Healthcare practitioners are expected to recognise and work within the limits of their training, experience and competence. This is crucial when confronted with a complex case and appropriately qualified assistance is available, write Natasha Naidoo and Sibusiso Madisha of Fairbridges Attorneys. They cite a recent decision of the UK’s Medical Practitioners Tribunal involving a surgeon to illustrate the importance of recognising the limits of one’s competence and seeking assistance where necessary.
Although the decision was made within the United Kingdom’s regulatory framework, it raises issues which are equally relevant to healthcare practitioners practising in South Africa.
Case background
The surgeon was working as a locum consultant general and colorectal surgeon at the Royal Oldham Hospital in England.
The patient had a complex medical history and was admitted to hospital with a small bowel tumour and a perforated, necrotic loop of small bowel, requiring emergency surgery. On 25 August 2020, the surgeon performed emergency bowel surgery by dividing the small bowel and performing a gastrojejunostomy, which involved the surgical connection of the small bowel to the stomach.
After surgery, the patient experienced ongoing pain, gastrointestinal symptoms and did not recover as expected. Concerns were raised by nursing staff and other practitioners, leading to the involvement of another surgeon and a second emergency operation.
The concerns were investigated by the General Medical Council (GMC), resulting in formal regulatory proceedings before the tribunal.
The concerns
The central clinical issue before the tribunal concerned how the surgeon had reconstructed the bowel.
After considering the evidence, including expert surgical evidence and imaging, the tribunal found that serious errors had occurred. It accepted evidence that a section of the small bowel had been connected in a manner that created a “closed loop”. Expert evidence suggested that this prevented normal gastrointestinal continuity and created a potentially life-threatening situation.
The tribunal further found that another section of bowel had been left disconnected within the abdominal cavity, and accepted that the operation was technically complex but that this did not excuse the errors. Rather, it raised the question of whether the surgeon ought to have recognised the limits of his own competence and obtained assistance.
Recognising clinical competence limits
The tribunal’s decision raised an important issue: the obligation on healthcare practitioners to recognise and work within the limits of their competence.
The issue was not that the surgeon undertook specialist surgery without the necessary qualifications. Rather, the tribunal considered the consultant general and colorectal surgeon’s conduct in the context of a particularly complex surgical case.
The distinction is important. The fact that a practitioner is qualified within a particular specialty, does not necessarily mean they possess the training, experience and competence required to undertake every procedure or manage every clinical situation without assistance.
The South African position
The principles arising from the tribunal’s findings are relevant when considered against the South African regulatory framework.
Rule 21 of the HPCSA’s Ethical Rules of Conduct for Practitioners Registered Under the Health Professions Act 1973 provides that, except in an emergency, a practitioner should perform only a professional act for which he or she is adequately educated, trained and sufficiently experienced, and which is performed under proper conditions and in appropriate surroundings.
The HPCSA’s Guidelines recognise that where there is a threat to life and an appropriately trained healthcare professional is not available, a practitioner may be required to intervene to the best of their ability.
Conversely, where a practitioner is unable to provide the required care within the limits of their training, experience and competence, Rule 21 contemplates referral of the patient to an appropriately qualified colleague or institution where the required care can be provided.
The relevant inquiry is therefore not whether a practitioner is permitted, in the abstract, to perform a particular procedure. Regard should also be had to the practitioner’s actual education, training and experience, the complexity of the procedure, the urgency of the patient’s condition, the availability of an appropriately qualified practitioner and whether referral is reasonably possible in the circumstances.
A genuine emergency in which no appropriately trained practitioner is available is therefore materially different from a situation in which a practitioner elects to undertake a complex procedure despite an appropriately qualified practitioner being available.
Events after the operation
After the procedure, the patient suffered increasing pain, ongoing bowel dysfunction, high nasogastric drainage volumes and a failure to improve as expected. The Tribunal found that there were warning signs which should have prompted further investigation and escalation.
Evidence indicated that nursing staff repeatedly raised concerns regarding the patient’s condition. The Tribunal found that those concerns were not adequately addressed and that the surgeon failed to obtain another opinion, despite the patient’s clinical course.
The findings illustrate the obligation to reconsider an earlier assessment when the patient’s subsequent clinical course suggests something may be wrong.
Where the patient fails to improve as expected, investigation results raise concerns, or other members of the multidisciplinary team identify deterioration, the practitioner should remain open to reconsidering the diagnosis or treatment plan and, where appropriate, seek assistance.
Communication with patients and families
The tribunal also considered that during a meeting with the patient’s parents, the surgeon expressed confidence that the procedure had been successful and that the patient was progressing appropriately. The tribunal found that these reassurances were not supported by the clinical and radiological findings at the time.
The findings emphasise the importance of accurate communication with patients and their families. Practitioners should be careful not to provide reassurance which goes beyond what can reasonably be supported by the clinical information.
Regulatory compliance
Interim conditions had been imposed on the surgeon’s registration during the GMC investigation. These included requirements relating to notification of certain employment arrangements.
The tribunal found that the surgeon subsequently began working in Ireland without complying with aspects of those conditions. It also made a finding of dishonesty, concerning information provided to the GMC regarding his employment.
The finding provides a separate reminder that a practitioner’s obligations to a professional regulator extend beyond clinical competence. Compliance with regulatory conditions remains a fundamental professional obligation.
Why the tribunal found impairment
It is important to distinguish between an adverse clinical outcome, negligence, and conduct which ultimately warrants regulatory sanction.
An adverse outcome does not, without more, establish negligence. Similarly, a clinical error does not necessarily mean that a practitioner’s fitness to practise is impaired.
The tribunal’s decision was not based simply on the fact that the patient suffered a serious surgical complication. It considered the seriousness of the clinical failings, the post-operative management, the failure to obtain appropriate assistance, the surgeon’s insight and remediation, his compliance with regulatory conditions and the finding of dishonesty.
The tribunal concluded that his fitness to practise was impaired and that immediate suspension after erasure from the UK Medical Register was the appropriate sanction.
Lessons for South African healthcare practitioners
Although the decision was made under the UK's regulatory framework, it provides a useful reminder that practitioners should continuously consider whether they possess the necessary education, training and experience to undertake a particular procedure or manage a particular clinical situation.
The emergency context is important. A practitioner faced with a life-or limb-threatening situation where appropriately trained assistance is unavailable may have little choice but to intervene to the best of their ability. The same considerations do not necessarily apply where an appropriately trained and experienced practitioner is available and referral or assistance is reasonably possible.
Practitioners should be alert to a patient’s failure to improve, concerns raised by nursing staff and other members of the multidisciplinary team, which may require an earlier clinical assessment to be reconsidered.
Finally, the decision illustrates that regulatory proceedings frequently involve more than the original clinical event. A practitioner’s subsequent conduct, including compliance with regulatory requirements, may become significant when a regulator considers fitness to practise and sanction.
The case: MPTS July 2026 – Dr Yasser Abdel Rahman
Natasha Naidoo (Director) and Sibusiso Madisha (Candidate Attorney) – Fairbridges Attorneys, Johannesburg
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