Fitness to PractiSe Panel
10-13 July 2007
7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ
Room 2
Name of Respondent Doctor: Dr Jagdish DASHORE
Registered Qualifications: Mb BS 1969 Indore/India
Area of Practice: London
Registration Number: 1597295
Type of Case: New case of impairment by reason of misconduct
Panel Members: Ms A Leslie, Chairman (Lay)
Mrs M Kakar (Lay)
Dr H Joesbury (Medical)
Dr P Mayer (Medical)
Legal Assessor: Mr B Searle
Secretary to the Panel: Ms D Montgomery
Representation:
GMC: Mr Nigel Grundy, Counsel, instructed by Field, Fisher, Waterhouse represents the GMC
Doctor: Mr David Morris, Counsel, instructed by RadcliffesLeBrasseur represents Dr Dashore
allegation
The Panel will inquire into the following allegation against Dr Jagdish Prasad
Dashore, Mb BS 1969 Indore.
“That being registered under the Medical Act 1983
1. Between November 1984 and 31 March 2005 you were a single handed General Practitioner with a practice at 108 High Street, North Dunstable; Admitted and Found Proved
Patient A
2. Between 24 December 2001 and 2 April 2002 you prescribed Patient A with 1440 co-proxamol tablets; Admitted and Found Proved
3. Between 4 November 2002 and 30 January 2003 you prescribed Patient A with 1620 co-proxamol tablets as per table one at appendix one; Admitted and Found Proved
4. In prescribing the above you prescribed co-proxamol
a. in quantities equivalent to at least 14.5 tablets per day at paragraph 2, Admitted and Found Proved
b. in quantities equivalent to at least 18 tablets per day at paragraph 3; Admitted and Found Proved
5. The British National Formulary states that the maximum dose of co-proxamol is 8 tablets per day; Admitted and Found Proved
6. Your notes in relation to Patient A regarding co-proxamol
a. consisted mainly of a list of repeat prescriptions except for entries on 25 February 2002 and 19 April 2002, Admitted and Found Proved
b. were blank between 19 April 2002 and May 2003 other than entries for repeat prescriptions, Found Proved
c. did not mention any review of the prescribing of co-proxamol or any care plan or contract with Patient A to reduce the dose of co-proxamol; Found Proved
7. Your prescribing of co-proxamol to Patient A was
a. dangerous, Admitted and Found Proved
b. excessive, Admitted and Found Proved
c. inappropriate, Admitted and Found Proved
d. not in the best interests of the patient, Admitted and Found Proved
e. not in accordance with the British National Formulary, Admitted and Found Proved
f. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
8. Your (1) notes relating to Patient A and (2) your failure to note a proper review of the prescribing of co-proxamol were
a. inadequate, Admitted and Found Proved
b. not in the best interests of the patient, Admitted and Found Proved
c. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
Patient B
9. Between 19 January 1995 and 20 April 1995 you prescribed Patient B with 1000 co-proxamol tablets; Admitted and Found Proved
10. Between 4 May 2000 and 31 December 2000 you prescribed Patient B with 2200 co-proxamol tablets; Admitted and Found Proved
11. Between January 2001 and the end of June 2001 you prescribed Patient B with 2200 co-proxamol tablets; Admitted and Found Proved
12. Between July 2001 and the end of December 2001 you prescribed Patient B with 3500 co-proxamol tablets; Admitted and Found Proved
13. Between January 2002 and the end of June 2002 you prescribed Patient B with 4700 co-proxamol tablets; Admitted and Found Proved
14. Between July 2002 and the end of December 2002 you prescribed Patient B with 4500 co-proxamol tablets; Admitted and Found Proved
15. Between January 2003 and the end of June 2003 you prescribed Patient B with 4600 co-proxamol tablets; Admitted and Found Proved
16. Between July 2003 and the end of December 2003 you prescribed Patient B with 2600 co-proxamol tablets; Admitted and Found Proved
17. Between January 2004 and the end of June 2004 you prescribed Patient B with 2700 2100 co-proxamol tablets; Admitted and Found Proved
18. Between July 2004 and the end of December 2004 you prescribed Patient B with 1940 co-proxamol tablets; Admitted and Found Proved
19. Within the period 1 November 2002 and 31 January 2003 you prescribed Patient B 3100 co-proxamol tablets; Admitted and Found Proved
20. In prescribing the above you prescribed
a. co-proxamol in quantities equivalent to at least 11 tablets per day at paragraph 9, Admitted and Found Proved
b. co-proxamol in quantities equivalent to at least 9 tablets per day at paragraph 10, Admitted and Found Proved
c. co-proxamol in quantities equivalent to at least 12 tablets per day at paragraph 11, Admitted and Found Proved
d. co-proxamol in quantities equivalent to at least 20 tablets per day at paragraph 12, Admitted and Found Proved
e. co-proxamol in quantities equivalent to at least 26 tablets per day at paragraph 13, Admitted and Found Proved
f. co-proxamol in quantities equivalent to at least 24 tablets per day at paragraph 14, Admitted and Found Proved
g. co-proxamol in quantities equivalent to at least 25 tablets per day at paragraph 15, Admitted and Found Proved
h. co-proxamol in quantities equivalent to at least 14 tablets per day at paragraph 16, Admitted and Found Proved
i. co-proxamol in quantities equivalent to at least 15 11 tablets per day at paragraph 17, Admitted and Found Proved
j. co-proxamol in quantities equivalent to at least 10.5 tablets per day at paragraph 18, Admitted and Found Proved
k. co-proxamol in quantities equivalent to at least 33 tablets per day at paragraph 19; Admitted and Found Proved
21. Your notes in relation to Patient B regarding co-proxamol do not
a. review Patient B’s medical condition after 18 February 1997, Admitted and Found Proved
b. contain a clinical history or examination findings after 18 February 1997, Admitted and Found Proved
c. mention any plan to manage Patient B’s symptoms appropriately, Admitted and Found Proved
d. mention any care plan or contract with Patient B to reduce the dose of co-proxamol; Admitted and Found Proved
22. Your prescribing of co-proxamol to Patient B was
a. dangerous, Admitted and Found Proved
b. excessive, Admitted and Found Proved
c. inappropriate, Admitted and Found Proved
d. not in the best interests of the patient, Admitted and Found Proved
e. not in accordance with the British National Formulary, Admitted and Found Proved
f. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
23. Your (1) notes relating to Patient B and (2) your failure to note a proper review of the prescribing of co-proxamol were
a. inadequate, Admitted and Found Proved
b. not in the best interests of the patient, Admitted and Found Proved
c. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
Patient D
24. In the period January 2000 to the end of March 2003 you prescribed Patient D on a continuous basis with temazepam and co-proxamol; Admitted and Found Proved
25. Your notes in relation to Patient D in the period January 2000 to the end of March 2003
a. consist mainly of repeat prescriptions for temazepam and co-proxamol, Admitted and Found Proved
b. do not mention any review of the prescribing of temazepam or co-proxamol or attempt to reduce or stop them, Admitted and Found Proved
c. reveal two different systems for prescribing temazepam and co-proxamol namely by computer entry and hand-written notes; Admitted and Found Proved
26. Your (1) notes relating to Patient D and (2) your failure to note a proper review of the prescribing of temazepam and co-proxamol were
a. inadequate, Admitted and Found Proved
b. not in the best interests of the patient, Admitted and Found Proved
c. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
27. The practice of using two systems for prescribing temazepam and co-proxamol was
a. dangerous, Admitted and Found Proved
b. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
Patient F
28. Between 5 December 2001 and 8 July 2002 you prescribed Patient F with 300 tablets of Welldorm and 840 tablets of nitrazepam; Admitted and Found Proved
29. Between 9 December 2002 and 23 January 2003 you prescribed Patient F with 60 tablets of Welldorm and 168 tablets of nitrazepam; Admitted and Found Proved
30. In prescribing the above you prescribed nitrazepam
a. in quantities equivalent to at least 20 mg per day at paragraph 28, Admitted and Found Proved
b. in quantities equivalent to at least 19 mg per day at paragraph 29; Admitted and Found Proved
31. The British National Formulary states that the maximum dose of nitrazepam is 5‑10 mg at bedtime; Admitted and Found Proved
32. Your notes in relation to Patient F
a. reveal that both Welldorm and nitrazepam were co-prescribed continually between December 2001 and February 2003 with no entries in the notes save a single entry on 11 October 2002 which states ‘Drug Review’, Admitted and Found Proved
b. contain no reference to any attempts to reduce the medications; Deleted following an application under Rule 17(2)(g)
33. Your prescribing of nitrazepam to Patient F was
a. excessive, Found Proved
b. inappropriate, Found Proved
c. not in the best interests of the patient, Found Proved
d. not in accordance with the British National Formulary, Admitted and Found Proved
e. not of a standard expected of a reasonably competent General Practitioner; Found Proved
34. Your (1) notes relating to Patient F and (2) your failure to note a proper review of the medications were
a. inadequate, Admitted and Found Proved
b. not in the best interests of the patient, Admitted and Found Proved
c. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
Patient G
35. In the period 11 January 2001 to February 2004 you prescribed Patient G on a continuous basis with Solpadol; Admitted and Found Proved
36. Your notes in relation to Patient G
a. consist mainly of a list of repeat prescriptions for Solpadol, Admitted and Found Proved
b. do not mention any review of the prescribing of Solpadol or an attempt to reduce or stop the prescribing except for an entry on 7 July 2003, Admitted and Found Proved
c. reveal two different systems for prescribing Solpadol namely computer entry and hand-written notes; Admitted and Found Proved
37. Your (1) notes relating to Patient G and (2) your failure to note a proper review of your prescribing of Solpadol was
a. inadequate, Admitted and Found Proved
b. not in the best interests of the patient, Admitted and Found Proved
c. not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
38. The practice of using two systems for prescribing Solpadol were
a. dangerous, Admitted and Found Proved
- not of a standard expected of a reasonably competent General Practitioner; Admitted and Found Proved
Patient I
39. Between 2 October 2001 and 2 April 2002 you prescribed Patient I with 1680 dihydrocodeine tablets; Admitted and Found Proved
40. Between 2 April 2002 and 30 September 2002 you prescribed Patient I with 1760 dihydrocodeine tablets; Admitted and Found Proved
41. Between 7 October 2002 and 27 January 2003 you prescribed Patient I with 1200 dihydrocodeine tablets; Admitted and Found Proved
42. In prescribing the above you prescribed dihydrocodeine
a. in quantities equivalent to at least 9.2 tablets per day at paragraph 39, Admitted and Found Proved
b. in quantities equivalent to at least 9.6 tablets per day at paragraph 40, Admitted and Found Proved
c. in quantities equivalent to 9.8 tablets per day at paragraph 41; Admitted and Found Proved
43. The British National Formulary states that the maximum dose of dihydrocodeine (non-proprietary) is 6 tablets of 30mg per day; Withdrawn by the GMC
44. Your notes in relation to patient I
a. consist mainly of repeat prescriptions of dihydrocodeine, Admitted and Found Proved
b. refer on 22 July 2002 to a warning being given about dihydrocodeine addiction, but you prescribed 100 tablets rather than the usual repeat of 60 tablets, Admitted and Found Proved
c. did not mention any review of the prescribing of dihydrocodeine or any care plan or contract with Patient I to reduce the dose or stop it; Found Proved
45. Your (1) notes relating to Patient I and (2) your failure to note a proper review of the prescribing of dihydrocodeine were
a. inadequate, Admitted and Found Proved
b. not in the best interests of the patient, Admitted and Found Proved
c. not of a standard expected of a reasonably competent General Practitioner;” Admitted and Found Proved
And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct.”
Determination on facts
Dr Dashore: The Panel has given consideration to all the evidence adduced in this case and has taken account of the submissions made by Mr Grundy on behalf of the General Medical Council (GMC) and those made by Mr Morris 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 Panel has considered each allegation separately.
Mr Morris has made a number of admissions on your behalf.
Allegations 1, 2, 3, 4, 5, 6a, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 as amended, 18, 19, 20a, 20b, 20c, 20d, 20e, 20f, 20g, 20h, 20i as amended, 20j, 20k, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32a, 33d, 34, 35, 36, 37, 38, 39, 40, 41, 42, 44a, 44b and
45 have been admitted and have already been announced as admitted and found proved.
Following an application under Rule 17(3) allegation 43 was withdrawn.
Following an application under Rule 17(2)(g) allegation 32b was deleted.
The Panel has considered each of the remaining allegations separately. Accordingly, it has made the following findings on the facts:
Allegation 6b has been found proved
Mr Morris submitted that a postscript to a letter you wrote dated 25 July 2002 to a Consultant Diabetologist states ‘Patient A is addicted to co-proxamol’. The Panel considered that this comment did not comprise a part of your notes of Patient A’s ongoing treatment and management.
Allegation 6c has been found proved
You gave evidence that you reviewed every patient at every consultation. The Panel did not accept this evidence. Dr Healy agreed that your notes did not actually mention any care plan or contract. The Panel did not accept that these elements could be inferred from your notes. The Panel also did not accept that your notes indicating warnings about co-proxamol constituted a proper review of care and treatment.
Allegation 33a has been found proved
The Panel has applied the ordinary English definition of excessive ‘exceeding the normal or permitted extents or limits; immoderate; inordinate’.
Allegation 33b has been found proved
The Panel considered inappropriate the excessive prescribing which was inadequately documented.
Allegation 33c has been found proved
Having found that your prescribing was excessive and inappropriate it followed that your prescribing was not in the best interests of the patient, particularly in the light of advice you gave that she could further increase the dose herself during a period when you failed to see her and review her.
Allegation 33e has been found proved
In all the circumstances and in the light of the requirements of Good Medical Practice (2001) in relation to the treatment of patients, the Panel considered your prescribing was not of the standard expected of a reasonably competent General Practitioner.
Allegation 44c has been found proved
You gave evidence that you reviewed every patient at every consultation. The Panel did not accept this evidence. Dr Healy agreed that your notes did not actually mention any care plan or contract. The Panel did not accept that these elements could be inferred from your notes. The Panel also did not accept that your notes indicating warnings about dihydrocodeine constituted a proper review of care and treatment.
Having reached findings on the facts, the Panel will now invite Mr Grundy 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. After that, Mr Morris will have an opportunity to address the Panel on your behalf.
Determination on impaired fitness to practise
Dr Dashore: Between November 1984 and 31 March 2005, you were a single handed GP with a practice at 108 High Street, North Dunstable.
Between 24 December 2001 and 2 April 2002, you prescribed Patient A with 1440 co-proxamol tablets, equivalent to at least 14.5 tablets a day. Between 4 November 2002 and 30 January 2003, you prescribed Patient A with 1620 co-proxamol tablets, equivalent to at least 18 tablets per day. The British National Formulary (BNF) states that the maximum dose of co-proxamol is 8 tablets per day.
Your notes in relation to Patient A regarding co-proxamol consisted mainly of a list of repeat prescriptions, except for entries on 25 February 2002 and 19 April 2002. Your notes in relation to Patient A regarding co-proxamol were blank between 19 April 2002 and May 2003, other than entries for repeat prescriptions. Your notes did not mention any review of the prescribing of co-proxamol or any care plan or contract with Patient A to reduce the dose of co-proxamol.
Your prescribing of co-proxamol to Patient A was dangerous, excessive, inappropriate, not in the best interests of the patient, not in accordance with the BNF and not of a standard expected of a reasonably competent General Practitioner. Your notes relating to Patient A and your failure to note a proper review of the prescribing of co-proxamol was inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner.
Between 19 January 1995 and 20 April 1995, you prescribed Patient B with 1000 co-proxamol tablets, equivalent to at least 11 tablets per day. Between 4 May 2000 and 31 December 2000, you prescribed Patient B with 2200 co-proxamol tablets, equivalent to at least 9 tablets per day. Between January 2001 and the end of June 2001, you prescribed Patient B with 2200 co-proxamol tablets, equivalent to at least 12 tablets per day. Between July 2001 and the end of December 2001, you prescribed Patient b with 3500 co-proxamol tablets, equivalent to at least 20 tablets per day. Between January 2002 and the end of June 2002, you prescribed Patient B with 4700 co-proxamol tablets, equivalent to at least 26 tablets per day. Between July 2002 and the end of December 2002, you prescribed Patient B with 4500 co-proxamol tablets, equivalent to at least 24 tablets per day. Between January 2003 and the end of June 2003, you prescribed Patient B with 4600 co-proxamol tablets,
equivalent to at least 25 tablets per day. Between July 2003 and the end of December 2003 you prescribed Patient B with 2600 co-proxamol tablets, equivalent to at least 14 tablets per day. Between January 2004 and the end of June 2004 you prescribed Patient B with 2100 co-proxamol tablets, equivalent to at least 11 tablets per day. Between July 2004 and the end of December 2004 you prescribed Patient B with 1940 co-proxamol tablets, equivalent to at least 10.5 tablets per day. Within the period 1 November 2002 and 31 January 2003 you prescribed Patient B 3100 co-proxamol tablets, equivalent to at least 33 tablets per day.
Your notes in relation to Patient B regarding co-proxamol do not review Patient B’s medical condition or contain a clinical history or examination findings after 18 February 1997. Your notes also do not mention any plan to manage Patient B’s symptoms appropriately or refer to any care plan or contract with Patient B to reduce the dose of co-proxamol.
Your prescribing of co-proxamol to Patient B was dangerous, excessive, inappropriate, not in the best interests of the patient, not in accordance with the BNF and not of a standard expected of a reasonably competent General Practitioner.
Your notes relating to Patient B and your failure to note a proper review of the prescribing of co-proxamol were inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner.
In the period January 2000 to the end of March 2003, you prescribed Patient D on a continuous basis with temazepam and co-proxamol. Your notes in relation to Patient D during this period consist mainly of repeat prescriptions for temazepam and co-proxamol. Your notes do not mention any review of the prescribing of temazepam or co-proxamol or attempt to reduce or stop prescribing them. Your notes also reveal two different systems for prescribing temazepam and co-proxamol, namely by computer entry and hand-written notes. Your notes relating to Patient D and your failure to note a proper review of the prescribing of temazepam and co-proxamol were inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner. The practice of using two systems for prescribing temazepam and co-proxamol was dangerous and not of a standard expected of a reasonably competent General Practitioner.
Between 5 December 2001 and 8 July 2002, you prescribed Patient F with 300 tablets of Welldorm and 840 tablets of nitrazepam, quantities equivalent to at least 20mg per day. Between 9 December 2002 and 23 January 2003 you prescribed Patient F with 60 tablets of Welldorm and 168 tablets of nitrazepam, quantities equivalent to at least 19mg per day. The BNF states that the maximum dose of nitrazepam is 5‑10 mg at bedtime.
Your notes in relation to Patient F reveal that both Welldorm and nitrazepam were co-prescribed continually between December 2001 and February 2003 with no entries in the notes, save a single entry on 11 October 2002 which states ‘Drug Review’. Your prescribing of nitrazepam to Patient F was excessive, inappropriate, not in the best interests of the patient, not in accordance with the BNF and not of a standard expected of a reasonably competent General Practitioner.
Your notes relating to Patient F and your failure to note a proper review of the medications were inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner.
In the period 11 January 2001 to February 2004 you prescribed Patient G on a continuous basis with Solpadol. Your notes in relation to Patient G consist mainly of a list of repeat prescriptions for Solpadol and do not mention any review of the prescribing of Solpadol or an attempt to reduce or stop the prescribing except for an entry on 7 July 2003. Your notes in relation to Patient G also reveal two different systems for prescribing Solpadol, namely computer entry and hand-written notes. Your notes relating to Patient G and your failure to note a proper review of your prescribing of Solpadol was inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner. The practice of using two systems for prescribing Solpadol was dangerous and not of a standard expected of a reasonably competent General Practitioner.
Between 2 October 2001 and 2 April 2002 you prescribed Patient I with 1680 dihydrocodeine tablets, quantities equivalent to at least 9.2 tablets per day. Between 2 April 2002 and 30 September 2002 you prescribed Patient I with 1760 dihydrocodeine tablets, quantities equivalent to at least 9.6 tablets per day. Between 7 October 2002 and 27 January 2003 you prescribed Patient I with 1200 dihydrocodeine tablets, quantities equivalent to 9.8 tablets per day.
Your notes in relation to patient I consist mainly of repeat prescriptions of dihydrocodeine. Your notes refer on 22 July 2002 to a warning being given about dihydrocodeine addiction, but you prescribed 100 tablets rather than the usual repeat of 60 tablets. Your notes did not mention any review of the prescribing of dihydrocodeine or any care plan or contract with Patient I to reduce the dose or stop it .
Your notes relating to Patient I and your failure to note a proper review of the prescribing of dihydrocodeine were inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner.
In deciding whether your fitness to practise is impaired, the Panel has had regard to paragraph 11 of the Indicative Sanctions Guidance (S1-2) which 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 had reference to paragraph 58 of the Indicative Sanctions Guidance (S3-14) which states:
“A question of impaired fitness to practise is likely to arise if: a doctor’s performance has harmed patients or put patients at risk of harm.”
The Panel has to determine whether, on the basis of facts admitted and found proved, your fitness to practise is impaired because of your misconduct. In doing so it has taken into account all the evidence before it and the submissions of both Counsel. Mr Grundy on behalf of the GMC, and those of Mr Morris on your behalf.
The GMC has issued guidance in ‘Good Medical Practice’ (May 2001) in relation to Good Clinical Care as follows:
“Good clinical care must include: an adequate assessment of the patient’s conditions, based on the history and symptoms and, if necessary, an appropriate examination…In providing care you must…keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed.”
The Panel heard that Patient A was a lady with complex medical conditions, including diabetes. Dr Archard, an expert witness for the GMC considered your overprescribing of co-proxamol for this patient as ‘grossly excessive’. The Panel also heard that the level of your prescriptions for this patient at times were such that she could be taking potentially lethal doses. Dr Archard described your notes in relation to Patient A as ‘inadequate in the extreme’. The Panel noted that there was no evidence of the systematic management of Patient A’s medication in the light of her underlying chronic disease.
Patient B was a gentleman suffering from long standing leg pain. Dr Archard described aspects of your prescribing practice in relation to this gentleman as ‘reckless, dangerous and unprofessional’. The quantity and frequency of the medication you prescribed potentially put at risk the life of this patient. Your records of this patient were completely inadequate.
Patient D was an eighty year old retired gentleman with multiple problems, including osteoarthritis of knees and spine. Your recording of medication for this patient revealed the use of two different systems which did not marry up. The failings in your system meant that it was difficult to identify his medication regime. This put the patient at risk.
Patient F was a lady with complex problems including diabetes and diverticulitis and depressive problems. Your recording of her medication was extremely inadequate and your failure to note and to review her medication was compounded by you advising this patient to increase the dose of a medication which you had prescribed at beyond the BNF recommendation.
Patient G was a gentleman that suffered from back pain. It is accepted you prescribed for him within the BNF recommendations. Your notes in relation to Patient G’s medication were described by Dr Archard as ‘very poor indeed’. They show no review of medication and no reasons for variations in medication.
Patient I was a lady that suffered from a complexity of illnesses, including anxiety and osteoarthritis. You failed to record or review her medication was of particular significance given the vulnerability of this patient.
The Panel accepts your submission that these were complex and difficult cases to manage and in some instances involved patients who had become addicted to or dependent on various forms of medication.
The Panel noted that you did not seek advice on management of patient analgesic medication from either consultant physicians or the Primary Care Trust Advisers.
Mr Morris conceded on your behalf that in the light of the Panel’s findings of fact your fitness to practise is impaired. Of course, he recognised that the question of impairment is a matter for the Panel’s judgement alone.
In the light of all the evidence and the conclusions it has drawn from it, the Panel has, pursuant to Section 35C(2)(a) of The Medical Act 1983 as amended, concluded that your fitness to practise is impaired, by reason of your misconduct.
The Panel will now invite further submissions from both Counsel as to the appropriate sanction, if any, to be imposed on your registration. Submissions on sanction should include reference to the Indicative Sanctions Guidance (April 2005), using the criteria as set out in the guidance to draw attention to the issues which appear relevant to this case.
Determination on sanction
Dr Dashore: The Panel has already announced its finding that your fitness to practise is impaired by reason of your misconduct and it must now determine what sanction, if any, to impose in this case. The Panel has had regard to all the evidence presented and the strong testimonials submitted on your behalf from patients and consultant colleagues. It also notes the commendation of your practice made by the PCT on your retirement in January 2005. It has considered the submissions made by Mr Grundy on behalf of the GMC, as to the appropriate sanction to impose on your registration, as well as those of Mr Morris on your behalf. It has also paid due regard to the guidance contained within the GMC’s Indicative Sanctions Guidance – April 2005.
Paragraph 17 of the Indicative Sanctions Guidance states:
‘The purpose of the sanctions is not to be punitive but to protect patients and the public interest, although they may have a punitive effect.’
The public interest includes the protection of patients, the maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour.
In considering what action, if any, to take against your registration, the Panel has considered the issue of proportionality and the need to balance the interests of the public with your own interests.
The Panel has already found that your prescribing in respect of Patient A and Patient B was dangerous, excessive, inappropriate, not in the best interests of the patient, not in accordance with the British National Formulary and not of a standard expected of a reasonably competent General Practitioner. Further, the Panel also found your note keeping, in particular your failure to note a proper review of your prescribing in relation to Patients A & B, was inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner.
In relation to Patient D and Patient G, the Panel found your note keeping, in particular your failure to note a proper review of your prescribing, was inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner. The Panel also found that your practice of using two systems to prescribe medication, namely computer and handwritten notes, was dangerous and not of a standard expected of a reasonably competent General Practitioner.
With regard to Patient F, the Panel found that your prescribing was excessive, inappropriate, not in the best interests of the patient, not in accordance with the British National Formulary and not of a standard expected of a reasonably competent General Practitioner. Further, the Panel also found your note keeping in relation to Patient F, in particular your failure to note a proper review of the medications, was inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner.
In respect of Patient I, the Panel found your note keeping, in particular your failure to note a proper review of your prescribing, in relation to Patient I was inadequate, not in the best interests of the patient and not of a standard expected of a reasonably competent General Practitioner.
In view of the nature of your misconduct, the Panel has determined that taking no action in this case would be insufficient.
Mr Grundy has submitted that the circumstances of your case justify a sanction of at least conditions and has referred the Panel to the Indicative Sanctions Guidance. Paragraph 23 states:
“Conditions might be appropriate where there is evidence of incompetence or significant shortcomings in the doctor’s practice… but where the Panel can be satisfied that there is potential for the doctor to respond positively to retraining and supervision of his or her work.”
The Panel considered whether it would be sufficient to place conditions on your registration. It has borne in mind that any conditions would need to be appropriate, proportionate, workable and measurable.
The Panel is satisfied that you have shown some insight into your failings. It notes that although you have not been proactive in addressing your difficulties you have responded positively when matters were brought to your attention. You have accepted that these matters are serious.
The Panel is concerned that your insight is limited in some respects by your narrow view of the actions you need to take to remedy your deficiencies. It notes you have attended numerous courses to update and enhance your knowledge. However, it considers you require a range of learning experiences, practical and reflective as well as didactic in order to improve and broaden your practice.
The Panel also believes it is important you acquire the skills to audit effectively your work and are able subsequently to demonstrate improvements in the areas where you have been deficient.
In order to provide you with the opportunity to remedy all the deficiencies in your practice and produce evidence of the steps you have taken, the Panel has concluded that it is appropriate, necessary and proportionate to impose conditions on your registration for a period of 24 months:
The following conditions relate to your employment and will be published:
1. You must notify the GMC promptly of any post you accept for which registration with the GMC is required and provide the GMC with the contact details of your employer and PCT on whose Medical Performers List you are included.
2. At any time that you are employed, or providing medical services, which require you to be registered with the GMC, you must agree to the appointment of a workplace supervisor nominated by your employer, or contracting body, and approved by the GMC.
3. You must allow the GMC to exchange information with your employer, or any organisation for which you provide medical services, and any individual involved in your retraining and supervision.
4. You must inform the GMC of any formal disciplinary proceedings taken against you, from the date of this determination.
5. You must inform the GMC if you apply for employment outside the UK.
6. You must work with a Postgraduate Dean / Director of Postgraduate General Practice Education, (or their nominated deputy), to formulate a Personal Development Plan, specifically designed to address the deficiencies in the following areas of your practice:
- Your lack of understanding of the need for robust, safe, prescribing systems;
- Your failure to engage and manage difficult patients;
- Your failure to exercise control in prescribing potentially dangerous drugs to which patients could become addicted;
- Your failure to practice systematic management of the medication needs of patients with chronic diseases;
- Your dangerous and excessive prescribing of analgesics, hypnotics and benzodiazepines which put six patients at risk of harm;
- Your inadequate records of individual consultations;
- Your lack of understanding of clinical audit and its application to your practice.
7. You must forward a copy of your Personal Development Plan to the GMC within six months of the date on which these conditions become effective.
8. You must only prescribe drugs under arrangements which have been agreed by the medical practitioner of GP principal grade supervising your work.
- You must not prescribe any medication by private prescription.
10. You must not prescribe any medication in excess of BNF limits.
11. You must confine your medical practice to general practice posts acceptable to the GMC within the National Health Service under the supervision of a medical practitioner of GP principal grade.
12. You must not undertake any private practice.
13. You must not undertake any out-of-hours work.
14. a. You must maintain a log detailing every case where you have prescribed strong analgesics (opioids and opiates), hypnotics or benzodiazepines.
b. You must provide a copy of this log to the GMC at the review.
15. You must develop and monitor practice protocols agreed by your supervisor for repeat prescribing and for the management of pain.
16. You must obtain the approval of your Postgraduate Dean / Director of Postgraduate General Practice Education, (or their nominated deputy), before accepting any post for which registration with the GMC is required.
17. You must agree to the appointment of a mentor, as approved by your Postgraduate Dean / Director of Postgraduate General Practice Education, (or their nominated deputy).
18. You must undertake courses of practical training in communication skills; managing challenging patients; audit and pain management within twelve months of the date from which these conditions become effective and forward a copy of your results to the GMC. These courses should be approved by your supervisor as adequate to address your learning needs.
19. You must inform the following parties that your registration is subject to the conditions, listed at (1) to (18), above:
a. Any organisation or person employing or contracting with you to undertake medical work
b. Any prospective employer (at the time of application)
c. The PCT in whose Medical Performers List you are included, or seeking inclusion (at the time of application)
The period of conditional registration for 24 months will enable you both to consolidate the steps you have already undertaken to remedy your deficiencies and also to concentrate on the areas of concern which you have not yet addressed.
Shortly before the end of the period of conditional registration, your case will be reviewed by a Fitness to Practise Panel. A letter will be sent to you about the arrangements for the review hearing. At this next hearing, the Panel reviewing your case will wish to be assured that you have addressed all your shortcomings. Prior to any further review by a Fitness to Practise Panel you shall arrange for reports of your performance to be submitted by all such supervisors.
These reports should include:
- Evidence of compliance with all the foregoing conditions
- Evidence of successful completion of practical courses in communications skills and pain management
- Evidence of training in audit
- Evidence of training in record keeping skills, including electronic records
- Evidence of appropriate prescribing practice from your logs
- An audit of your prescribing practice in relation to analgesics, hypnotics and benzodiazepines. The form of the audit must be agreed with and approved by your workplace supervisor.
- Evidence of your compliance with the standards of Good Medical Practice for record keeping.
You will be expected to provide the Council with the names of professional colleagues and other persons of standing to whom the Council may apply for information as to their knowledge of your conduct throughout the interval since this hearing of your case including your compliance with the conditions imposed on your registration.
Having directed that your registration be subject to conditions for a period of 24 months the Panel will now consider whether it is necessary to order that your registration be subject to immediate conditions. Before doing so, however, the Panel will invite submissions from Mr Grundy and Mr Morris on this matter.
Determination on immediate sanction
Dr Dashore: The Interim Order for the suspension of your registration is revoked forthwith.
Having determined that conditions should be imposed on your registration, the Panel has now considered in accordance with Section 38(2) of the Medical Act 1983 as amended, whether conditions should be imposed immediately.
The Panel has noted Mr Grundy’s submissions on behalf of the General Medical Council that it is appropriate to make an immediate order as the Interim Order has today been revoked. Mr Morris has not opposed this application.
The Panel has therefore determined it is necessary for the protection of members of the public, in the public interest and in your own interests that your registration should be made subject to conditions with immediate effect.
This means that your registration will be subject to conditions from today. The substantive direction for conditions for a period of 24 months, as already announced, will take effect 28 days from when written notification is deemed to have been served upon you, unless you lodge an appeal in the interim. If you do lodge an appeal, the immediate conditions will remain in force until the substantive conditions take effect.
That concludes the case.
Confirmed
13 July 2007
Chairman