How was a drug-addicted doctor with hep C able to infect his patients?

Anaesthetist James Latham Peters transmitted the virus to his patients after he injected himself with the drug fentanyl. Image from shutterstock.com

Fifty-five women contracted hepatitis C after having abortions in Melbourne between 2008 and 2009. James Latham Peters, an anaesthetist with a drug dependence, has been prosecuted in Victoria for infecting these women while in his care. He is currently awaiting sentencing.

Hepatitis C is a common infection among injecting drug users. Peters transmitted the virus to them when he injected himself with fentanyl (a fast-acting morphine-like drug used as part of an anaesthetic) before he administered the remainder of the drug to his patients.

In a class action, lawyers for the victims are seeking damages from the doctors who engaged Peters as an anaesthetist and the Australian Health Practitioner Regulation Agency (AHPRA). AHPRA, which has taken over from the former Medical Practitioners Board of Victoria (MPBV), is responsible for the protection of the public through the registration of medical practitioners.

This tragic case demonstrates an unequivocal failure of the system. But what went so wrong?

Peters was suspended in 1996 for abusing opiates and returned to work a year later. Found to be abusing fentanyl in 2003, he took a year off and returned to work under supervision. The flawed monitoring process failed to detect ongoing drug use and drug-seeking behaviour which put patients at risk.

Fentanyl, the drug preferred by Peters, is easily accessed by anaesthetists. It rapidly breaks down to metabolites which are not part of a routine toxicology screen and are only measured when specifically requested. It is unclear as to why fentanyl was not tested in the ongoing monitoring of Peters.

Hepatitis C is a disease that must be reported to the local health authorities to protect public health. This reporting enabled the source of the hepatitis C outbreak to be traced back to Peters. But it’s unclear whether this information was communicated to the Medical Board in 1997. Disease notifications are not linked to databases held by other organisations such as AHPRA. And there are over 10,000 hepatitis C notifications annually in Australia and many other infectious disease notifications, so it’s feasible this information fell through the cracks.

This breakdown of process raised some important questions: could this communication have prevented the spread of hepatitis C in this case? And what are the implications for the privacy of individuals if information were to be shared? In 2011, AHPRA sought public comment on the possibility of the Board taking a stronger role in monitoring hepatitis C, but the outcomes of the consultation were not made available to the public.

Around one in ten doctors experience problems with addiction. Image from shutterstock.com

Managing drug-dependent doctors

The proportion of doctors who develop a substance use disorder during their lives is similar to the general population – around 10% to 12%. Doctors, like other members of society, are vulnerable human beings but they have access to restricted medications which are highly addictive.

When a doctor is suspected of drug dependence or any other form of impairment, the operating principles are: ensure public safety and treat the doctor.

There is both an ethical and legal requirement for health professionals who believe a doctor is drug dependent and places the public at substantial harm to report this to AHPRA. Reporting triggers a comprehensive assessment, treatment and a risk management plan. Strategies to ensure public safety include removing the doctor from the workplace (voluntarily or involuntary), restricting their prescribing and access to drugs, and placing them in a non-clinical role.

Treatment programs exist within all Australian jurisdictions to help manage impaired doctors. Such programs may be provided by individuals such as psychiatrists, addiction specialists or general practitioners, or by independent organisations such as the Victorian Doctors Health Program. Regardless of who provides the treatment, AHPRA has a critical oversight role in managing drug-dependent doctors and protecting the public.

Strict monitoring programs involve a combination of regular reviews by treating doctors, a responsible person in the workplace who observes day-to-day behaviour, and drug testing. Monitoring usually intensifies with return to work since public safety is the primary consideration.

Substantial resources go into training doctors and rehabilitation means this investment is not wasted. Medical practitioners with drug dependence have better treatment outcomes than that of other opioid-dependent people, and the majority successfully return to medical work.

As with all complex systems, errors occur. But key questions remain: How was a drug-dependent doctor – who relapsed several times and was on the radar for many years – allowed back to a job that gave him unsupervised access to his drug of choice? Could Peters’ recurrent relapses to fentanyl abuse and hepatitis C have been detected earlier? And could the tragic consequences have been avoided with better monitoring processes?

The answers may come out in the Supreme Court of Victoria as victims seek damages for Peters’ crimes.

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