Fitness to PractiSe Panel
22- 25 May 2007
7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ
Name of Respondent Doctor: Dr Raigamage Kawshala PEIRIS
Registered Qualifications: Mb ChB 2001 Leic
Area of Practice: Leicestershire
Registration Number: 6031350
Type of Case: New case of impairment by reason of: misconduct.
Panel Members: Dr A Montgomery, Chairman (Lay)
Mr P Worobec (Lay)
Mrs G Anderson (Lay)
Mr M Garfield (Medical)
Legal Assessor: Dr D Jess
Secretary to the Panel: Miss L Pearce
Representation:
GMC: Mr Daryll Allen, Counsel, instructed by GMC Legal, represents the General Medical Council
Doctor: Ms Christina Lambert, Counsel, instructed by Berrymans Lace Mawer Solicitors, represented Dr Peiris.
allegation
“That being registered under the Medical Act 1983
‘1. At all material times you were registered as a Medical Practitioner under the Medical Act 1983, as amended; Admitted and found proved
‘2. From 7 August 2002 to 4 February 2003 you were employed as a Senior House Officer in the Accident & Emergency Department (“A&E”) of the Queen’s Hospital (“the Hospital”), part of the Burton Hospitals NHS Trust; Admitted and found proved
‘3. On 26 December 2002 Patient A (“the patient”) attended the A&E Department at 13:43,
- You examined the patient at about 14:20 and noted that she presented with the following complaints,
- pain on taking deep breaths,
- muscle pain around her left shoulder,
- cold like symptoms,
- The patient complained that she had been suffering from these symptoms for 3 days,
- On examination you noted the following,
- tender over muscles on chest;
- throat inflamed,
- You diagnosed the patient as suffering from a viral upper respiratory tract infection,
- You prescribed her with Diclofenac, a non-steroidal anti-inflammatory agent, and discharged her home; Admitted and found proved in its entirety
‘4. The patient was not seen or assessed by a Triage Nurse prior to your consultation; Admitted and found proved
‘5. There was no record of the patient’s
a. temperature,
b. pulse,
c. blood pressure,
d. respiratory rate,
e. oxygen saturation level,
in her A&E notes and records; Admitted and found proved in its entirety
‘6. During the consultation on 26 December 2002, you did not measure
- the patient’s temperature, Admitted and found proved
b. the patient’s pulse, Found proved
- the patient’s blood pressure, Admitted and found proved
- the patient’s respiratory rate, Found proved
- the patient’s oxygen saturation level; Admitted and found proved
‘7. Your examination of the patient on 26 December 2002 was inadequate by reason of the omissions referred to at Head of Charge 6a and 6b; Found proved
‘8. Your notes of the consultation on 26 December 2002, do not record
- the patient’s temperature,
- the patient’s pulse,
- the patient’s blood pressure,
- the patient’s respiratory rate,
- the patient’s oxygen saturation level; Admitted and found proved in its entirety
‘9. By reason of the omissions referred to at Head of Charge 8a and 8b, your notes of the consultation on 26 December 2002 were
- inadequate,
- below the standard to be expected of a registered medical practitioner; Found proved in its entirety
’10. Prior to discharging the patient on 26 December 2002, you did not make any arrangements for a member of nursing staff to measure
a. the patient’s temperature,
- the patient’s pulse,
- the patient’s blood pressure,
- the patient’s respiratory rate,
- the patient’s oxygen saturation level; Admitted and found proved in its entirety
’11. Your investigation of the patient’s condition on 26 December 2002 was inadequate by reason of the omissions referred to at Head of Charge 10a and 10b; Found not proved
’12. On 28 December 2002 at 11:17, the patient re-attended the Hospital following referral by her General Practitioner with a diagnosis of lobar pneumonia
- antibiotics were administered,
- at 17:00 the patient was admitted to the Critical Care Unit,
- at 18:30 it was noted that the patient had sustained multi organ failure secondary to pneumonia,
- at 23:15 the patient entered cardiac arrest and was successfully resuscitated,
- at 01:00 on 29 December 2002, the patient entered cardiac arrest and resuscitation was unsuccessful,
- the patient was pronounced dead at 01:10.
- the cause of the patient’s death was pneumococcal septicaemia secondary to pneumococcal pneumonia; Admitted and found proved in its entirety
’13. Your conduct as set out at Heads of Charge 6a, 6b, 8a, 8b, 10a and 10b was
- inadequate, Found proved except in relation to 10a and 10b
- unprofessional, Found proved except in relation to 10a and 10b
- not in the best interests of the patient, Found proved except in relation to 10a and 10b
- below the standard to be expected of a registered medical practitioner. Found proved except in relation to 10a and 10b
By reason of the matters set out above, your fitness to practice is impaired by reason of your misconduct.”
Determination on facts
Dr Peiris: The Panel has considered all the evidence adduced in this case including the expert evidence of Drs A and B and your own oral evidence. It has taken into account Mr Allen’s submissions on behalf of the General Medical Council (GMC) and those made by Ms Lambert on your behalf.
It has borne in mind that the burden of proof rests on the GMC and that the standard of proof required is that the Panel should be sure.
The following allegations have already been admitted and announced as found proved:
Allegations 1, 2, 3, 4, 5, 6a, 6c, 6e, 8, 10 and 12.
The Panel has considered each remaining allegation separately and has made the following findings on the remaining facts:
Allegation 6b has been found proved.
The Panel is satisfied that you made an informal assessment of Patient A’s pulse, however, the Panel concluded that you did not actually measure the pulse in terms of beats per minute.
Allegation 6d has been found proved.
The Panel is satisfied that although you made an informal assessment of Patient A’s respiratory rate, you did not actually measure this in terms of breaths per minute.
Allegation 7 has been found proved.
You have admitted that you did not measure Patient A’s temperature and having found that you did not measure Patient A’s pulse, the Panel are of the opinion that your examination of Patient A was incomplete and therefore inadequate.
Allegation 9a has been found proved.
You have admitted that your notes of the consultation on 26 December 2002 do not record the patient’s temperature or the patient’s pulse. The Panel notes that, although your notes were otherwise of a high standard, both experts who have given evidence in this case have said that both the pulse and temperature should have been recorded.
Allegation 9b has been found proved.
The Panel are of the opinion that recording a patient’s temperature and pulse are vital and basic observations, which should have been recorded. The Panel therefore find that the records did fall below the standard to be expected of a registered medical practitioner in the post of a Senior House Officer in Accident and Emergency medicine.
Allegation 11 has not been found proved.
Notwithstanding the omissions during your consultation, the Panel concluded that it was not essential that you make arrangements for these measurements to be taken prior to discharge of the patient.
Allegation 13a has been found proved in relation to heads of charge 6a, 6b, 8a and 8b but not in relation to 10a and 10b.
The Panel have already found proved that your omissions at heads of charge 6a, 6b, 8a and 8b were inadequate and therefore also find this charge proved.
Allegation 13b has been found proved in relation to heads of charge 6a, 6b, 8a and 8b but not in relation to 10a and 10b.
In considering this allegation, the Panel has had regard to ‘Good Medical Practice’ (2001), which was applicable at the time, and has noted the principles outlined in the heading ‘Good Clinical Care’. The Panel has found that the conduct found proved fell short of the standards set out in this accepted code of conduct and was therefore unprofessional.
Allegation 13c has been found proved in relation to heads of charge 6a, 6b, 8a and 8b but not in relation to 10a and 10b.
The Panel are of the view that since your actions fell below the standard of ‘Good Clinical Care’ in ‘Good Medical Practice’ your conduct was not in the best interests of the patient.
Allegation 13d has been found proved in relation to heads of charge 6a, 6b, 8a and 8b but not in relation to 10a and 10b.
The Panel have already found that your omissions at heads of charge 6a and 6b did fall below the standard to be expected of a registered medical practitioner.
With regard to allegations 8a and 8b, the Panel were of the opinion that your omissions were contrary to the principles of ‘Good Clinical Care’ in ‘Good Medical Practice’ and therefore the Panel has found that your conduct did fall below the standard to be expected of a registered medical practitioner in the post of an Senior House Officer in Accident and Emergency medicine.
Having reached findings on the facts, the Panel now invites Mr Allen and Ms Lambert to adduce further evidence and make any further submissions as to whether, on the basis of the facts found proved, your fitness to practise is impaired by reason of your misconduct.
Determination on impaired fitness to practise
Dr Peiris: The Panel has considered, on the basis of the facts found proved, whether your fitness to practise is impaired by reason of your misconduct. It has taken account of all the evidence presented, including the oral evidence of Dr C, Mr Allen’s submissions on behalf of the General Medical Council (GMC) and those made on your behalf by Ms Lambert.
The Panel has heard that at all material times you were registered as a Medical Practitioner under the Medical Act 1983, as amended. From 7 August 2002 to 4 February 2003 you were employed as a Senior House Officer in the Accident & Emergency Department (“A&E”) of the Queen’s Hospital (“the Hospital”), part of the Burton Hospitals NHS Trust.
On 26 December 2002 Patient A (“the patient”) attended the A&E Department at 13:43. You examined the patient at about 14:20 and noted that she presented with the following complaints; pain on taking deep breaths, muscle pain around her left shoulder and cold-like symptoms. The patient complained that she had been suffering from these symptoms for 3 days.
On examination you noted the following; tender over muscles on chest and throat inflamed. You diagnosed the patient as suffering from a viral upper respiratory tract infection and prescribed her Diclofenac, a non-steroidal anti-inflammatory agent, and discharged her home.
The patient was not seen or assessed by a Triage Nurse prior to your consultation and there was no record of the patient’s temperature, pulse, blood pressure, respiratory rate or oxygen saturation level in her A&E notes and records.
During the consultation on 26 December 2002, you did not measure the patient’s temperature, pulse, blood pressure, respiratory rate or oxygen saturation level. The Panel has found that your examination of the patient on 26 December 2002 was inadequate by reason of the lack of measurement of the patient’s temperature and pulse. The Panel accepts, however, that you did assess both the temperature and pulse of the patient when conducting your examination. Your omissions in not recording the patients temperature or pulse in your notes of the consultation on 26 December 2002 was inadequate and below the standard to be expected of a registered medical practitioner.
Your conduct in not measuring or recording in the notes the patient’s temperature or pulse was inadequate, unprofessional, not in the best interests of the patient and below the standard to be expected of a registered medical practitioner in an SHO post in Accident and Emergency medicine.
Patient A subsequently contracted pneumococcal septicaemia secondary to pneumococcal pneumonia. The Panel has heard evidence from 2 experts that this condition can develop within hours and it has not been suggested at this hearing that Patient A was suffering from this condition at the time of your examination on 26 December.
In determining whether your fitness to practise is impaired, the Panel has considered the GMC’s Indicative Sanctions Guidance (April 2005). In particular, at paragraph 11 it states:
“…it is clear that the GMC’s role in relation to fitness to practise is to consider concerns which are so serious as to raise the question whether the doctor concerned should continue to practise either with restrictions on registration or at all.”
The Panel has also considered page S3-14, paragraph 57, which states:
“All human beings make mistakes from time to time. Doctors are no different. While occasional one off mistakes need to be thoroughly investigated by those immediately involved where the incident occurred, and any harm put right, they are unlikely in themselves to indicate a fitness to practise problem. Good Medical Practice puts it this way: ‘serious or persistent failures to meet the standards in this booklet may put your registration at risk’.”
Furthermore, paragraph 58 states:
“An isolated lapse from high standards of conduct – such as an atypical rude outburst– would not in itself suggest that the doctor’s fitness to practise was in question. But the sort of misconduct, whether criminal or not, which indicates a lack of integrity on the part of the doctor, an unwillingness to practise ethically or responsibly or a serious lack of insight into obvious problems of poor practice will bring a doctor’s registration into question.”
The Panel has heard that this was an isolated incident, which occurred over 4 years ago whilst you were a junior doctor and it has received no evidence to suggest that your misconduct has been repeated. In addition, the Panel has received no evidence to suggest that your omissions in not measuring and recording Patient A’s pulse or temperature caused harm to the patient. The Panel is satisfied that save for this isolated oversight, your assessment of the patient and your notes of the consultation were otherwise of your usual high standard.
The Panel considers that your misconduct was not sufficiently serious as to either undermine public confidence in the medical profession or otherwise call for any action on your registration and is therefore satisfied that your fitness to practise is not impaired by reason of your misconduct.
The Panel is not presently minded to impose a warning but will consider submissions if either party so requests.
Determination on warning
Dr Peiris: Having found that your fitness to practise is not impaired, the Panel has considered the submissions made by Mr Allen, on behalf of the GMC, and those made by Ms Lambert, on your behalf, regarding the question of issuing a warning under Section 35D (3) of the Medical Act 1983, as amended. The Panel also noted all the testimonials from 10 Consultants submitted on your behalf and the oral evidence of one of them, Dr D, a Consultant Anaesthetist and college tutor at Leicester Royal Infirmary.
The Panel was referred to the guidance at Section 2 of the GMC’s Indicative Sanctions Guidance. This guidance states that it may be appropriate to issue a warning in order to mark the fact that the behaviour was unacceptable and must not happen again.
In deciding whether a warning should be issued in your case, the Panel has considered the need to protect patients and the wider public interest, which includes the maintenance of public confidence in the profession and the upholding of proper standards of conduct and behaviour. It has also considered the issue of proportionality and the effect that any order would have on you as a doctor.
The evidence presented to this Panel indicates that you are a doctor of high potential. Both the testimonials and the 360 degree appraisal attest to your competence and describe you as a “conscientious”, “excellent” and “very professional” practitioner.
The Panel considers that it would be both disproportionate and inappropriate to issue you with a warning.
That concludes this case and the Panel wishes you success on your career.
Confirmed
May 2007
Chairman