Warning for doctor who left hospital while patient was still anaesthetised

The Medical Practitioners Tribunal Service (MPTS) said the actions of Dr Klaus Mahler in the incident at the Nuffield Health hospital in Shrewsbury amounted to serious misconduct.

But the panel accepted Dr Mahler had demonstrated remorse and insight into his actions, and concluded his fitness to practise was not currently impaired.

At the outset of the eight-day hearing, Dr Mahler admitted he had failed to keep adequate records before and during the procedure, left the hospital while the patient was still anaesthetised, and failed to provide an adequate handover of the patient.

On this basis, the majority of the facts were found proved by admission.

However the panel ruled Dr Mahler had no case to answer in relation to one aspect of one allegation and, after hearing evidence from Dr Mahler and other witnesses, found three other aspects of the allegations were not proved.

A report on the hearing said that at the time of the incident, Dr Mahler was employed by the NHS at Walsall Manor Hospital and also worked privately for Nuffield Health at its hospitals in Shrewsbury and Wolverhampton.

On the day in question, June 27, 2019, Dr Mahler had “double-booked” himself and left the Shrewsbury site to get to Wolverhampton for his next shift.

Dr Mahler accepted the seriousness of his actions in a statement to the panel, which said: “My decisions led to a significant breach of patient safety principles, forced members of the theatre team to work outside their usual practice and to perform an emergency intervention.”

The report says the patient came to no harm and the hospital later brought the incident to the attention of the General Medical Council (GMC).

On the allegation of poor record keeping, evidence from an expert witness, named in the report as Dr F, said: “The standard of documentation in relation to the pre-operative assessment and conduct of anaesthesia fell seriously below the standard expected.”

Turning to Dr Mahler’s actions in leaving the hospital while the patient was still in theatre, Dr F said: “The decision to leave this patient whilst still anaesthetised and with anaesthetic agents still being administered, with no other anaesthetic practitioner in direct attendance and with no reasonable handover of care to any other anaesthetic practitioner, with no justifiable mitigating circumstances, falls seriously below the standard expected of a reasonably competent consultant anaesthetist.”

The panel agreed with Dr F’s judgements and recorded findings of serious misconduct. It then had to consider whether Dr Mahler’s practice was currently impaired as a result of the misconduct.

The panel noted he had apologised to each witness who gave evidence and had “undertaken numerous relevant and targeted courses”.

The report says: “The tribunal also noted there had been 20 glowing testimonials from a variety of peers and colleagues, attesting to the trust and confidence they have in Dr Mahler, and how his actions in this incident were a significant deviation from his normal practice.”

Dr Mahler’s own statement to the tribunal said: “The sense of guilt and shame that followed were starting to be unbearable for me.

“All this anxiety to meet my commitment at Wolverhampton blinded me to the real risk of not being able safely to finish my list at Shrewsbury.”

Mr Paul Williams, presenting the case on behalf of the GMC, submitted that Dr Mahler had not developed full insight into his actions and this “continues to give rise to a real risk of repetition and therefore to patient safety”.

However Mr David Morris, representing Dr Mahler, argued a finding of impairment would be “unnecessary and disproportionate” in the circumstances.

The report said the panel was satisfied that Dr Mahler “has gained full insight into his actions” and “the likelihood of repetition was very low”.

It added: “The tribunal considered that there is a public interest in facilitating the return to work of a skilled doctor.”

The panel found Dr Mahler’s fitness to practise was not impaired as a result of his misconduct, but resolved that it was necessary to issue him with a warning, “to maintain public confidence in the profession, as well as to declare and uphold proper professional standards”.

A Nuffield Health spokesperson said: “The safety and wellbeing of our patients is our priority.

“Following a single episode of care in late June 2019 that fell below the clinical standard we expect, Dr Klaus Mahler was suspended from working at our Nuffield Health Shrewsbury and Wolverhampton hospitals.

“This suspension took place in early July 2019 following our investigation into the incident. After our investigation, a referral to the General Medical Council was made.

“Dr Klaus Mahler has not worked for Nuffield Health since his suspension in early July 2019 and no longer holds practising privileges with Nuffield Health.”