CENSURE: IC2936
DR. FAYEZ FOUAD FAHIM GOUDA
On December 11, 2018 in accordance with Section 47(1)(c) of The Medical Act, the Investigation
Committee censured Dr. Gouda as a record of its disapproval of his conduct in failing to meet the
standard of care of the profession, conducting himself in an unprofessional manner and displaying a lack
of judgment in respect to management of X while he was on duty in the Emergency Department (“ED”),
which includes on-call responsibilities for the personal care home (“PCH”) where X was a resident on
August 8 and 9, 2016, in that he:
1. failed to satisfy himself with respect to X’s condition and respond to what was an urgent
medical situation; and
2. failed to meet the standard of the profession in his communications with other healthcare
providers.
Censure creates a disciplinary record which may be considered in the future by the Investigation
Committee or an Inquiry Panel when determining the action to be taken following an investigation or
hearing.
I.

PREAMBLE

The physician-patient relationship is a fiduciary one in which the physician has an obligation to consider
first the best interests of the patient. Integral to the discharge of this duty, the physician must
demonstrate good faith and candour in dealing with the patient and other healthcare providers within the
patient’s circle of care. This fiduciary duty informs all ethical and legal obligations owed by physicians
to their patients.
On-call physicians are crucial to the provision of good care within our healthcare system and,
consequently, the responsibilities that come with assuming the role as an on-call physician are great.
Ethical and professional obligations undertaken by an on-call physician are informed by the fiduciary
duty that is owed by the physician to patients and by the expectations and procedures of the healthcare
institution. Applicable professional obligations include the duty to promptly provide whatever
appropriate assistance the physician can to any person with an urgent need for medical care and the duty
to provide services to patients when the physician has accepted the responsibility to do so until they are
no longer required or wanted, or until another suitable physician has assumed responsibility for the
patient.
In caring for and managing patients, the physician is expected to demonstrate knowledge, clinical skills
and a professional attitude in order to provide quality medical care. Specifically, quality medical care
frequently requires communication with other healthcare providers and effective and professional
communication skills are an expectation of the profession. In communicating with other healthcare
providers, the physician must be respectful and attentive to details. Where disagreement arises, an
attempt should be made to resolve the issue.
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 II.

THE RELEVANT FACTS ARE:

1.

X, age 62 at the material time, was a resident in the PCH who became ill while Dr. Gouda was
the physician working in the ED in a rural hospital, which included on-call responsibilities for
the PCH that required responding to emergent PCH matters on August 8-9, 2016.

2.

X suffered from several chronic illnesses, with multiple sclerosis and diabetes being particularly
significant. Her Advanced Care Planning (ACP) status was documented at the PCH as ACP-4
which included full treatment and resuscitation. She became ill with diarrhoea for several days
leading up to August 8, 2016. Her care was generally being managed by her family physician
(“X’s attending physician”).

3.

During the afternoon and evening of August 8, 2016, X’s condition deteriorated significantly.
Per X’s chart:
a. X became ill having had loose bowel movements in the previous week and 4-5 episodes
of diarrhea in the previous 24 hours.
b. At 17:40, the nurse noted receiving verbal orders from X’s attending physician for
laboratory investigations and antibiotics (five-day course of ciprofloxacin). Vital signs at
that time were: BP 156/79; pulse of 107; SPO2 97%; RR 21; and a temperature of 37
degrees Celsius.
c. X’s condition continued to deteriorate that evening. At 22:30, the attending nurses
noted that X’s condition was becoming poor. Vital signs were: BP 145/79; pulse of 121;
SPO2 95%; and a temperature of 38.6 degrees Celsius. A Tylenol suppository was given.

4.

The CMO of the regional health authority in which the ED is located, states that in a situation
where nursing staff at the PCH have concerns about the medical condition of one of the
residents outside office hours, the process is to call either the on-call ED physician or the
resident’s attending physician. Dr. Gouda believes that the resident’s attending physician should
be called first. He agreed that if the situation is emergent and the attending physician is not
available, the on-call ED physician is contacted and is expected to respond. Dr. Gouda
acknowledged that he was aware of and supportive of this responsibility.

5.

Nurse 1 contacted Dr. Gouda on August 8, 2016 at approximately 23:15 regarding X’s medical
condition. He documented his conversation with Dr. Gouda as follows:
Phoned Dr. Gouda [on-call doctor] on his cell phone and informed him about the
resident’s condition that she is getting poor and the family wants to do
everything possible for her, wants to stick with ACP – 4, wants transfer her to
the hospital to do IV therapy. Doctor denied to transfer her to the hospital and
was getting mad at the nurse writer. According to Dr. Gouda give her comfort
care for now and talk to the family doctor in the morning [August 9, 2016] when
he comes in the office. Nurse tried to explain him again that the resident is
getting dehydrated and eating nothing per oral also states that she is an ACP – 4
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 and family wants the advanced care. Dr. still refuses to transfer her to the
hospital.
6.

Nurse 1 confirmed the accuracy of his note during the College’s investigation. He advised that
he felt Dr. Gouda’s tone was disrespectful and was troubled by the fact that he was not listening
to concerns about X.

7.

Nurse 2 says that she had heard Nurse 1’s side of the above phone conversation with Dr. Gouda
at 23:15 and made the following late entry at 06:00 on August 9, 2016:
Writer witnessed and heard nurse on duty [Nurse 1] phone conversation with Dr.
Gouda on-call physician. Writer witnessed [Nurse 1] LPN explain resident’s
poor condition and request to transfer to hospital as per family’s request and
ACP 4. Dr. Gouda denied transfer. Resident’s condition again explained and Dr.
Gouda continued to deny seeing resident.

8.

After speaking with Dr. Gouda, Nurse 1 called the PCH clinical manager who advised him to
attempt to contact X’s attending physician if the family wanted. Nurse 1 then phoned X’s
daughter and left a voice message for her response. He then attempted to reach X’s attending
physician. X’s attending physician twice did not answer his cellphone and a message was left
after the second call. X’s daughter returned Nurse 1’s call shortly thereafter, was informed about
her mother’s condition and stated she would be coming to the PCH.

9.

Nurse 1 called the ED asking the nurse there if there was anything else that could be done. He
says that he was told that if the doctor was not accepting the patient, then the patient could not
be transferred to the ED.

10.

The CMO states that if a nurse at the PCH believes a resident requires urgent care and the oncall physician refuses to transfer the patient to hospital, there should be an attempt to contact
another physician, presumably the resident’s attending physician, and keep the PCH’s clinical
manager apprised. It would generally not be acceptable to arrange for transport to the ED if the
physician on-call advised same is not necessary or appropriate.

11.

Dr. Gouda does not agree with Nurse 1’s recollection of events, but acknowledges that:
a. based upon subsequent review, the medical record reflects that X’s medical condition
required urgent attention when Dr. Gouda was first contacted by the nurses, though he
states that at the time this was not his understanding;
b. X’s ACP status was 4, including full resuscitation, though Dr. Gouda states he
understood her ACP status was 1, indicating comfort care, at the material time;
c. Dr. Gouda’s communication with Nurse 1 was influenced by his misunderstandings
about X’s ACP status and that Nurse 1 perceived him as angry and abrupt; and
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 d. although Dr. Gouda understood the request to be for a transfer to the hospital ward, there
were no beds on the ward and Dr. Gouda did not suggest that X be brought to the ED for
assessment.
12.

Dr. Gouda stated that, when working as the on-call physician for the PCH, in situations where
he receives a call from the PCH and believes the patient’s situation is emergent, he would have
that patient transferred to the ED for assessment. Dr. Gouda noted that generally patients may
only be admitted to the hospital ward by the attending physician or, alternatively, the on-call
physician after being assessed in the ED. Dr. Gouda also noted that he can only admit patients to
the ward subject to the availability of beds. Dr. Gouda believes that residents of the PCH can be
brought at any time to the ED of the hospital by the PCH staff, without first contacting the oncall physician but usual practice is for the attending physician to call ahead.

13.

X’s daughter arrived at the PCH at 0445 on August 9, 2016. Upon arrival and seeing that her
mother was in serious condition, X’s daughter asked Nurse 1 to call Dr. Gouda again, which
Nurse 1 did. X’s daughter heard Nurse 1’s side of the conversation. She states it was clear that
Dr. Gouda was not accepting transfer of X and would not speak with her directly when asked.
At 0545, Nurse 1 documented this phone call as follows:
Nurse writer phoned Dr. Gouda on his cell phone as per resident’s daughter’s
request and tried to explain the situation and family’s wish. Dr. refused to listen
to that and told the writer that he already answered the question and call the
doctor in the morning after 0800 a.m. Family was present at the nursing desk
while the nurse talk to the doctor.

14.

Dr. Gouda stated that his understanding was that the appropriate protocol in this situation would
have been for Nurse 1 to call X’s attending physician. Dr. Gouda felt that it was up to X’s
attending physician to request and arrange the transfer to the ward of the hospital and it was his
understanding as well that no beds were available at the time. It is Dr. Gouda’s recollection that
there was no discussion about the patient’s poor condition and that Nurse 1 continued to
emphasize that it was the family that wanted the transfer. Dr. Gouda’s advice to Nurse 1
reflected this understanding and his being unaware of any attempts to call X’s attending
physician.

15.

At 06:15, Nurse 1 left voicemails to two nurse managers seeking further advice. At 0640 the
vital signs were noted to be BP 133/72, P131, T 38.4 and SPO2 96%. Another Tylenol
suppository was given.

16.

Through the night the PCH nurse(s) monitored X’s condition. Nurse 1 did not document any
attempt to contact X’s attending physician between 23:35 and 06:50. At 06:50, X’s attending
physician was successfully contacted by phone and attempted to arrange a transfer to the ward of
the hospital, but it was full and so X could not be admitted to the ward until 10:00. X’s
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 attending physician subsequently arranged transfer of X to the ED. By 0800 another nurse
documents that X was unresponsive, and her blood sugar was 29 mmol/L. Another ED
physician assumed X’s care when X arrived at the hospital from the PCH at 08:21.
17.

When X arrived at the ED, she was unresponsive (Glasgow Coma Scale of 6), responding only
with poor withdrawal to a very brisk sternal rub. Her heart rate was 132 and her blood pressure
was 110/52 but quickly decreased to 92/48 despite fluid resuscitation. She was seriously
dehydrated. Lab work revealed she had severe metabolic acidosis, hyperglycemia,
hypernatremia and acute renal failure.

III.

ON THESE FACTS, THE INVESTIGATION COMMITTEE RECORDS ITS
DISAPPROVAL OF DR. GOUDA’S CONDUCT IN:
1. Failing to meet the standard of care, displaying a lack of judgment and failing to conduct
himself in a professional manner in that he failed to provide appropriate assistance when X
required urgent medical care on August 8-9, 2016. Particularly, in his responsibilities toward X
as the on-call ED physician:
a. Dr. Gouda’s communication with the health care provider who sought his assistance was
hampered by the unprofessional manner in which he approached the conversations;
b. although Dr. Gouda had more than one opportunity to resolve the matter, as a result of
the ineffective communication, he did not adequately inform himself about X’s clinical
status and Nurse 1’s inability to reach X’s attending physician; and
c. Dr. Gouda provided advice to Nurse 1 that did not address the relevant concerns
including the need for care in excess of what could be provided at the PCH.
Dr. Gouda’s failure to address the relevant concerns contributed to X’s further deterioration. The
Committee considered Dr. Gouda’s lack of action in light of Nurse 1’s requests for assistance
particularly egregious.

Dr. Gouda paid the costs of the investigation in the amount of $9,727.50.

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