Fitness to PractiSe Panel
28 – 30 April 2008
7th Floor, St James’s Buildings,
Name of Respondent Doctor: Dr
John GRAY
Registered Qualifications: MB
ChB 1975
Registered Address:
Registration Number: 2277073
Type of Case: New case of impairment by reason of: misconduct
Panel Members: Mr D Kyle, Chairman (Lay)
Mr S Burton (Lay)
Ms E Samupfonda (Lay)
Mr S Galbraith (Medical)
Legal Assessor: Mr T Ward
Secretary to the
Panel: Miss L Meads
Representation:
GMC:
Ms B Baxter, Counsel, instructed by Field Fisher Waterhouse Solicitors
Doctor:
Not present or represented
allegation
“That being
registered under the Medical Act 1983
1. Between about January 2004 and May 2006
a. you pre-signed blank
prescriptions for use by your Nurse Practitioner, Mrs A, within your GP
Practice, Found proved
b. you pre-signed blank
Med.3 sickness certificates, for use by Mrs A, within your GP Practice, Found proved
c. Mrs A was not qualified
or registered as a supplementary Nurse Prescriber, Found proved
d. Mrs A completed the
pre-signed blank prescriptions and issued them to Patients registered with your
GP Practice when she was not qualified or registered to do so, Found proved
e. Mrs A completed the
pre-signed blank Med. 3 sickness certificates and issued them to Patients
registered with your GP Practice when she was not qualified or registered to do
so, Found proved
f. you were aware of the
matters set out at (c) (d) and (e) above;
Found proved
2. On or about 10 May 2006
a. approximately 2000 blank
prescriptions, pre-signed by you, were found at your GP Practice, at a time
when you were away on holiday,
Found proved
b. approximately 5 blank
Med 3 sickness certificates, pre-signed by you, were found at your GP Practice
at a time when you were away on holiday, Found
proved
c. During your absences
from your GP Surgery on holiday
i. you engaged a locum GP
to provide medical cover for only two, two hour sessions per day (morning and
afternoon), save for Thursday (half day) when there was cover for one two hour
session in the morning, Found proved
ii. Mrs A provided medical
and emergency cover in the absence of the locum GP, Found proved
iii. you knew that Mrs A was
not medically qualified or registered to provide the cover referred to at 2 (c) (ii) above;
Found proved
3. At all material times
a. your Nurse Practitioner
conducted an open morning surgery, which included
i. examining
patients, Found proved
ii. writing
up Patient notes, Found proved
iii. issuing
pre-signed prescriptions, Found proved
iv. issuing
pre-signed Med. 3 sickness certificates,
Found proved
b. Mrs A undertook home
visits,
c. Mrs A provided medical
and emergency cover in your absence and the absence of a locum GP, Found proved
d. You did not provide Mrs A
with any adequate
i. training, Found proved
ii. appraisal, Found proved
iii. clinical supervision,
for the role she was performing within your GP surgery as set out at (a), (b)
and (c) above; Found proved
4. At all material times you did not have
a written policy in place to monitor and manage repeat prescriptions; Found proved
5. Your conduct as set out in paragraphs 1
(a), (b) and (f), 2 (a), (b), (c) (i) and (iii), 3 (d), and 4 above was
a. inappropriate, Found proved
b. improper, Found proved
c. not in the best
interests of your patients.” Found
proved
And that by reason
of the matters set out above your fitness to practise is impaired because of
your misconduct.” Found proved
Determination on facts
Ms Baxter: The
Panel notes that Dr Gray is neither present nor represented.
At the start of the
hearing you made an application for the Panel to proceed in Dr Gray’s
absence in accordance with Rule 31 of the General Medical Council (GMC) (Fitness
to Practise) Rules 2004. The Panel noted the letter from Berrymans Lace Mawer,
Dr Gray’s solicitors, dated 22 April 2008, which confirms that Dr Gray will not
be attending or represented here today. Having considered this information, the
Panel determined that it was in the interests of justice to proceed with the
hearing in Dr Gray’s absence, pursuant to Rule 31, being satisfied that Dr
Gray had received notice of this hearing.
The Panel has given careful consideration to
all the evidence adduced in this case, including the oral evidence of Mr E,
Pharmacy Manager, Dr B, Associate Director of Medicine for Oldham Primary Care
Trust, Mrs C, Practice Manager and Mrs D, Practice Nurse. The Panel has
noted that the evidence which it heard has not been challenged. Further it has
judged all four witnesses to be both reliable and consistent.
The Panel has also taken account of your
submissions on behalf of the GMC. It has acceded to your submission to delete
(f) from paragraph 5.
The Panel has borne in mind that the burden
of proof rests on the GMC and that the standard of proof required is that the
Panel has to be satisfied so that it is sure that the facts and allegations
have been proved. In this case the Panel, having considered each paragraph separately
is sure, on the basis of all the evidence adduced, that the following
allegations and facts have been proved.
Paragraph 1a has been found proved.
Paragraph 1b has been found proved.
Paragraph 1c has been found proved.
Paragraph 1d has been found proved.
Paragraph 1e has been found proved.
Paragraph 1f has been found proved.
Paragraph 2a has been found proved.
Paragraph 2b has been found proved.
Paragraph 2c has been found proved in its
entirety.
Paragraph 3a has been found proved in its
entirety.
Paragraph 3b has been found proved.
Paragraph 3c has been found proved.
Paragraph 3d has been found proved in its
entirety.
Paragraph 4 has been found proved.
Paragraph 5a in relation to paragraphs 1a,
1b, 2a, 2b, 2ci, 2ciii, 3d, and 4 has been found proved.
Paragraph 5b in relation to paragraphs 1a,
1b, 2a, 2b, 2ci, 2ciii, 3d, and 4 has been found proved.
Paragraph 5c in relation to paragraphs 1a,
1b, 2a, 2b, 2ci, 2ciii, 3d, and 4 has been found proved.
Having reached its findings on the facts, the Panel now invites you to adduce any further evidence and make any further submissions as to whether, on the basis of the facts found proved, Dr Gray’s fitness to practise is impaired.
Determination on impaired fitness to practise
Ms Baxter: The Panel has considered whether, on the basis of the
facts found proved, Dr Gray’s fitness to practise is impaired by reason of his misconduct.
You have submitted on behalf of the General Medical Council (GMC) that Dr Gray’s fitness to practise is impaired.
The facts found
proved are as follows:
Between about
January 2004 and May 2006 Dr Gray pre-signed blank prescriptions and pre-signed
blank Med 3 sickness certificates for use by his Nurse Practitioner, Mrs A,
within his GP Practice. Mrs A was not qualified or registered as a
supplementary Nurse Prescriber. She completed the pre-signed blank prescriptions,
and the pre-signed blank Med. 3 sickness certificates, and issued them to patients
registered with Dr Gray’s GP Practice when she was not qualified or registered
to do so. Dr Gray was aware of all these matters. The Panel judged Dr Gray’s
conduct in this regard to be inappropriate, improper and not in the best
interests of his patients.
On or about 10 May
2006 approximately 2000 blank prescriptions, and approximately 5 blank Med 3
sickness certificates, pre-signed by Dr Gray, were found at his GP Practice, at
a time when he was away on holiday. During his absences from his GP Surgery on
holiday Dr Gray engaged a locum GP to provide medical cover for only two, two
hour, sessions per day (morning and afternoon), save for Thursday (half day)
when there was cover for one, two hour, session in the morning. Mrs A provided
medical and emergency cover in the absence of the locum GP, when Dr Gray knew
that Mrs A was not medically qualified or registered to provide this cover. The
Panel judged Dr Gray’s conduct in this regard to be inappropriate, improper and
not in the best interests of his patients.
At all material
times Dr Gray’s Nurse Practitioner, Mrs A, conducted an open morning surgery,
which included examining patients, writing up Patient notes, issuing pre-signed
prescriptions, and issuing pre-signed Med. 3 sickness certificates. Further Mrs
A undertook home visits, and provided medical and emergency cover in Dr Gray’s
absence and the absence of a locum GP. Dr Gray did not provide Mrs A with
any adequate training, appraisal, or clinical supervision, for the role she was
performing within his GP surgery. The Panel judged Dr Gray’s conduct in this
regard to be inappropriate, improper and not in the best interests of his
patients.
At all material
times Dr Gray did not have a written policy in place to monitor and manage
repeat prescriptions. The Panel judged that his conduct was inappropriate,
improper and not in the best interests of his patients.
In determining
whether Dr Gray’s fitness to practise is impaired, the Panel considered the
GMC’s Indicative Sanctions Guidance (April 2005). In particular, at paragraph
11 of section 1, it states that:
“Neither the Act nor the Rules define what is meant by impaired fitness
to practise but for the reasons explained below, 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 heard
that Dr Gray was on the Oldham Primary Care Trust (the PCT) performers list
since 1981. He was a single handed GP, based at the Crofton Street Surgery (the
Practice) with a list of approximately 5000 patients. The practice was
previously a two partner practice until the resignation of the senior partner
in April 2003.
The PCT complaints
department was alerted on 3 May 2006, when Dr Gray was on holiday, to the
possible use by non-medically qualified staff of blank prescriptions pre-signed
by Dr Gray before he went on holiday. As a result an investigation was
initiated by the PCT which revealed the use of pre-signed blank prescriptions
by the nurse practitioner.
In reaching its
judgement on whether Dr Gray’s fitness to practise is impaired, the Panel has
considered the duties and responsibilities of doctors set out in Good Medical
Practice (2001) which was applicable at the time.
It is apparent to
the Panel that, following the senior partner’s resignation in April 2003, Dr
Gray found himself running a practice in which, given the size of the patient
list, a single GP could not provide the necessary level of medical cover.
The Panel considers
that this was a major problem for the practice which Dr Gray should have
appreciated and taken appropriate action to address. Under the heading “Good
Clinical Care”, Good Medical Practice states at paragraph 4
“If you have good reason to think that your ability to treat patients safely
is seriously compromised by inadequate premises, equipment, or other resources,
you should put the matter right, if that is possible. In all other cases you
should draw the matter to the attention of your Trust, or other employing or
contracting body. You should record your concerns and the steps you have taken
to try to resolve them.”
On the evidence
which the Panel has heard, Dr Gray does not appear to have sought the
assistance of the PCT or to have taken any steps to recruit additional GP
resources for the Practice or to remedy the situation through engagement of
sufficient locum cover. Rather, he chose to make use of his nurse practitioner,
Mrs A, in a role which was described by Mrs C, the practice manager, and Mrs D,
the practice nurse, as being akin to that of a GP. This, in the panel’s view,
led, over a substantial period of time, to the development of dangerous,
illegal and unacceptable practices and to the creation of a dysfunctional
regime which undermined the ability of staff to work as a team and provide
effective health care.
Good Medical
Practice at paragraph 19 states that a doctor should always be prepared to
explain and justify his actions and decisions. In the Panel’s opinion,
Dr Gray has singularly failed to do so and in particular has given no
explanation either for his failure to pursue additional GP resources or his
decision to delegate the provision of GP services to a nurse practitioner.
With reference
again to Good Medical Practice, it states in the section “Good Clinical Care”
under the heading “Providing a good standard of practice and care”
“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;
- providing or arranging investigations
or treatment where necessary;
- taking suitable and prompt action when
necessary;
- referring the patient to another
practitioner, when indicated.”
Although
the Panel accepts that nurse practitioners can deal with patients within the
limits of their qualifications and competence, the Panel finds that Dr Gray
seriously failed in his duty of care towards those of his patients who were
regularly seen on a daily basis by Mrs A who appears to have provided a range
of GP services when not qualified to do so and without any supervision by Dr
Gray.
Paragraph 3 of Good
Medical Practice states that a doctor must
“prescribe drugs or treatment,
including repeat prescriptions, only where you have
adequate knowledge of the patient’s health and medical needs. You must not give or recommend to patients
any investigation or treatment which
you know is not in their best interests,
nor withhold appropriate treatments or referral;”
It is clear to the
Panel that Dr Gray has over a considerable period of time breached this duty of
care to his patients by pre-signing blank prescription forms and leaving them
to be used by Mrs A. The Panel is particularly struck by the fact that
Dr Gray had pre-signed in the order of 2000 prescription forms which
leaves no room for doubt about his intention that Mrs A should play a
substantial and improper part in the delivery of medical services.
The Panel further
finds that Dr Gray breached this section of Good Medical Practice by failing to
have in place an effective written policy to monitor and manage repeat
prescriptions.
In the section
“Dealing with problems in professional practice” under the heading “Conduct or
performance of colleagues” it states
“If you have management responsibilities
you should ensure that mechanisms are
in place through which colleagues can raise concerns about risks to patients.”
The Panel heard
evidence from both Mrs C and Mrs D that there were concerns within the Practice
but that there was no facility to deal with those concerns. They also said
that, given the personalities of Dr Gray and Mrs A, they felt inhibited from
voicing these concerns.
In the section
“Working with Colleagues” under the heading “Working in teams” it states
“Healthcare
is increasingly provided by multi-disciplinary teams. Working in a team does
not change your personal accountability for your professional conduct and the
care you provide. When working in a team, you must:
- respect the skills and contributions of
your colleagues;
…
- communicate effectively with colleagues
within and outside the team;
- make sure that your patients and
colleagues understand your professional status and specialty, your role and
responsibilities in the team and who is responsible for each aspect of
patients’ care;”
As already stated,
the Panel finds that this was a dysfunctional practice in which there was no
effective team working. As the sole practitioner, Dr Gray must be held
responsible for this state of affairs.
The guidance goes
on say under the heading “Leading teams”
“If you lead a team, you must ensure that:
- medical team members meet the standards
of conduct and care set in this guidance;
- any problems that might prevent
colleagues from other professions following guidance from their own regulatory
bodies are brought to your attention and addressed;
- all team members understand their
personal and collective responsibility for the safety of patients, and for
openly and honestly recording and discussing problems;
- each patient’s care is properly
co-ordinated and managed and that patients know who to contact if they have
questions or concerns;
- arrangements are in place to provide
cover at all times;
- regular reviews and audit of the
standards and performance of the team are undertaken and any deficiencies are
addressed;
- systems are in place for dealing
supportively with problems in the performance, conduct or health of team
members.”
Dr Gray did not
take steps to replace his former partner with another GP, nor did he arrange
adequate locum cover. Instead he allowed Mrs A to act as a quasi-GP which
compromised patient safety. Dr Gray did not regularly review or audit his team
which is demonstrated by his approach to recruitment and the lack of training
or induction of new staff.
In the same section
under the heading “Arranging cover” it states
“You must be satisfied that, when you are off duty, suitable arrangements
are made for your patients’ medical care. These arrangements should include
effective hand-over procedures and clear communication between doctors.
If you arrange cover for your own practice, you must satisfy yourself that
doctors who stand in for you have the qualifications, experience, knowledge and
skills to perform the duties for which they will be responsible. Deputising
doctors and locums are directly accountable to the GMC for the care of patients
while on duty.”
Dr Gray did not put
any appropriate permanent arrangements in place to provide cover after his
partner resigned in 2003, nor did he provide adequate temporary cover when he
went away on holiday.
Under the heading
“Delegation and referral” it states
“Delegation involves asking a nurse, doctor, medical student or other health
care worker to provide treatment or care on your behalf. When you delegate care
or treatment you must be sure that the person to whom you delegate is competent
to carry out the procedure or provide the therapy involved. You must always
pass on enough information about the patient and the treatment needed. You will
still be responsible for the overall management of the patient.”
Dr Gray told the PCT that Mrs A was competent in performing the role she
undertook at the Practice. The Panel considers that this assertion indicates a
lack of insight and understanding on Dr Gray’s part and that his subjective
belief in Mrs A’s competence cannot excuse the fact that she should never
have been given such a role.
In the section
“Probity” under the heading “Writing reports, giving evidence and signing
documents” it states
“You must be honest and trustworthy
when writing reports, completing or signing
forms, or providing evidence in litigation or other formal inquiries. This means that you must take reasonable steps to
verify any statement before you sign a document. You must not
write or sign documents which are false or
misleading because they omit relevant information.”
In addition to
pre-signing prescriptions, Dr Gray also adopted a practice of pre-signing Med 3
sickness certificates for Mrs A to complete. A sickness certificate is accepted
by employers as evidence of a person’s inability to work on the basis of a
doctor’s examination. There was no such examination by a doctor in cases where
Mrs A completed the certificate and Dr Gray accordingly connived in the
presentation of dishonest information. The danger of this practice was
evidenced by Mrs D who told the Panel of an occasion when Mrs A issued a
certificate pre-signed by Dr Gray to a patient who had earlier the same day
been refused a certificate by the GP locum.
The Panel has
concluded that Dr Gray has seriously breached numerous aspects of Good Medical
Practice. The Panel is mindful that this guidance describes the principles of
good medical practice and standards of competence, care and conduct expected of
doctors in all aspects of his or her professional work.
The Panel is conscious
of its responsibility to protect the public interest, particularly with
reference to the protection of patients, maintaining public confidence in the
profession and declaring and upholding proper standards of conduct and
behaviour. The Panel is in no doubt
that Dr Gray’s conduct was inappropriate and improper; that it put patient
safety at risk; and that as such it undermines public confidence in the profession.
In all the
circumstances, the Panel has, pursuant to Section 35C(2)(a) of the Medical Act
1983, as amended, concluded that Dr Gray’s fitness to practise is impaired by
reason of his misconduct.
The Panel will now
invite further submissions from you as to the appropriate sanction, if any, to
be imposed on Dr Gray’s registration. Submissions on sanction should include
reference to the Indicative Sanctions Guidance, using the criteria as set out
therein to draw attention to the issues which appear relevant to this case.
Determination on sanction
Ms Baxter: Having
made and announced its finding that Dr Gray’s fitness to practise is impaired
by reason of his misconduct, the Panel has now considered what action, if any,
it should take with regard to his registration.
The Panel has taken
into account your submissions on behalf of the General Medical Council (GMC)
and all the evidence adduced in this case. You submitted that the only appropriate
sanction, to protect the public interest, is erasure.
The Panel has had
regard to the GMC’s Indicative Sanctions Guidance (April 2005). It has borne in mind that any sanction must
be proportionate and that its purpose is not to be punitive, though it may have
a punitive effect. The Panel has balanced Dr Gray’s interests with those of
patients and the wider public interest. The public interest includes not only
the protection of patients but also the maintenance of public confidence in the
profession and the declaring and upholding of proper standards of conduct and
behaviour.
Firstly, the Panel considered whether to conclude Dr Gray’s case and
take no further action. In the light of the extent of his misconduct, it
concluded that to take no action on his registration would be wholly
insufficient.
The
Panel next considered whether it would be sufficient to impose a period of
conditions on Dr Gray’s registration. Any conditions should be appropriate, proportionate, workable and
measurable. It has determined that, although
conditions might be formulated to address some of Dr Gray’s failings, the imposition
of conditions would not adequately reflect the gravity of his prolonged misconduct, which includes significant abuse
of position and trust and lack of probity. Nor would it uphold professional
standards or maintain public confidence in the medical profession.
The Panel went on
to consider whether it would be sufficient to suspend Dr Gray’s registration
and noted the Indicative Sanctions Guidance which states at paragraph 27
“Suspension
can be used to send out a signal to the doctor, the profession and public about what is regarded as
unacceptable behaviour. Suspension from
the register also has a punitive effect, in that it prevents the doctor from practising (and therefore from earning a
living as a doctor) during the period of suspension.
It is likely to be appropriate for misconduct that is serious, but not so serious as to justify erasure (for
example where there may have been acknowledgement
of fault and where the panel is satisfied that the behaviour or incident is unlikely to be repeated).”
The Panel also
considered the factors set out, in the Indicative Sanctions Guidance, relevant
to when suspension may be the appropriate sanction. These include amongst
others: a serious instance of misconduct but where a lesser sanction is not sufficient;
not fundamentally incompatible with continuing to be a registered doctor; and
where the Panel is satisfied that a doctor has insight and does not pose a
significant risk of repeating such behaviour.
The Panel
considered such mitigating factors as it has been able to discern in this case,
bearing in mind that Dr Gray himself has chosen not to participate in the
hearing. There is no evidence that any patients actually came to harm, that Dr
Gray has any previous findings against him, that there are any doubts about his
clinical competence or that there has been any repetition of his misconduct
since it came to light.
Weighed against
this however, the Panel is mindful that Dr Gray has significantly breached
numerous aspects of the standards set out in Good Medical Practice. It regards
as particularly serious the extent to which, over a prolonged period, he was
instrumental in misleading patients as to the nature of care they were
receiving and exposing them to risk through treatment by Mrs A, the nurse
practitioner, who was not qualified to act at the level that she did. Inherent in all of this was the widespread
deceit of others brought about by Dr Gray’s dangerous and unprofessional
practice of pre-signing prescriptions and sickness certificates for Mrs A’s
use. In the Panel’s judgement, although Dr Gray admitted at the time of the PCT
hearing that he was wrong to have given Mrs A the role that she undertook,
there is no evidence to show that he has true insight into the seriousness or
consequences of his actions.
The Panel noted
that the Privy Council has stated in the case of Dr Willem Bijl v GMC (Privy
Council appeal No. 78 of 2000) that a Panel should not feel it necessary to
erase
“an otherwise competent and useful
doctor who presents no danger to the
public in
order to satisfy [public] demand for blame and punishment”.
But it has weighed this against the words of Lord Bingham, Master of the
Rolls, in the case of
“The reputation of the profession is
more important than the fortunes of an individual
member. Membership of a profession
brings many benefits, but that is part of the price.”
Doctors have a
respected position in society and their work gives them privileged access to
patients. A doctor whose conduct has shown that he cannot justify the trust
placed in him should not continue in unrestricted practice while that remains
the case. In short, the public is entitled to expect that their doctor is fit
to practise, and follows the GMC’s principles of good practice described in Good
Medical Practice.
The Panel has
concluded that Dr Gray’s behaviour is fundamentally incompatible with being a
doctor. It has therefore determined that it would be neither proportionate nor
appropriate to suspend his registration. Accordingly, the Panel directs that Dr
Gray’s name be erased from the medical register.
The effect of this
direction is that Dr Gray’s name will be erased from the Medical Register 28
days from the date on which notice of this direction is deemed to have been
served upon him.
Having reached this
decision, the Panel is minded to consider whether it is necessary for his
registration to be suspended with immediate effect and will take submissions on
this point.
Determination on immediate sanction
Ms Baxter: The
interim order for suspension on Dr Gray’s registration is hereby revoked.
Having determined
that Dr Gray’s name should be erased from the register, the Panel has now
considered in accordance with Section 38(1) of the Medical Act 1983 as amended,
whether his registration should be suspended immediately.
The Panel has
considered your submissions on behalf of the GMC, that an immediate order is
necessary.
The matters
identified during this hearing which necessitated the erasure of Dr Gray’s name
from the register are so serious that the Panel has decided it is in the public
interest that his registration should be suspended with immediate effect.
This means that Dr
Gray’s registration will be suspended from the date on which written
notification of this decision is served on him. The substantive direction for
erasure, as already announced, will take effect 28 days from when notice is
deemed to be served upon him, unless Dr Gray lodges an appeal in the
interim. If he does lodge an appeal, the
immediate suspension will remain in force until the substantive direction takes
effect.
That concludes this case.
Confirmed
April 2008 Chairman