Privy Council Appeal No. 46 of 2001

Dr. Sivagurunathan Srirangalingham	Appellant
	v.
The General Medical Council	Respondent

	FROM

	THE PROFESSIONAL CONDUCT COMMITTEE OF
THE GENERAL MEDICAL COUNCIL
	---------------

	JUDGMENT OF THE LORDS OF THE JUDICIAL
	COMMITTEE OF THE PRIVY COUNCIL,
	Delivered the 12th November 2001
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	Present at the hearing:-
			Lord Millett
			Lord Mackay of Clashfern
			Sir Swinton Thomas
		  	[Delivered by Lord Mackay of Clashfern]
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1. 	The appellant was brought before the Professional Conduct Committee (PCC) of the respondent Council and on his own admission on 12th April 1999 the following charges were found proved:-
“That, being registered under the Medical Act,
(1)	On 16 June 1994
a.	you were consulted by Mrs Atkinson, a patient for whom you were responsible under the NHS at the material times,
b.	You did not carry out an adequate examination of Mrs Atkinson,
c.	You thereby did not place yourself in a position in which to assess adequately her condition and treatment needs;
(2)	a.	On 22 August 1994, during two home visits  to
			Mrs. Atkinson,
b.	You did not carry out an adequate examination of Mrs. Atkinson,
c.	You thereby did not place yourself in a position to assess adequately her condition and treatment needs;

(3)	At the relevant times you did not keep adequate medical records of Mrs. Atkinson’s treatment;

(4)	On 27 January 1996 
a.	You were requested by telephone by Mr T Hutchinson to visit Mr Ronald Hutchinson, a patient registered on the NHS list of your partner, Dr (Mrs) S Srirangalingam, 
b.	i.	You did not obtain full details of Mr 
R Hutchinson's condition from Mr T Hutchinson, 
ii.	You did not visit Mr R Hutchinson, 
c.	You thereby did not place yourself in a position in which to assess adequately Mr R Hutchinson's condition and treatment needs; 

(5)	On 27 January 1996 
a.	You were unable to move your car from your drive because of snow, 
b.	You did not have alternative arrangements in place for your patients to receive home visits, if required,
c.	Your practice arrangements on 27 January 1996 were thereby inadequate; 

(6)	On 28 January 1996 
a.	You visited Mr R Hutchinson at his home,
b.	During the course of this visit, Mr Hutchinson wounded himself with a knife, 
c.	After calling an ambulance, you departed before the ambulance arrived, 
d.	You thereby disregarded your professional responsibilities to Mr Hutchinson at a time when he required the care and attention of a registered medical practitioner; 

(7)	On 5 October 1996 
a.	You visited Mrs C S Magee, a patient for whom you were responsible under the NHS at the material time, 
b.	You did not carry out an adequate examination of Mrs Magee, 
c.	You thereby did not place yourself in a position in which to assess adequately her condition and treatment needs; 

And that in relation to the facts you have been guilty of serious professional misconduct.”

2. 	Following the aforesaid findings the PCC determined and directed that for a period of twelve months the registration of the appellant be conditional on his compliance with the following requirements:-
“1.	You shall continue to seek and follow the advice of Dr James Harrison to improve the standards of your clinical care and communication skills;

 2.	Before the next hearing of your case by this Committee, you shall supply the Council with objective evidence of your professional development under Dr Harrison’s advice;

3.	You shall seek and follow the advice of the independent medical adviser in general practice to your local health authority about the size of your patient list with a view to reducing your own workload which has contributed to the findings today.”

3. 	The PCC resumed consideration of the appellant’s case at a hearing on 5th May 2000.  There had been no alleged breach of the above conditions in the interim.  The PCC determined and directed that for a further period of twelve months the appellant’s registration should be subject to the following requirements:-
“1.	You shall consult and follow the advice of Dr Harrison and Dr Ruffett to continue to improve the standards of your clinical knowledge and skills, and communication skills.  Under their guidance you should undertake such further professional development as is necessary to achieve the clinical standards of a general practitioner completing vocational training.

2.	As part of this process you shall keep a portfolio of your personal development plan, and through that demonstrate how you are ensuring that your continuing education is directed towards your clinical performance as a general practitioner. This portfolio should be produced at a resumed hearing of your case.

3.	You shall continue to undertake regular audits of your practice - of your own devising - and produce the results for consideration at the resumed hearing of your case.  These reports of your audits should indicate where you have changed your practice as a result.

4.	You shall submit the video evidence of your patient consultations to appropriate assessors appointed by the Postgraduate Institute for Medicine and Dentistry at the University of Newcastle, so that your skills can be objectively addressed.  You should make any improvements considered necessary.  You should submit evidence to the Committee that your interpersonal skills in these consultations are of an adequate standard. 

5.	You shall maintain your efforts through the assistance offered by the Health Authority about reducing the size of your patient list and seeking further assistance in your practice to help reduce your workload.”

4. 	The PCC resumed consideration of the appellant’s case at a hearing on 30th May 2001.  The PCC were invited to determine whether there had been a breach of the second section of the conditions 1 and 4 which their Lordships have quoted.  It was accepted on behalf of the respondent Council that in respect of the other conditions there had been total compliance by the appellant.

5. 	At the conclusion of the hearing on 31st May the PCC made the following decision.  Addressing the appellant the Chairman said:-
“… when the Committee considered your case in April 1999 and judged you guilty of serious professional misconduct, they found you had provided a poor standard of care to your patients.  On a number of occasions you had failed to take proper history, failed to examine patients and consequently failed to assess adequately their treatment needs.  Conditions were imposed on your registration.

“In May 2000 when the case was resumed, the Committee were satisfied that you had complied with those conditions. They noted that you had made good progress towards improving your standards of clinical knowledge and care and your communication skills.  However, some concerns remained and further conditions were imposed on your registration.

“The Committee’s first task today has been to consider whether you have complied with the conditions imposed in May 2000.  In this, we have been assisted by the reports provided to us and the evidence given by Dr Bailey and Dr Harrison which we have accepted, and the Committee have considered carefully the evidence given by you and Miss Storey [the appellant’s practice manager].

“Dr Bailey and Dr Lewis reviewed a video recording of your consultations with 10 patients.  The Committee accept the approach adopted by them as representing an independent and objective assessment of your performance against the minimum standards expected of a general practitioner completing vocational training.  The use of video assessment in this way is widely accepted across the profession. 

“The Committee recognise that you have been assessed against minimum entry requirements for doctors newly trained in general practice.  However, Good Medical Practice states that registered medical practitioners must keep their knowledge and skills up to date throughout their working life. 

“The Committee have therefore concluded that it is appropriate that your performance be judged against the standards expected today of new entrants to the specialty of general practice.  Indeed, the proper protection of patients demands nothing less. 

“The Committee accept that you have continued to work hard since May 2000 in an attempt to rectify the deficiencies that were previously identified in your performance. However, in the first of two formal objective assessments of your consultations, the assessors concluded that they had serious worries about your safety.  In the second, they concluded that you had not demonstrated any improvement in the standard of your clinical knowledge and skills and communication to the standard of a general practitioner completing vocational training.  Nor had you demonstrated that your interpersonal skills in consultations were of an adequate standard.  In this respect, you have failed to comply with the first and fourth conditions imposed by the Committee in May 2000. 

“The Committee, having seen the second video of your ten consultations, are seriously concerned by the deficiencies in your clinical management demonstrated in your performance as highlighted by Dr Bailey.  Furthermore, you appear to have little or no insight into the considerable extent to which your performance falls below acceptable standards.  They are seriously concerned also that although over the last two years while your registration has been subject to conditions and you have received a considerable amount of support and advice about your professional development, you have nevertheless failed to achieve the national minimum standard of a general practitioner completing vocational training. 

“The relevant legislation necessarily requires the Committee to consider what has emerged as to your current clinical performance.  If, as is the case here, it is evident that it falls significantly below appropriate minimum standards, the Committee must consider whether and, if so, what steps properly should be taken in the interests of the public and in your own interests.  Therefore, the Committee have had to consider what further steps are required in relation to your registration.  Their duty in this respect includes whether action is required to protect your current and future patients. 

“In the light of the serious deficiencies in your performance, the Committee have concluded that a further period of conditional registration would not adequately protect patients.  They have directed the Registrar to suspend your registration for a period of nine months.  The Committee have further determined that it is necessary for the protection of members of the public and in your own interests that your registration should be suspended with immediate effect and have accordingly ordered that your registration should be suspended forthwith. 

“The effect of the foregoing direction and order is that your registration will be suspended from today and, unless you exercise your rights of appeal, your name will be suspended from the Register 28 days from today. 

“The Committee will resume consideration of your case at a meeting to be held before the end of the period of nine months.  They will then consider whether to take further action in relation to your registration.  You will be informed of the date of the meeting which you will be expected to attend. 

“At that meeting, the Committee will wish to receive a report of an objective assessment of your current clinical knowledge and skills of a nature which will be determined by assessors nominated by the Council.  The report of that assessment will be available at the resumed hearing of your case.  You will be expected to demonstrate through this assessment that you are fit to continue in unrestricted practice. 

“Shortly before the resumed hearing, you will be asked to furnish the Council with 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 the hearing of your case.” 

6. 	The appellant appeals solely on the ground that the final determination to suspend the appellant’s registration was disproportionate and excessive.

7. 	In elaboration the appellant submitted that the apparent aim of the Committee in May 1999 was to rehabilitate the appellant and conditions were then imposed on his registration.  In May 2000 when the case was resumed the Committee were satisfied that these conditions had been complied with and that good progress had been made towards improving the standard of clinical knowledge and care and his communication skills by the appellant.  The appellant further submitted that the suspension was made during sustained substantial improvement on his part, an improvement the Committee acknowledged was produced by hard work.  Counsel went on to offer some criticisms of the assessments on which the Committee had relied, which had been raised in cross-examination.  

8. 	The submission for the respondent Council was that the course of action taken by the PCC was within their powers and should not be interfered with by this Board except for very good reason.

9. 	It is apparent that the PCC did not reach the conclusion in 1999 that the appellant could not become an adequately competent medical practitioner and therefore they did not direct erasure of his name from the Register but allowed him to practice subject to conditions which at the next hearing they found that he had fulfilled.  They then imposed the new conditions which were the subject of the latest consideration by the PCC.  Again the purpose of imposing these conditions was to further improve the appellant’s skills as a doctor.  Against that background their Lordships had difficulty in seeing how an order of suspension fitted into the programme hitherto followed.  The Committee gave as their reason that in the light of the serious deficiencies in the appellant’s performance conditional registration would not adequately protect patients.  But there is no suggestion that the appellant’s skills have deteriorated since 1999 when the original decision was taken.  And no suggestion is made in the decision of the Committee and no suggestion was offered to their Lordships at the hearing on how suspension could assist in further improving the appellant’s skills as a doctor.  The emphasis appears to be on assessment whereas it seems to their Lordships that further training is required.  The precise form of conditions which would sufficiently protect patients while at the same time enable the appellant to continue by hard work to improve the standards of his performance are for the Committee to consider but their Lordships have in view the possibility that a condition should be imposed requiring the appellant to practice only under the supervision of a properly qualified general practitioner, for example, as an employee, in the meantime making other arrangements for the care of the patients on his practice list.  Their Lordships consider that it has to be borne in mind that the breaches of conditions 1 and 4 found by the Committee are not deliberate but have been found to exist notwithstanding hard work to rectify the deficiencies that were previously identified in the appellant’s performance.

10. 	In the light of these considerations their Lordships take the view that the decision to suspend the appellant is not consistent with the decisions previously taken by the Committee and with the aim that appears to underlie the present decision of the Committee. Their Lordships will accordingly humbly advise Her Majesty that the case ought to be remitted to the Committee to consider conditions that should be imposed on the appellant’s practice as a doctor and in particular to consider whether such practice should be under the supervision of a registered medical practitioner, the appellant’s suspension to be lifted when that consideration is completed.

11. 	Their Lordships express the hope that the Committee can arrange an early date for the necessary consideration of this matter so that the appellant’s present suspension should continue only for as short a time as is possible.

12. 	The appellant is entitled to his costs of his appeal to this Board.