when he had a telephone conversation with Dr Janusic about a week before the hearing of this matter in 2008.
[194] Dr Boffa gave evidence that he had put in place steps to try and locate the page from the appointment book on many occasions. He said that there had been an extensive search for the missing page at the time of the initial investigation and on subsequent occasions. Dr Boffa stated that Dr Janusic was present at Congress meetings where the system failures that may have contributed to the death of the deceased were discussed. He said Dr Janusic did not mention or discuss at any of those meetings the appointment book page that she said she had located.
[195] It is Dr Boffa's evidence that he filled in the pink referral slip for the deceased and that he had also made a copy of it and placed it in the internal mailbox so that whoever filled in the appointment book would have that information to refer to. He agreed that not all GP's at Congress followed that procedure at that time.
[196] He gave evidence that if the receptionists had looked on Comcare and found there were two Clive Impu's, it was within their authority to look inside the file to see whether either file contained a pink referral slip. It is his evidence that the procedure for booking a specialist appointment was to ring the receptionist and ask them to make a booking. Failing that, the doctor would ask the health worker to make the booking and, if neither the receptionist nor the health worker could be contacted, the doctor would track down the appointment book and make the appointment.
[197] He stated in cross examination that he only found out approximately one or two weeks before the hearing that Dr Janusic had found the appointment book. Dr Boffa gave evidence about the telephone conversation he had with Dr Janusic shortly before the commencement of the trial. He said Dr Janusic had confided in him that she was afraid of being sued for anything she might have done on 21 March 2000. She had asked if Congress would be prepared to give a letter guaranteeing she would not be sued. After speaking with his solicitor, Dr Boffa informed Dr Janusic it was highly unlikely that she would be sued.
[198] Dr Janusic agreed that she had not written a memo about the conclusions she drew from the page from the appointment book. She stated she did not mention it at the Coronial Inquest because she had not been asked about it. She agreed that at the Inquest she had said that if a patient did not attend a specialist clinic their files would be retrieved, that it would be documented in their file that they did not attend and that a judgment would be made as to whether the patient should be recalled, whether a letter should be sent or whether a note should be made in the file to discuss the patient's non-attendance at the next visit. She agreed that at the Inquest she had not volunteered that within the timeframe being discussed it was mostly she who was the doctor making that judgment. She agreed she had not volunteered at the Inquest that she was the doctor who had written the note in the file of Clive Impu Snr about his failure to attend the clinic. She agreed she had not said anything at the Inquest about the deficiency in the appointment book as it was not unusual for the file number not to have been written in. Usually there would be an address so the patient would be picked up. She stated she assumed Dr Boffa had earlier seen the page from the appointment book. She had told senior management about the deficiency in the page from the appointment book and stated she had never mentioned the appointment page to Dr Boffa as she assumed he had seen it.
[199] Dr Janusic stated it would have been impractical to send a memo round to the various doctors on the day following the cancelled clinic to ascertain which doctor had referred a patient who had not attended the specialist clinic on 21 March 2000. Dr Janusic stated this would not be in accordance with good medical practice (tp 549).
[200] Dr Janusic was then cross examined by Ms Kelly, counsel for the third party. Dr Janusic stated that if a patient had a condition that required urgent attention they would be referred to the hospital and if they had been referred to one of the four specialist clinics, then it was not a critical or urgent condition. If the patient failed to attend, a letter would be sent to them or they could be booked into the general clinic the following day. If the patient's condition was not serious, and it was a patient who came in from time to time, then Dr Janusic said she would write on that patient's file "please review next visit and follow up".
[201] Dr Janusic gave evidence that she would, during the course of the clinic, attend to the diabetic patients and would follow up the "did not attends" when the clinic finished. She agreed that, from time to time, a practitioner would refer a patient to the Physician Clinic without filling out a referral form. It was less common but did occur that sometimes there was also nothing written in the progress notes on the file of the referred patient. She agreed that it was probably only one or two files from each clinic that did not contain sufficient information to allow for a follow up. Dr Janusic stated that she did not consider it was practical to send around a memo about the non-attendees. She said it was no longer an issue as all those details are now placed on a computer system. It was only a doctor who could make a referral or sign off on a referral to the specialist clinic. It is Dr Janusic's evidence that it was not until 2002/2003 that the practice was introduced of having a pink referral form in duplicate, one placed on the file and one given to reception.
[202] Dr Janusic agreed it was not uncommon for there to be two files with the same name. Dr Janusic stated that the practice in those circumstances, was to write in thick ink or texta on the front of the files "NOTE: Two patients with the same name". She agreed that she did know at the time that not every double up had been noted on the files. Dr Janusic was taken to the file of Clive Impu Snr. She agreed there was nothing in the previous entries on the progress notes to indicate why Clive Impu Snr would have been referred to the Physician Clinic. Dr Janusic gave evidence, by reference to the file of Clive Impu Snr, that the various attendances went back to 1998 and that there was nothing to indicate why he would have been referred to a Physician Clinic. She stated that she knew that it was not always noted on the file when there was more than one file with the same name. Her evidence is there was nothing to suggest to her she may have had the wrong file. She agreed that some of the conditions which Clive Impu Snr suffered, in particular diabetes, could have required urgent follow up. Dr Janusic stated her clinical judgment at the time was not to pursue the matter further, but to follow up the matter with Clive Impu Snr the next time he attended the clinic. Her evidence was that this was the correct clinical judgment. Dr Janusic then gave the following evidence in cross examination by counsel for the third party, Ms Kelly (tp 563-564):