Supreme Court of Ireland Decisions
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URL: http://www.bailii.org/ie/cases/IESC/2015/S9.html
Cite as: [2015] IESC 9, [2015] 1 ILRM 395, [2015] 2 IR 304
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Judgment
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THE SUPREME COURT JUDICIAL REVIEW [037/2014] The Chief Justice Hardiman J. O’Donnell J. McKechnie J. Dunne J.
MARTIN CORBALLY APPLICANT/RESPONDENT AND
THE MEDICAL COUNCIL, IRELAND AND THE ATTORNEY GENERAL RESPONDENTS/APPELLANTS AND
THE HUMAN RIGHTS COMMISSION NOTICE PARTY JUDGMENT of Mr. Justice William M. McKechnie delivered on 4th day of February, 2015 Background: 2. On examination of patient X on the 25th February, 2010, Professor Corbally correctly diagnosed her referring complaint but in his out-patient notes inaccurately described it as an “upper lingual frenulum”. There are three frenula (congenital folds of tissue) in the mouth: an upper frenulum (between the inner aspect of the upper lip and the anterior gum margin), which can also be referred to as a “upper labial frenulum”: a lower frenulum (between the lower lip and the anterior low gum margin) and a tongue or lingual frenulum (under the anterior surface of the tongue). There is no frenulum that can be accurately described as an “upper lingual frenulum”. That was an error on his part which was also included in a letter which he sent to the patient’s General Practitioner (“G.P.”) on the 11th March, 2010. Thereafter however, it was never repeated in any subsequent note or record, made or endorsed by him. 3. When booking the patient in, Professor Corbally described the intended procedure as a “Tongue Tie (Upper Frenulum)”. That was an accurate description of the procedure intended to relieve the patient of her complaining symptoms. As a matter of some serious surprise is the fact that, in the Hospital’s coding system at the time, all of the three procedures relating to mouth frenula were described as “Tongue Tie”, without distinction being made between any one or more of them. A doctor could however, when contacting the Admissions Department, add a clarification by way of “free text”. The applicant did so, by further describing the procedure as involving the “Upper Frenulum, ” but unfortunately, some unknown administrator omitted the “free text” when inputting the intended procedure into the system. That input is used to generate the theatre list. It therefore followed that as the clarifying words were omitted, they were not included in the theatre list,as information pertinent to this patient. 4. On the 30th April, 2010, Patient X was admitted: the parents of this very young child specifically told both the Senior House Officer (“S.H.O.”), who obtained consent to the procedure, and the accompanying nurse, that the problem was not her tongue, but that she needed an upper lip release. This was once again accurately recorded in the consent form by the S.H.O. as a “Tongue Tie (Upper Frenulum) release”, and in a Nursing Assessment Sheet by the nurse as “Tongue Tie release (Upper Frenulum)”. The nurse in question passed a correct description of the required procedure onto her manager, who should have, but did not transmit the information upwards, to include the surgical team, as required by hospital policy. 5. As it happened, Professor Corbally, could not, as he had intended, do his full theatre list on the day in question. He had to attend an exceedingly ill patient in the Intensive Care Unit (“ICU”) . He asked his senior registrar to start the list until he was ready to resume it: this included carrying out the procedure on Patient X. This was totally within the capacity of that registrar and nothing turns on this delegation. In doing so, there was no additional information furnished to the registrar save that which appeared on the theatre list which simply recorded the procedure as “Tongue Tie”. 6. To ensure that it is the correct patient, correct procedure and at the correct site, the hospital has a policy, entitled “Correct Site Surgery Policy”, which requires the surgical team to “pause” or take “time out” before commencing an operation. The file which included all of the above information, save for the letter to the G.P., is with the patient at this time. Some form of time out apparently did take place in this case, but even if no document was looked at, other than the respondent’s incorrect note, any competent doctor would instantly have recognised that there was no procedure known as “Upper Lingual Frenulum”. If observed or detected, a simple inquiry would have identified the error and prevented an incorrect dissection, namely a “Tongue Tie”, the third of the type referred to at para. 2 above, from having first taken place. Very shortly thereafter this error was noticed by Professor Corbally, the parents were informed and later that day their child had the correct procedure carried out. Some added discomfort and pain followed but very quickly the entire incident had passed for the patient. 7. The parents understandably were disturbed and made a complaint to the Medical Council. The Preliminary Proceedings Committee (“P.P.C.”) was satisfied that further action was warranted and thus, referred the matter to the Fitness to Practise Committee (“F.P.C.”). That Committee notified Professor Corbally of its intention to hold an inquiry under Part 8 of the Medical Practitioners Act 2007 (“the 2007 Act”). As required, the doctor was informed of the allegations against him. In all these totalled nine in number. After a five day hearing the F.P.C. found that allegations 1, 6 and 8, by reference to poor professional performance, had been proven and in its report to the Medical Council, recommended that the doctor be censured or admonished. The other allegations fell away in the manner later described. The Medical Council accepted this recommendation and consequently, issued the admonishment as suggested. 8. By reason of the relevant statutory provisions the only course available to Professor Corbally so as to challenge the findings made, was to seek leave to apply for judicial review. His claim was that the failure of the 2007 Act to provide for an appeal on the merits from the findings made and the sanction imposed, breached certain of his constitutional rights and for that reason, was unconstitutional. He also claimed that such failure was incompatible with the State’s obligations under Article 6 of the European Convention on Human Rights: these claims, by agreement, were held over until the other issues had been determined. As it happened the applicant was successful in that both the leave application and the subsequent application for substantive relief were decided in his favour. For the reasons set out in his judgment, the learned President of the High Court concluded that the first named respondent had committed or was responsible for, a series of legal errors which could only be corrected by quashing the findings of the F.P.C. and the subsequent sanction imposed by the Medical Council. It is the Medical Council’s appeal from that decision which is now the subject matter of this judgment. The Allegations Made:
2. On or around 11 March 2010 completed an admissions card dated 11 March 2010 in respect of Patient X incorrectly recording Patient X’s diagnosis as “Tongue Tie (Upper Frenulum)” and/or 3. On or around 30 April 2010, failed to ensure that the consent form signed by Patient X’s father prior to Patient X’s first surgery, adequately described the procedure to be performed and/or 4. Prior to Patient X’s first surgery on around 30 April 2010, failed to ensure that a team meeting occurred in relation to the procedure planned for Patient X and/or 5. On or around 30 April 2010, failed to tell Patient X’s parents, either personally or through a member of your team, that you would not be performing Patient X’s first surgery and/or 6. On or around 30 April 2010, delegated Patient X’s surgery to Dr. Fahran Khaliq Tareen (“Dr. Tareen”) in circumstances where you failed to communicate adequately or at all to Dr Tareen the procedure to be performed on Patient X and/or 7. On or around 30 April 2010, failed to supervise, either adequately or at all, Patient X’s surgery and/or 8. Failed to apply the appropriate standards of clinical judgment that could be expected from a surgeon with your experience or expertise and/or 9. Such further allegations as may be notified to you in advance of the inquiry.” Findings and Report of the Fitness to Practise Committee:
By majority the Committee was satisfied that this amounted to poor professional performance as:
Allegation 6: The F.P.C. was satisfied that such amounted to poor professional performance as when delegating the procedure, which it acknowledged Professor Corbally was entitled to do, he had a responsibility “…to issue the correct instruction…”. It went on to state:
The F.P.C. found that this constituted poor professional performance noting that “…the surgical booking/coding system was known to be incapable of coding a procedure such as division of upper lip frenulum”. In such circumstances the F.T.C. assigned to Professor Corbally “…a particular responsibility to ensure that all necessary precautions were taken…” so as to ensure that the patient received the correct surgery. It concluded by stating that “[h]is failure to do so, by relying on systems known or suspected to be flawed, constitutes poor clinical judgment”.
The system issues which cause concern include:
2. The lack of implementation of the hospitals’ own ‘Correct Site Surgery’ Policy. 3. Failure to effectively implement the surgical pause procedure. 4. Weaknesses in communication and leadership.” 12. On the 24th October, 2012, the report of the F.P.C. was considered by the Medical Council which was satisfied to adopt its recommendation as to sanction and thereby issued an “admonishment or censure” with regard to Professor Corbally. He was so notified in writing on the 28th October, 2012. The High Court Judgment: 14. Being of the opinion that the essence of the definition of poor professional performance (s. 2 of the 2007 Act) focused on the “…knowledge and skill or the application of knowledge and skill or both…” aspect of it, the judge noted the statutory obligation on the Medical Council under s. 91 of the 2007 Act, which was to ensure the maintenance of professional competence, and thus, knowledge and skill within the profession. The discharge of this responsibility was informed by the later provisions of that section, as well as by rules made by the Medical Council under that title, contained in S.I. 741/2011. By a combination of the provisions of both of these statutory instruments, there was, in his view, either an explicit or at least an implicit recognition that an evaluation of competence was to be assessed overall by reference to some representative sample of a practitioner’s work. That being so, such assessment should not be confined solely, to an isolated or single incident. 15. In the absence of Irish authority, reference was made to what was described as “similar legislation” in England and Wales upon which the judgment in R. (Calhaem) v. General Medical Council [2007] EWHC 2606 (Admin) (“Calhaem”) is based. The term “deficient” used in the English legislation was in effect the same as “poor” which is used in this jurisdiction. At para. 39 of his judgment in Calhaem, Jackson J. made five points, the third and fourth of which were described by the High Court as being “the appropriate principles for construing s. 2 of the 2007 Act”. In short, point 3, when dealing with the phrase “deficient professional performance”, stated that save in exceptional circumstances, a breach of the term could only be demonstrated by reference “to a fair sample of the doctor’s work”, with point 4 declaring that a single incident of “negligent treatment”, would be unlikely to constitute such a deficiency unless it “was very serious indeed”. 16. Relying therefore on Calhaem in the construction of the term “poor professional performance” in s. 2 of the 2007 Act, and noting the mandatory imposition of a sanction as well as the absence of an appeal, the trial judge was of the view that in respect of a single lapse, the threshold of “seriousness” had to be met before a medical practitioner could be found guilty of breaching that standard. O’Laoire v. Medical Council (unreported; High Court; Keane J.; 27th January, 1995) (“O’Laoire”) was applied. It is however, unclear whether the same requirement should apply if the conduct comprised of more than an isolated incident, or where precisely in this context, the “fair sample condition”, fits in. 17. On the other question raised, the trial judge was satisfied that an error correctly classified as “grave” or “very serious”, even if singular in commission or omission, could constitute poor professional performance but short of that, a single lapse or error of a minor nature should not normally be so considered. 18. The learned judge then quite appropriately applied this view of the law to the facts of the case before him and having regard to the legal arguments as made, considered each of the allegations numbered 1, 6 and 8. He felt that the real problem behind the entire episode was the systems deficit in the Hospital, not only in its coding process but also in the manner in which the error of the note was not picked up, via the surgical pause, or by reference to other sources such as the consent form or the discussion between the parents and the S.H.O./nurse on their child’s admission to the hospital. As there was no evidence of any causative link between the error and the incorrect dissection, the lapse could not be described as grave. 19. On such basis the finding of poor professional performance and the sanction imposed on allegation 1 were unreasonable and disproportionate, following Meadows v. the Minister for Justice, Equality and Law Reform [2010] 2 IR 701. It was however noted, that the finding of fact was appropriate given the admissions as made, but it was the follow on adjudication which was flawed. Regarding allegation 6, it was inappropriate to rest any responsibility on Professor Corbally’s shoulders for the inadequate performance of the “pause or time out” requirement before surgery commenced. Moreover, the particulars of allegation 6 did not suggest that the applicant was responsible for the hospital’s communication failure or that additional safeguards should have been applied by him in view of the known weaknesses of the system. The finding so made and the sanction so imposed could not survive on fair procedure grounds. Finally, allegation 8 was repetitious and would be quashed on that basis. 20. Although on notice, the Human Rights Commission did not participate in the proceedings in the High Court. The Appellant’s Submissions: 22. The Medical Council says that this is a simple case with the issue being, what is the correct statutory interpretation of the phrase “poor professional performance”? There is, in its view, no justification for suggesting that an isolated event could not breach this standard, or for imposing a threshold of “seriousness” even where the error was one of singularity, by act or omission, or of importing into the meaning of that phrase any requirement of assessing a representative sample of a doctor’s work or knowledge (“the fair sample requirement or test”). 23. It points out that under the Medical Practitioners Act of 1978 (“the 1978 Act”) the only ground upon which complaint could be made, apart from unfitness to practise on mental or physical grounds, was an allegation of professional misconduct. It traced the history of that phrase, up to and including O’Laoire, and what the accepted practice was from that decision until the enactment of the 2007 Act. Under the preceding regime, it accepts that an act or omission, negligent in nature, would not always be, but would be capable of, amounting to such professional misconduct. 24. In 2007 the Medical Council says that the legislature intended to introduce a new regime, which it did by expanding the base upon which a complaint could rest against a medical practitioner. It did so via the concept of “poor professional performance” which relates to conduct, involving either a single, or a series, of errors, which are less serious in nature than those which would give rise to a finding of professional misconduct. The difference between both is therefore simply one of degree. It denies that the statutory system in England is the same as that enacted in this jurisdiction and accordingly, describes the case law referred to as having limited, if any, application. In particular, phrases mentioned in the English authorities such as “seriously deficient performance” and “deficient performance” have all been used without any legislative definition, unlike the Irish concept of “poor professional performance”. Furthermore, it points out that the approach taken in Krippendorf v. General Medical Council [2001] 1 WLR 1054 (“Krippendorf”), had a very special context and was based on a booklet published by the General Medical Council (“G.M.C.”) which issued guidance as to how a practitioner’s performance should be assessed. The approach of the Court is therefore entirely unsurprising given the absence of any comparable definition in that relevant legislation. Likewise, the decision in Calhaem must be understood in the context of this quite different regime. 25. The Medical Council also submits that if it is a correct proposition of law that only a “very serious or grave error” can constitute “poor professional performance”, then there is in fact no difference between that phrase and professional misconduct. In effect, to so conclude would be to disregard the significance of the amendment made in 2007. 26. It is further claimed that the reliance by the learned President on the provisions of Part 11 of the 2007 Act to inform the meaning of the phrase in question was misplaced, as there is a very limited connection between that part of the Act and Parts 7 - 9 which deal with complaints, investigations and sanctions (“the disciplinary provisions”). The only real interplay between both is that if, as a result of operating the provisions of s. 91 of the 2007 Act, and if despite being afforded all reasonable opportunity, a medical practitioner’s competence still falls below an acceptable standard, the Medical Council can make a complaint which when made feeds into Parts 7 - 9 of the Act. Apart from and save for this connection, there is in reality quiet a distinct and definite separation between the provisions of these respective parts of the Act. 27. Finally, on the individual facts of this case it submits that the findings of the F.P.C., and the imposition of the lowest available sanction, could not be said, given the evidence, to be irrational, unreasonable or disproportionate. The absence of effect flowing from the error or the fact that others or other causes, even including a systems failure, may also be at fault, do not absolve the admitted mistake of the respondent from attracting consequences. All and every constitutional right of the respondent was preserved and accordingly, save to a limited extent regarding allegation 8 only, the learned President of the High Court was incorrect in his interpretation of the statutory phrase, and in his application of the other legal principles invoked. The Respondent’s Reply: 29. The evidence tendered before the F.P.C. with regard to Professor Corbally’s qualifications, his knowledge, his diagnostic, surgical and other skills, and the application of such to his practice, his commitment to patient care and his communication and understanding ability of patients needs, all points to a single conclusion that his admitted error, as above described, could not be said to impinge upon his overall competence in any way. Consequently, proceedings taken by him alleging, inter alia, that the findings being impugned were irrational and disproportionate, were correctly upheld by the High Court and such applies in respect of all allegations. Furthermore, he claims that he had no responsibility whatsoever for the system’s failures which undoubtedly were identified, and accordingly, for the F.P.C. to build into its findings a responsibility on his part therefor, is also a breach of fair procedures. He thus submits that the appeal in its entirety should be rejected. Issues:
• If so, what is the resulting relationship between professional misconduct and poor professional performance: in essence, what is the difference between both?
• In particular does it feed into the disciplinary provisions of the Act? • If it does, is its application subject to what has been described as “exceptional circumstances”, and if so, can this caveat be more narrowly described? Two Preliminary Observations: 32. Allegation 2 relates to the admission card, 3 to the consent form, 4 to the surgical pause out and 7 to an alleged failure to adequately supervise the surgery of Patient X. On any sustainable view of the admitted/established facts, the most pertinent of which gave rise to little or no controversy, it is very difficult indeed to see how the respondent could have been so charged with having any level of responsibility in relation to these matters. 33. As appears from the wording of allegation 2, the description given by Professor Corbally to have the patient booked in, was accurate, in that it referenced the “Upper Frenulum”. The consent form had been obtained by an S.H.O. with no direct involvement of the respondent. In any event, the description of the intended procedure was accurately recorded by that doctor. How Professor Corbally could have ensured the surgical pause, at a time when he was not present and was not a direct participating member of the surgical team, is terribly difficult to understand as is the allegation that the surgery was inadequately supervised. He was not, quite evidently, present when the first dissection took place, and to my knowledge no one has ever suggested that the correct procedure, when performed, was not appropriately carried out. In such circumstances, I fail to see any possible justification for suggesting any level of responsibility for such matters. 34. The second aspect of this point involves the manner in which such charges were phrased and alleged, that is as constituting both poor professional performance and professional misconduct. On its own submission, the Medical Council agrees that the facts of the case could never have met the standard of professional misconduct, and neither could they have met the standard of poor professional performance if a “seriousness” threshold, should be imputed to that phrase. I wonder why therefore, was he so charged in this way? Quite clearly it is a very significant matter for a member of any profession to have allegations made against him which form the subject matter of disciplinary proceedings. The more serious the allegations obviously, the more concern there will be. Professional misconduct has the highest possible status with the gravest of consequences. Such process is not and should not be equated with a criminal prosecution whereby it is not infrequent to charge an accused with a lesser offence in addition to the more serious one, where the facts might justify a conviction under either. It is also quite distinct from inter partes litigation. Whilst I fully understand the role of the Medical Council, it seems to me that in its justifiable pursuit of protecting the public, sight must not be lost of the significant stress and anxiety as well as potential consequences which a disciplinary process inherently has for the practitioner in question. By all means, if the circumstances, as known at the time and if capable of being established by available evidence, would justify the most serious of charges, then so be it. But where that is not the case, I deprecate any practice or approach which unnecessarily and unjustifiably increases that concern or anxiety. 35. The second observation is this: after the detail of the case is absorbed, the legislative provisions considered and the case law scrutinised, if one should withdraw a little from such matters and step for a moment outside the immediate confines of the litigation arena, one may ask how could a case like this, ever, have travelled the distance it has. Confining myself purely to the disclosed facts of the instant case and disregarding, as every player must, any previous background - whilst noting the admitted absence of all effect, the multiple intervening opportunities of detecting the respondent’s error and the institutionalised systems failures at the Hospital- I cannot help but feel that this is not truly the case to have such important issues determined. Simply put, the circumstances do not lend the mistake to such a course. 36. In so expressing these remarks, I am not in the least underestimating the importance of accurate transcription: such is a vital part of a doctor’s responsibility and critical for patient welfare: I therefore fully support the views of the learned President of the High Court in this regard. General Importance of the Case:
• No definition of poor professional performance.
• Definition of both professional misconduct and poor professional performance.
• Definition of poor professional performance in terms identical to the 2007 Act. 38. A further aspect of these legislative schemes might profitably be noted at this point which is, that in some situations there is a duty on the regulatory body to maintain professional standards and to that end, establish and operate professional schemes etc. In others, there is no such duty. The importance of this point will become clear when further reference is made to the justification or otherwise of evaluating poor professional performance by reference to the fair sample requirement. The Historical Position: 40. It would appear that from at least the Medical Act 1886 onwards, medical practitioners had been subject to some form of regulation. Under s. 29 of that Act the General Council of Medical Education and Registration had power to erase the name of a medical practitioner from the Register if he was found to have been guilty of “infamous conduct in a professional respect”. 41. In 1894 (Allinson v. General Council of Medical Education and Registration [1894] 1 QB 750), such conduct was described as “disgraceful or dishonourable” as so regarded by colleagues of good repute and competence. Its relationship with the profession was essential so that conduct which for outsiders would not be so described, could be so described for the practitioner. Accordingly, the original phrase was expanded and became termed infamous or disgraceful conduct in a professional respect. Throughout the years that phrase was described in different ways and its then level of experience and understanding was captured in the judgment of Lord Jenkins in Felix v. General Dental Council [1960] AC 704. In general terms, it was said that such conduct involved conscious wrongdoing or shameful activity, of a type deserving of infamy or utter reprobation. These descriptions of “infamous” and “disgraceful” can be condensed to suggest that such conduct had to involve some element of moral turpitude, fraud or dishonesty. Carelessness, inadvertence or a mistaken belief honestly held, were never so regarded. 42. As time went on this dated way of expressing the type of conduct intended to be captured was replaced with the phrase “professional misconduct”. Section 45 of the Medical Practitioners Act 1978, used the phrase “professional misconduct” as one of two grounds upon which a complaint could be made against the practitioner. The other, not relevant, was an allegation of unfitness by reason of physical or mental disability. That Act did not define or otherwise describe the phrase in question. Keane J. was called upon to do so in O’Laoire. That decision remains the most important one on this topic to date. 43. Some years prior to O’Laoire the Privy Council offered an opinion on what constituted “serious professional misconduct” in respect of a dental professor in Doughty v. General Dental Council [1988] A.C. 164 (“Doughty”). In England the former historical expression was replaced in the Medical Act 1983 (“the 1983 Act”), by the expression “serious professional misconduct”. Whilst stating that “infamous or disgraceful conduct in a professional sense”, would continue to constitute professional misconduct, the Privy Council felt that in light of a lesser sanction which the 1983 Act also provided for, it would no longer be appropriate to require the G.M.C. to establish on all occasions conduct to the former level. So, it expressed the view that conduct which seriously fell short of the standards of conduct expected of a dentist, would also constitute professional misconduct. 44. In O’Laoire, having referred to much of the background and its evolution throughout the years, Keane J. set out five principles to establish and thereafter so verify the meaning of “professional misconduct” for the purpose of s. 45 of the 1978 Act (pp. 106-107). 45. Numbers 1, 2 and 3 were to the effect that infamous or disgraceful conduct, touching upon one’s profession, involving some degree of moral turpitude, fraud or dishonesty and, if established, constituted professional misconduct (“the moral turpitude test”). Principle No. 4 excluded from that description a situation where a person wrongly but honestly formed a particular opinion. It was the last principle which reflected the second limb of what thereafter became professional misconduct. It reads:-
46. There is one further aspect of this judgment which is not frequently referred to: it is the reference to s. 69 of the 1978 Act which assigned to the Medical Council as one of its functions, the requirement to give guidance to the medical profession generally, and on all matters relating to ethical conduct and behaviour. At that stage the 3rd edition of the Guide had been issued (Guide to Ethical Conduct and Behaviour and to Fitness to Practice (1989; 3rd ed.) (“the Guide”)) . It defined “professional misconduct” as “conduct which doctors of experience, competence and of good repute, consider disgraceful or dishonourable”. By reference to that section of the Guide, the learned judge said that:-
48. It is only correct to point out that Kelly J., in Prenderville v. The Medical Council & Ors [2008] 3 IR 122, made a number of references to the qualification contained in O’Laoire. Leaving those aside however, I find much to commend itself in what the learned judge said at para. 172 of the report where, whilst accepting that the Guide is no more than simply that, he stated:-
The 2007 Act:
• Part 4:- deals with members, committees and staff of the Medical Council, • Part 6:- covers the registration of medical practitioners, • Parts 7, 8 and 9:- deal with complaints regarding medical practitioners, the investigation of such complaints, the imposition of sanctions, if such is established, and access to the High Court by way of cancellation or confirmation, as the case may be, • Part 10:- deals with education and training, • Part 11:- deals with maintenance of professional competence. 51. The powers and responsibilities given, which must be performed in the public interest (s. 7(1)(b) of the Act), are designed to further the single stated object of the Medical Council, which is “to protect the public by promoting and better ensuring high standards of professional conduct and professional education, training and competence amongst registered medical practitioners” (s. 6). 52. As with the 1978 Act, there is no definition of professional misconduct but “poor professional performance” is defined as:
(b) a censure in writing and a fine not exceeding €5,000; (c) the attachment of conditions to the practitioner’s registration, including restrictions on the practice of medicine that may engaged in by the practitioner; (d) the transfer of the practitioner’s registration to another division of the Register; (e) the suspension of the practitioner’s registration for a specified period; (f) the cancellation of the practitioner’s registration; (g) a prohibition from applying for a specified period for the restoration of the practitioner’s registration.” (s. 71) 55. As is clear from the object of its establishment and the functions required of it, the Medical Council has the duty of establishing and maintaining the register and to do so in the public interest. An essential part of this responsibility is to set standards of competence and to maintain such standards throughout the medical profession. As the practice of medicine is so diversified, what will be required to establish standards in one discipline may greatly differ from what may be necessary in another discipline. What may be appropriate for a general practitioner may not be for an S.H.O.: again, what may be appropriate for a cardiologist may not be for a cardiac surgeon etc. Consequently, to ensure that the specified standards across all disciplines should not drop, the Medical Council is empowered to establish and operate one or more schemes for this purpose. It must periodically review, and if necessary take steps to improve the operation of such schemes. It can recognise medical training bodies and engage with them to that end. All of this is provided for in s. 91 of Part 11 of the 2007 Act. 56. To compliment this duty so that in an overall sense the public can be best served, every registered practitioner himself or herself, is obliged to maintain standards on a continuing basis and to do so pursuant to a professional competence scheme, which is both appropriate and applicable to him or her (s. 94(1)). From time to time, quite evidently, some practitioners may not keep abreast of what is required of them under the scheme, or as part of resolving a complaint may be required by the F.P.C. to attend a particular scheme and fail to do so, or fail adequately to do so. In either situation there may well exist a concern about competence, in respect of which an opportunity for improvement has been afforded, but for whatever reason such competence to the required level has not been re-established. Accordingly, if and when these circumstances occur, the Medical Council is given a right to make a complaint (s. 91(6) of the Act). 57. A similar situation can arise where a doctor is registered in a specialist division or in a trainee specialist division. Where concerns arise in respect of such practitioner, the Medical Council will give that person “…every reasonable opportunity” to improve his performance, but where on review it continues to be at an unacceptable level then once again the Medical Council may make a complaint (s. 91 of the Act). Accordingly, for those, whether standing within or outside a specialist division, in respect of whom an issue of competence arises and is dealt with under Part 11 of the Act, it is explicitly provided for that, save in exceptional circumstances not relevant, a complaint will be made only after the practitioner has failed to take the opportunity afforded to him to regain the required standard. 58. The Medical Council has been given power to make regulations for the purposes of Part 11, which it has, and which are contained in the Medical Council - Rules for the Maintenance of Professional Competence (No.2), S.I. 741/2011. Under rule 2, provision is made for the assessment of a practitioner’s knowledge and skill by the Professional Competence Committee (“P.C.C.”) of the Medical Council, which assessment is conducted by reference to several listed activities, including interview with the doctor in question, any relevant third party, inspection of his work place, review of his clinical records, direct observation of his practice of medicine etc. Having conducted such a review, the P.C.C. has the power to initiate or confirm an action plan designed to improve the knowledge and skill or the application of the knowledge or skill of that practitioner. Such will be monitored over a period of time to determine whether or not the action plan is being implemented. In the event of that being unsuccessful and the required standard not being regained, the Medical Council, on this, and on other grounds, may make a complaint under the complaints provision of the Act. 59. I have gone to some considerable length on this aspect of the case as the duty placed on the Medical Council under these provisions of the Act, have been relied upon as justifying the fair sample test. I regret but I cannot agree that this is so. 60. As can be seen, the entire thrust and focus of Part 11 is to regulate competence on an ongoing and continuous basis. It does so through the P.C.C., and not through either the P.P.C. or the F.P.C. It is a support mechanism for practitioners who for whatever reason may have temporarily fallen below the required standard, but who are capable of regaining that status with appropriate help. It is, I believe, essentially rehabilitative in purpose and is not designed as an investigative tool for identifying or detecting conduct or activity with a view to engaging with the disciplinary provisions of the Act. The relationship between this Part and Parts 7 and 9 of the Act, intersect only when complaint is made by the Medical Council having regard to a failed opportunity/opportunities of meeting the necessary standards. Any connection in a disciplinary sense, with Parts 7 to 9 of the Act, is therefore in my view, purely incidental. 61. Accordingly, I do not believe that it is appropriate to draw upon the provisions of Part 11 of the 2007 Act as a sustainable basis for suggesting that, save in exceptional circumstances or where an isolated complaint is a grave one, a fair sample assessment of work or practice is a preliminary requirement to the making of a complaint against a practitioner. I do not believe that such a deduction is appropriate from the relevant provisions outlined or that it is otherwise required for the operation of the disciplinary process. In fact, on the contrary, it would seriously jeopardise the mandatory obligation on the Medical Council to protect the public from sub-standard competence or the performance thereof by those subject to its remit. 62. There is a further reason for this view which is this: some of the other statutory schemes where “poor professional performance” is included as a ground of complaint (para. 37 supra), do not have any provisions comparable to those in Part 11 of the 2007 Act. Accordingly, if the basis for interpreting the term, relied or relied heavily on the obligation to maintain competence, it might be suggested that within those statutory schemes the phrase might have a different meaning which surely is not the case. Accordingly, I believe that the conclusion reached is justified. UK Legislative Position and Applicable Case Law: 64. Under s. 36 of the 1983 Act, the G.M.C. could erase or restrict a doctor’s registration only in cases of “serious professional misconduct”, or where a criminal conviction had been recorded: the third basis upon which complaint could be made related to a serious impairment of fitness to practise for health reasons, which was dealt with by the Health Committee (s. 37 of the Act). No other grounds of complaint were available and neither was any sanction lesser than those mentioned. Such matters were within the remit of the Professional Conduct Committee of the G.M.C. 65. Section 1 of the Medical (Professional Performance) Act 1995 (“the 1995 Act”), inserted a new s. 36A into the 1983 Act, which permitted a doctor’s registration to be suspended for not more than 12 months or to have conditions attached to it for not more than 3 years: this applied if his or her standard of “professional performance” had been found to have been seriously deficient. Responsibility for and control of these matters were vested in two new Committees specifically established under the Act for this purpose: these were the Committee on Professional Performance (“C.P.P.”) and the Assessment Referral Committee. Section 40 of the 1983 Act conferred a right of appeal from a decision of the C.P.P. to the Privy Council, but unlike an appeal from a decision of the Professional Conduct Committee, was confined to a question of law. However, such a question is to be interpreted generously so as to avoid an injustice (Stefan v. General Medical Council [2002] UKPC 10 and Sadler v. General Medical Council [2003] 1 WLR 2259 (“Sadler”) (para. 11)). 66. As Krippendorf explains, two important observations require noting at this point: first the statutory test set out in the amendment was that of “professional performance” by reference to past work and not “professional competence” (p. 1056): secondly, neither the Act as amended or otherwise, nor the rules made thereunder, defined “seriously deficient performance” (p. 1056): (General Medical Council (Professional Performance) Rules Order of Council 1997) (S.I. 1997/1529) (“The English Rules”). 67. In a booklet published in November, 1997 the G.M.C. indicated what interpretation it placed on this phrase. In short, the Medical Council viewed the term “seriously deficient professional performance” as referring to conduct, sufficiently serious to call into question a doctor’s registration: it instanced that this might arise if one “repeatedly or persistently” fell below the required professional standard. The Privy Council in Krippendorf saw “no reason to criticise the general guidance thus given in the booklet, provided that it is not regarded as exhaustive” (p. 1057). When the facts in Krippendorf are looked at, and when the process involved is considered, it was perfectly in keeping with the statutory provisions and the attendant Council rules for such process, for the Privy Council to have applied the description as given. 68. In short, a complaint was made that Dr. Krippendorf had used the incorrect injection technique when administering the BCG vaccine to over 200 children, giving rise to a high incidence of side effects. On receipt of the complaint, it was looked at by a “medical screener” who took the view that an assessment was required. The doctor so agreed, thus obviating the necessity for the Assessment Referral Committee to make such decision. An assessment panel was therefore constituted to conduct a review, which it did in two phases. A great deal of documentation was generated for this exercise, including the doctor’s response to what was in effect an 85 page questionnaire. Phase 1 included an examination of 40 medical records relating to the doctor’s work. Phase 2 was conducted at a clinical skills laboratory where she had an opportunity to complete objective tests in what was said to have been “her paediatric practice”. Between the carrying out of Phase 1 and Phase 2, the matter was referred to the C.P.P. At the conclusion of the process, the panel produced an assessment report which the C.P.P. accepted, at a subsequent hearing held by it. Based primarily on the findings of the report, the C.P.P. determined that the practitioner’s professional performance had been seriously deficient and suspended her registration for 12 months. All of the steps as described in this process were governed by detailed rules made under the primary legislation: in total these numbered 34, with 3 schedules. 69. Omitting non-essential detail, the Privy Council, whilst describing the report as long and careful, found that the approach of the panel in conducting the assessment had been carried out on a seriously erroneous basis which had followed into its report. Essentially, the panel had failed to apply the statutory test of “professional performance”, which should have involved an assessment of the doctor’s track record, in work actually completed by her: but rather it had dealt with her professional competence, this by testing her knowledge and clinical skills. That was an incorrect approach which in their lordships’ opinion demonstrated a “basic error of law” in the discharge of the panel’s statutory function (p. 1063). Accordingly, for this and several other reasons, based on circumstances which I have not set out, the appeal was allowed, with the determination of the C.P.P. being quashed. 70. Quite evidently it was always intended to evaluate the work of Dr. Krippendorf by and via this assessment process, which in so doing was conducted procedurally, that is step by step, in accordance with the English rules. 71. The case most relied upon is Calhaem, which was decided pursuant to an amendment made by way of substitution to both the 1983 and 1995 Acts. From 2003 onwards the only allegation which could be made against a registered practitioner was that “his fitness to practise was impaired”. Under s. 35C(2) of the 1983 Act, inserted by the Medical Act 1983(Amendment) Order 2002 (S.I. 2002/3135), a person’s fitness to practise “shall be regarded as “impaired” for the purposes of this Act by reason only of -
(b) deficient professional performance; (c) … (d) … (e) …” (Jackson J., para. 26). Accordingly, the test of “impairment” became the essential threshold which had to be met in this disciplinary process. 73. In order to reflect the new regime overall, which included revised rules (The General Medical Council (Fitness to Practise) Rules Order of Council 2004 (S.I. 204/2608)) and, in particular so as to accommodate the “impairment requirement”, the proceedings before the Fitness to Practise Panel thereafter fell into three parts. First, the findings of fact, secondly, the panel’s determination as to whether the practitioner’s fitness to practise was impaired and if that was established, thirdly, the question of sanction. At each stage of the process the parties were entitled to call evidence and make submissions relevant to the issues under consideration (Calhaem, para. 25). 74. Dr. Calhaem had several allegations made against him arising out of a particular operation and his involvement with the patient in its immediate aftermath. He admitted several breaches of duty with the panel describing his actions in other contested areas as being irresponsible and as constituting a serious departure from good clinical care and practise. Indeed, the professional expert called on his behalf agreed that there were many significant failures but argued that these were not of sufficient gravity as to call into question his resignation. After announcing its findings, submissions were then received on the issue of practise impairment. The panel held that his fitness was so impaired and suspended him for three months. His appeal therefrom was heard before the Administrative Court which for appeal purposes, had by then replaced the Privy Council in this regard. 75. Jackson J., before setting out five principles at para. 39 of the judgment, which have been referred to in the instant case, reviewed a number of recent cases most of which involved allegations of serious professional misconduct, and therefore require no referencing in this judgment, save perhaps with the possible exception of Sadler. That was a case decided under the 1995 amendment with the investigation of the complaint, just as in Krippendorf , involving a detailed evaluation of the doctor’s work as provided for by the English Rules. That assessment covered the surgeon’s practice over a long period which included several operations, a number of which were found to have been carried out unsatisfactorily. The Privy Council picked up on the reference in the G.M.C.’s booklet to “repeated and persistent” substandard conduct and pointed out that one should keep in mind the generality of what the booklet was intended to cover when applying this phrase. It instanced how the professional demands made of practitioners, differed greatly and that self evidently very different evidence would be required when assessing shortcomings of technique in major surgery as compared with assessing a continuing failure by a G.P. to maintain, for example, an efficient practice. 76. At para. 62 of the judgment it was stated:-
(2) A single negligent act or omission is less likely to cross the threshold of “misconduct” than multiple acts or omissions. Nevertheless, and depending upon the circumstances, a single act or omission, if particularly grave, could be characterised as “misconduct”. (3) “Deficient professional performance” within the meaning of 35C(2)(b) is conceptually both separate from negligence and from misconduct. It connotes a standard of professional performance which is unacceptably low and which (save in exceptional circumstances) has been demonstrated by reference to a fair sample of the doctor’s work. (4) A single instance of negligent treatment, unless very serious indeed, would be unlikely to constitute “deficient professional performance”. (5) It is neither necessary nor appropriate to extend the interpretation of “deficient professional performance” in order to encompass matters which constitute “misconduct”.” 80. The following are the most material ones:
(b) The phrase “deficient professional performance” has not been statutorily defined in England, whereas the corresponding phrase has been in s. 2 of the 2007 Act. This means that the prominence which a booklet like that of the G.M.C. has in that jurisdiction would not, in respect of the Guidelines of the Medical Council, have the corresponding effect in this jurisdiction. (c) It is not sufficient in that jurisdiction to simply establish that the practitioner has been guilty of misconduct or of deficient professional performance: unless it is shown that such impairs his fitness to practise, no sanction can be imposed. This additional requirement of the English test is not applicable in this jurisdiction. Therefore findings can be made under the 2007 Act even where the conduct complained of, does not reasonably call into question a doctor’s resignation. (d) The rules made to facilitate the operation of s. 35 of the 1983 Act (as substituted), are particularly detailed regarding evaluation. Lord Walker summarises these in Sadler (para. 4 - 11 inclusive). These include an initial screening, the carrying out of an assessment unless no further action is required: with such involving interviewing the complainant, witnesses, the practitioner and up to five persons nominated by him: on completion the report must offer a view as to whether the standard of the practitioner’s performance has been seriously deficient and also whether such performance could be improved by remedial action. On its finalisation, several options are open including the immediate referral to the C.P.P. or the drawing up of a “Statement of Requirements”, which if the practitioner agrees to and complies with, the matter may go no further. If he disagrees or if the requirements have not been satisfied, there are several other options available; whereas, (e) The rules under the 2007 Act are not remotely as detailed. 82. In conclusion, very little assistance in my view can be derived from the English legislative position or from the case law created thereby. The Meaning of “Poor Professional Performance”:
84. It is well accepted that the essential task of a court in the construction of any statutory provision is to ascertain therefrom the true intention of the Oireachtas. To this end, it is not confined to any particular provision but may consult other provisions and even the Act as a whole, if necessary. Reference to repealed enactments which can be considered in paria materia is also permitted as is any relevant case law on the provisions in question. 85. Even though much debate was had on the general meaning of the phrase “poor professional performance” it is not necessary for the purposes of dealing with this appeal to dwell fully on each aspect of the definition as, if the threshold of “seriousness” is part of the test, it is accepted by the appellant that the findings of the F.P.C. and the admonishment which followed, proceeded on an erroneous basis of law and consequently, must be set aside. Since I have arrived at such conclusion, it is not therefore essential to explore the full implications of this term. However, could I make some brief observations. 86. It is not altogether clear what was intended by the amendment and of more significance what the amendment, as enacted, actually means. It is said by the appellant that even with the establishment of the less demanding test in 1978, there remained conduct which could not be said to equate with either the “moral turpitude test” or the “expected standards test”, and yet was such, that in view of its significance, ought to be capable of regulatory control. Hence, the creation of this concept of “poor professional performance” in the 2007 Act. 87. I can readily understand the logic of incorporating within the process, conduct, which although not insignificant, falls below either of the standards as mentioned. Indeed, to make provision therefor may be entirely justified or even desirable but of course such, in the first instance, is a matter for the Oireachtas. Inherent in this suggestion is an acceptance that the difference between the intended conduct and conduct which would constitute professional misconduct is simply a question of degree: the former being somewhat akin to a summary matter to be dealt with by a summary process. In my view however, if this was what was intended, neither the provisions nor the structure of the 2007 Act itself, implemented same. 88. There is a further view as to the kind of activity which the amendment was to address. It is that the Oireachtas intended to refer to conduct of a type or quality, quite separate and distinct from that, which might constitute professional misconduct: in other words conduct qualitatively different, and not simply that which could be measured in terms of seriousness, by comparison with professional misconduct. Again however, if that was the ambition, the provisions of the Act likewise in my view, failed to reflect it. 89. Having referred to many of the standard cases dealing with statutory interpretation, the Medical Council submits that on a literal interpretation, which is appropriate, there is no room for importing into the definition any threshold or qualification whatsoever. Accordingly if correct, this submission has the logical effect of meaning that any deviation from acceptable standards, would constitute poor professional performance and thereby expose the practitioner to the full range of sanctions contained in s. 71 of the Act. 90. Prior to 1978, the only sanction available on a finding of professional misconduct was erasure: s. 45 of the Act added the possibility of suspension for a definite period or conditional registration. Evidently, erasure had the consequence of prohibiting the doctor from practising medicine, subject presumably to an application to reinstate, whereas the first of the lesser sanctions was definite in duration with the second demanding no break in the practise of medicine. In view of the lesser sanctions so provided for, it was logical to add the second tier at the time (Doughty at p. 173). Following therefore the enactment of s. 45 of the 1978 Act, and in light of the decision in O’Laoire, there existed immediately prior to 2007 what can be classified in general terms as effectively two tiers of seriousness, both of which constitute professional misconduct. The higher and more demanding standard has been described as the “moral turpitude test” with the lower threshold being described as the “expected standards test”. The type of conduct which falls into each category is clearly different. 91. Even with such relaxation however, quite clearly a finding of professional misconduct, added to in light of the sanction imposed, was quite a grave matter for a practitioner. Professional reputation lay in tatters, personal reputation quickly followed, with the deprivation of one’s career having devastating consequences for person, family, social and societal relationships. However, if the conduct in question was such as to attract that designation, then it was entirely justified both in the interests of the public and for patient protection. 92. Given these and many other relevant considerations including the standard which had to be met so as to satisfy the “moral turpitude test”, it was entirely appropriate for O’Laoire to insert the requirement of “seriousness” before professional misconduct could be established, even if that term was not contained explicitly in s. 45 of the Act. Quite clearly that interpretation of the 1978 Act has been widely known and unconditionally followed for almost 20 years before the amendment. It must therefore, be accepted that the Oireachtas was fully aware of this jurisprudence when contemplating, and later enacting, the 2007 Act. Should therefore the same threshold apply to “poor professional performance”? 93. There are some striking features of this statutory regime which must be highlighted. Firstly, no distinction is made, within the terms of s. 71 of the 2007 Act, between what sanctions might be imposed on a finding of poor professional performance as distinct from professional misconduct, thus leaving available to the Medical Council, on a finding under the former heading, each and every one of the specified sanctions, including the cancellation of a practitioner’s registration. Secondly, there is no provision whereby a practitioner, who receives advice or is the subject of admonishment or censure, can appeal the finding of the F.P.C. or the sanction imposed by the Medical Council, to the High Court, in the manner available in respect of all other sanctions. Furthermore, in conjunction with this restriction, there is no obligation either on the Medical Council to seek confirmation of the decisions involved, whereas even in the absence of appeal it must do so, in all other circumstances. In effect therefore, save for judicial review which continues to have significant limitations regarding fact and inferences, there is no way in which such findings can be re-assessed on merits. These matters last mentioned can only be seen as reflecting a view that admonishment or censure should be regarded (by a practitioner) as almost meaningless. As the evidence discloses in the case this is far from the reality. 94. Furthermore, in view of the public media attention which is paid to proceedings before the F.P.C. and the Medical Council, having regard to the notification of any finding to the public and other regulatory bodies, both domestically and internationally and noting the absence of any process of challenge on merits, it seems to me that the conclusion above arrived at is well justified. 95. To agree with the submission of the Medical Council would mean that any lapse or mishap, no matter how trivial, minimal, devoid of effect or consequence, or truly de minimis in every respect, would be capable of constituting poor professional performance. If this should be the result of the amendment in 2007, the same resulted in the creation of a harsh or even ruthless regime, making the practice of medicine over one’s career almost hazardous to the point of virtual folly: it would indeed be few who could navigate that journey without having to berth at some point at the port of the F.P.C. I cannot believe that such was intended nor do I accept that such would be in the public interest: such would not reflect an appropriate balance between practice and protection. Therefore I would refuse to adopt such an interpretation of the term, unless coerced into so doing. Thankfully, that is not the situation. 96. For the reasons above stated, it follows therefore in my view, that the definition of poor professional performance must be read as if qualified by the word “serious” in the same manner as the phrase “professional misconduct” is. 97. It is neither desirable nor necessary to try, by some other form of words or expression, to further elaborate on what the word “serious” means. It can however be said that not every error, lapse or mishap will qualify: conduct which can truly be described as trivial, minor or which can be classified as de minimis will fall outside its meaning. Whilst outcome, adverse consequence or causative effect are not essential, where present, such will be factors for consideration. Tortuous acts or contractual breaches may or may not meet the threshold, depending on context and circumstances. Some activity will clearly fall within the definition and other clearly outside. Some evidently will be borderline, in which case the same must be judged on a case by case basis. 98. These remarks do not relate to how an assessment or evaluation should be carried out under Part 11 of the 2007 Act. There are in existence clearly defined and easily understandable statutory provisions and the Medical Council rules in this regard. 99. Having decided on this threshold, I can see no reason or benefit in using additional phrases such as “very serious” or “very grave” to describe what conduct might constitute poor professional performance. To do so simply adds confusion and makes the functional operation of the disciplinary process more complicated. 100. I am also of the view that for the purposes of s. 2 of the 2007 Act one does not have to wait, before moving, for “persistent or repeated” substandard events to have occurred: to have to, may lead patients to be unnecessarily compromised. However circumstances and context will be vital in order to assess whether particular conduct meets the threshold of poor professional performance, just as such matters are in order to see whether conduct amounts to professional misconduct. Secondly, I see no justification within the definition, or necessity arising out of the public interest, to treat any differently, conduct, by act or omission, which has been committed only on a single occasion. If the threshold for substandard competence or misconduct is met, it would be both illogical and anomalous to increase the threshold or elevate the test simply because such conduct had not taken place previously. Again, context and circumstance will be crucial. 101. Summary of Main Findings:
(2) This threshold applies whether the allegation be one of singularity or as involving more than one incident or activity. (3) There is no different and by implication a more serious test, for an isolated incident such as “very serious” or “grave” or words of similar description: such is not justified by the statute nor is it necessitated in the public interest: to require the same would simply add confusion. (4) Evidently in the normal course of events, it will be more difficult to meet the test if there is but one incident alleged. (5) Conduct which can truly be described as trivial, minor or which can be classified as de minimis, will not qualify. (6) Whilst outcome, detrimental consequences or causative effect are not essential, where present will be factors for consideration. (7) Negligent acts or contractual breaches, may or may not qualify: circumstances and context will determine. (8) A finding of poor professional performance does not depend on an assessment of a representative cross section of a practitioner’s work, or as has been put, on the application of a “fair sample” test. (9) Such type of evaluation is appropriate for the purposes of the provisions of Part 11 of the 2007 Act: when invoked and where, despite opportunity having been given, the practitioner’s standard of competence remains below the required level, the Medical Council can make a complaint: only at this point does the requirement of fair sample, intersect with, the disciplinary provisions. (10)Subject to such link however, this process is entirely separate and distinct from the making, investigation and adjudication of a complaint made under Parts 7 - 9 of the Act. (11)A finding of poor professional performance does not depend on conduct which impairs a practitioner’s fitness to practise, or which calls into question his resignation. (12)This equally applies to a finding of professional misconduct, although in either situation such finding may, but does not necessarily have to, have such effect. | ||||||||||||||||||||||||||||||||||||||||||||||
