Fitness to PractiSe Panel

11 June 2008

7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ


Name of Respondent Doctor:       Dr Marisa VIEGAS


Registered Qualifications:              MB BS 1980 University of London


Registered Address:                        London


Registration Number:                      2653479


Type of Case:                                     Review case of impairment by reason of: misconduct.


Panel Members:                                Dr E Melrose, Chairman (Medical)

                                                               Mr S Galbraith (Medical)

                                                               Mr C Wheeler (Lay)


Legal Assessor:                                Mr T Jones 


Secretary to the Panel:                    Miss L Meads



GMC: Mr D Friesner, Counsel, instructed by GMC Legal.


Doctor: Present but not represented.


Determination on impaired fitness to practise


Dr Viegas: This is a review hearing of your case following a Fitness to Practise Panel’s finding in June 2007 that your fitness to practise is impaired by reason of your misconduct.


This Panel has noted the background to your case and your fitness to practise history as outlined by Mr Friesner, on behalf of the General Medical Council (GMC), and set out in the documents presented to the Panel which include the minutes of the Fitness to Practise Panel of 19 to 30 March and 14 to 28 June 2007.


In summary the Panel, in 2007, found that up to around the end of 1995 you were Ms A’s General Practitioner. Thereafter you advised Ms A on alternative therapies. You knew that Ms A had been diagnosed with idiopathic dilated cardiomyopathy in 1995 and had thereafter been under the care of Professor B, Professor of Cardiac Medicine at the Royal Brompton Hospital.


The Panel made findings that in June and August 2004 you did not adequately assess Ms A’s condition based upon history, symptoms or an examination. You did not take any, or any adequate steps to communicate with Ms A’s General Practitioner and/or treating consultant to ensure that they were advised as to the changes in treatment you were recommending. You also gave advice by email or telephone which you knew was contrary to the advice given and treatment prescribed by Ms A’s treating doctors. The Panel found that your conduct in August 2004 contributed to Ms A’s death. It also found that your conduct, in both June and August 2004, was inappropriate, unprofessional, not in the best interests of Ms A and irresponsible.


That Panel determined that your fitness to practise was impaired by reason of your misconduct and suspended your registration for a period of 12 months. It also stated that for this review hearing you should provide evidence that you have developed full insight into your actions and understand the gravity of your misconduct so that you are not at risk of repeating this behaviour. In addition, the previous Panel stated that it would be helpful for this Panel today to receive evidence that you have kept your clinical knowledge up to date, and that this could include attending accredited refresher courses in clinical medicine.


The Panel has today reviewed your case. It has considered, under Rule 22(f) of the GMC (Fitness to Practise) Rules 2004, whether your fitness to practise is impaired.  It has taken into account all the evidence placed before it, the submissions made by Mr Friesner, on behalf of the GMC, and your own evidence.


In determining whether your 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 noted your evidence that you have spent time since the last hearing thoroughly reviewing all of Ms A’s medical records and that you dispute the findings of the Fitness to Practice Panel in 2007.


The Panel has not been provided with any evidence from you that you have developed insight into your actions or any evidence that you understand the gravity of your misconduct so that you are not at risk of repeating this behaviour.


Furthermore, you have not provided any relevant evidence that you have kept your clinical knowledge up to date neither have you attended any accredited refresher courses. You were specifically asked to provide this information at the previous hearing. You told the Panel that the reason for not doing so is that you reside in Jamaica where such courses do not exist and that you were unaware that you could complete courses online. The Panel does not consider your explanation acceptable.


It is not within this Panel’s remit to go behind the previous Panel’s findings. You told the Panel that you consider a gross miscarriage of justice has occurred. However, you had the right to appeal the decisions made by the previous Panel but you did not do so.


In view of the absence of any objective evidence that you have addressed the concerns raised previously, the Panel has, pursuant to Section 35C(2)(a) of the Medical Act 1983, as amended, determined that your fitness to practise is impaired by reason of your misconduct. 


The Panel will now invite further submissions from Mr Friesner as to the appropriate sanction, if any, to be imposed on your registration. You will then be given an opportunity to respond. 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


Dr Viegas: The Panel has already determined that your fitness to practise is impaired by reason of your misconduct. The Panel must now determine what action, if any, to take in relation to your registration.


Mr Friesner on behalf of the General Medical Council (GMC) submitted that erasure is the appropriate sanction in this case. You told the Panel that you had nothing further to say in response. The Panel has used its own independent judgment as to what sanction, if any, should be imposed.


In determining whether to take action against your registration, the Panel has balanced the public interest against your own interests and taken into account the principle of proportionality. The Panel is mindful that although the purpose of sanctions is not to be punitive but to protect the public interest, they may have a punitive effect. The public interest includes the protection of patients, the maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour.


The Panel has had regard to all the guidance contained within the Indicative Sanctions Guidance, and has noted paragraph 32 at page S1-7 which states:


“It is important that no doctor should be allowed to resume unrestricted practice following a period of conditional registration or suspension unless the panel can be certain that he or she is safe to do so. …The Panel will also need to satisfy itself that the doctor has fully appreciated the gravity of the offence, has not re-offended, and has maintained his or her skills and knowledge and that patients will not be placed at risk by resumption of practice or by the imposition of conditional registration.”


In view of the serious nature of the findings against you the Panel has determined that it is necessary to take further action against your registration.


The Panel considered whether it would be sufficient to impose a period of conditions on your registration. Any conditions should be appropriate, proportionate, workable and measurable. It has determined that the imposition of conditions would not uphold professional standards or maintain public confidence in the medical profession.


The Panel went on to consider whether it would be sufficient to suspend your registration for a further period. 


Apart from the testimonial from Dr C, dated 20 May 2008, you have not provided any other information requested by the previous Panel which might have assisted this Panel in its assessment of your fitness to practise or demonstrated your commitment to keep your clinical knowledge up to date. 


The Panel has noted paragraph 46 at page S1-10 of the Indicative Sanctions Guidance which states under the heading: Failing to provide an acceptable level of treatment/care


            “Cases in this category are ones where a practitioner has not acted in a patient’s best interests and has failed to provide an adequate level of care, falling well below expected professional standards. Such cases may involve     factors identified on page S1-15 of this     guidance. A particularly important             consideration in such cases is whether or not a doctor has, or has the potential to develop, insight into             these failures. Where this is not evident, it is likely that conditions on registration or suspension may not be appropriate or sufficient.”


The Panel has noted your own evidence at page 38 of your documentation where you state


            “This would suggest that my standards of diagnosis and protection of patients are not shared by the profession or its regulators and       therefore I request that this review panel do not restore my name to the Medical Register of the United Kingdom.”


The Panel has considered the Indicative Sanctions Guidance relating to suspension found at page S1-14 which states a number of factors to be considered including:


            “Panel is satisfied doctor has insight and does not pose a significant risk of repeating behaviour.”


The Panel has also considered the previous Panel’s determination on sanction. It states


            “The Panel considers that, although you lack insight into your conduct in this regard, you have the potential to develop insight into this            crucial area of medical care.”


You told the Panel today in your own evidence that given the same identical circumstance, you would do the same thing again.


Therefore the Panel is not satisfied that you have demonstrated any insight into the serious matters which have brought you before this Panel, despite having been suspended for a year.


The Panel has concluded that your behaviour is fundamentally incompatible with your continuing to be a registered medical practitioner and has determined that, for the reasons set out above a further period of suspension is insufficient.


Accordingly, the Panel has determined to direct that your name be erased from the Medical Register. 


The effect of the foregoing determination is that, unless you exercise your right to appeal, your name will be erased from the register, with effect from 27 July 2008, once the current period of suspension has expired on 26 July 2008. Should you appeal, your current period of suspension will remain in place until the appeal is decided. Written notice of this decision will be served upon you in accordance with the Medical Act 1983, as amended.


That concludes this case.




June 2008                                                                                                                   Chairman