“Miss A was born on23 May 1985 and became ill over the year from the summer of 1996 until approximately June 1997, aged 12. At that time she was a pupil at the local primary school, where she played netball and enjoyed choir and orchestra. Apart of these events, Miss A had had a normal, healthy childhood, with no unusual or relevant hospital admissions and few, out of the usual visits, to her general practitioner. As early as November 1996 Dr Earley a consultant paediatrician at the claimant’s local hospital, Wycombe General Hospital had given Miss A and her parents an oral diagnosis at consultation that Miss A had ME. By June 1997 Miss A was bedridden. She was bedridden because she was in constant physical pain. She was confined to bed for 24 hours a day. She ached physically in every part of her body. Her muscles ached, her eyes ached, it hurt to listen and her head ached so that she was unable to concentrate. By her own instruction she moaned and whined a lot. She could not hold conversations. From the age of 12 she was confined to bed with what was diagnosed to her as a physical condition without the ability to read, to watch television, to listen to the radio or to music or to hold conversations of any meaningful nature. She could not move from the bed, so she did nothing at all for two whole years. She did not go out, she did not go downstairs in the family home, as moving was so excruciatingly painful. She could not even walk to the bathroom, and her parents and other carers toiletted and bathed her in bed. She did not develop bedsores because she moved around in pain so constantly, as no position was really comfortable for her. At the time that Dr Cheetham came to see her in June 1997 Miss A was seriously ill, but able to comprehend different types of treatment. She is clear that she wanted to remain at home with her parents in the face of an understanding that Doctor Cheetham wished her to be admitted as an in-patient at hospital for ‘treatment’. She was however, in no position at all, to do other than convey these views to her parents unless someone was at her bedside. Muscular pain made it too painful to write or type, but she could make her views known. From about the age of 14, in mid 1999, Miss A was gradually able to read again and to converse and thus communicate more fully. However she remained physically ill and totally bedridden, but she was able to participate in conversations with her parents and other visitors.”
“31(2) A court may only make a Care Order or Supervision Order if it is satisfied – a) that the child concerned is suffering, or is likely to suffer, significant harm; and b) that the harm, or likelihood of harm, is attributable to – i) the care given to the child, or likely to be given to him if the order were not made, not being what it would be reasonable to expect a parent to give to him; or………….. (9) In this section “harm” means ill treatment or the impairment of health or development; “development” means physical, intellectual emotional social or behavioural development; “health” means physical or mental health; and “ill-treatment” includes sexual abuse and other forms of ill treatment which are not physical. (10) Where the question of whether harm suffered by a child is significant turns on the child’s health or development, his health or development shall be compared with that which could reasonably be expected of a similar child.” a) that the child concerned is suffering, or is likely to suffer, significant harm; and b) that the harm, or likelihood of harm, is attributable to – i) the care given to the child, or likely to be given to him if the order were not made, not being what it would be reasonable to expect a parent to give to him; or………….. (9) In this section “harm” means ill treatment or the impairment of health or development; “development” means physical, intellectual emotional social or behavioural development; “health” means physical or mental health; and “ill-treatment” includes sexual abuse and other forms of ill treatment which are not physical. (10) Where the question of whether harm suffered by a child is significant turns on the child’s health or development, his health or development shall be compared with that which could reasonably be expected of a similar child.”
“This means that he advocates doing nothing, keeping the child at home, I think at all costs. On the other hand there are also many other doctors I think the overwhelming majority who would not adhere to such a view, and I would have thought that most would have called it into question with a child who had been so ill for so long. The fact that there is a division of opinion about whether it is a psychiatric or a physical condition, and I think that most doctors agree with Dr Speight that we do not have an effective cure to offer for this condition, does not mean to say that many doctors would share the view that nothing can or should be done. In the absence of physiotherapy the child may develop muscle atrophy, spinal and other joint deformity which may prove seriously disabling during the currency of the condition and intractable after the ME has recovered. Where a child is having this sort of difficulty in eating the nutritionist may have a vital contribution to make. A speech therapist may have an important contribution to make. The fact that the condition may be physical or may be psychological that in either event there seems to be no predictable or usually effective cure does not mean that there is not a vital role for the multi-disciplinary approach to support and protect the child. It is not clear to me from the papers how effective the support was that this child was receiving or whether this was best given in the home. I can readily understand that Dr Cheetham questioned how Dr Speight could organise this from 200 miles away. I understand that at the hearing before the GMC neither the general practitioner nor Doctor Speight gave evidence and that the family refused permission for the solicitors acting for Doctor Cheetham to obtain a statement from either of them. This means that the treatment philosophy and regime to which Doctor Cheetham was expected to defer, was not described to the Committee by the doctors responsible for it. The effectiveness of this secondary pattern of care must have been as obscure to the GMC as I suspect it was to Doctor Cheetham.”
“Having made these findings of fact, the Committee had to consider whether they, together with the admitted facts, would be insufficient to support a finding of serious professional misconduct. In order to do so they had further to consider whether the General Medical Council had disproved your case that your conduct was justified on a number of grounds all of which were capable of entitling you to ignore what might be regarded as the normal rules applying to patient consent and confidentiality. In this case, of course, that consent and confidentiality related to the parents of Miss A, Mr and Mrs B. The Committee followed the advice of the Legal Assessor in paragraph 10 of his written advice that: ‘It is for the GMC to negative Doctor Cheetham’s case i.e to prove he was not justified in his conduct / did not have reasonable cause and, to reject it, the Committee would have to feel that he was not justified / did not have reasonable cause.’ The over-riding principle and potentially the most comprehensive justification for your conduct, as it seemed to the Committee, was where a doctor has reasonable cause to suspect that the child concerned is suffering or is likely to suffer significant harm. This was the issue they next considered. As again they have been advised, the right to intervene in such cases derives from theChildren Act 1989 which contains a definition of ‘harm’. They took into account all the circumstances relating to Miss A’s condition and management as known to you at the material time and your integrity, expertise and reputation as a senior paediatrician. In the result they could not feel sure that you did not have reasonable cause to suspect that Miss A was suffering or was likely to suffer significant harm. Since this meant you could not be said not to have a right to intervene it followed that the Committee determined that the facts that they had found proved and those which had been admitted were insufficient to support a finding of serious professional misconduct against you. Having made their finding in relation to the overriding principle with the consequences that flow from it, the Committee did not consider it necessary to consider other aspects of your case which were said to justify your conduct. Accordingly the Committee find you not guilty of serious professional misconduct. The Committee would not wish Mr and Mrs B to regard this determination as reflecting any sort of criticism of them. It is clear to the Committee that they are intelligent, loving and devoted parents whose paramount concern has been for their daughter’s welfare. They were entitled as are all parents to have the treatment of their choice for their child. However, that did not nullify the right of a doctor with legitimate concerns for his former patient in the special circumstances permitted by law from expressing those concerns in the way that you did. In a case where competing interests cannot be reconciled the Committee can do no more than faithfully apply the law to the facts of the case and reach their determination accordingly. That concludes the case. ” “-------------------------------------” ‘It is for the GMC to negative Doctor Cheetham’s case i.e to prove he was not justified in his conduct / did not have reasonable cause and, to reject it, the Committee would have to feel that he was not justified / did not have reasonable cause.’ That concludes the case. ”
“We both know that I did a domicillary on this child yesterday……… I met [the father] downstairs and from time to time there were small crying noises from the room upstairs. After a period [the mother] joined us and then we went upstairs to have a look at Miss A who was lying in bed with her eyes half open making continuing voluntary movements of arms, back and leg. Every so often she cried. She spoke in a weak and complaining voice. It was possible to engage her in conversation. When I did this she started to speak in a more normal voice but after a bit her parents would interrupt a question I would ask her, and that would have the effect of making her cry and retreat into the small complaining voice again. The whole episode was quite distressing. I advised that Miss A should be admitted to hospital and that she should have a planned gradual rehabilitation programme and this advice has not been accepted. I was told that Doctor Speight , a paediatrician in Durham had been contacted and had advised that hospital admission was contra indicated. Since visiting the home I have tried to telephone Doctor Speight and discovered that he is on annual leave and he will be back next week and I will telephone him then. I have telephoned [the father] to tell him what has happened. He then introduced the names of other doctors. I have explained to [the father] that I am pleased to try and help with Miss A. However, if whenever I suggest a course of action, he says that another doctor disagrees with that course of action, it then becomes imperative upon him to seek the advice of that doctor properly and professionally. I think that he understood the force of that argument and he has promised to give me the names of any other doctors who he thinks will disagree with my proposed course of action. I propose to telephone him early next week.”
“My wife and I have decided that we no longer wish your involvement, nor the involvement of Wycombe General Hospital in the treatment of our daughter [Miss A] with effect from today. We shall continue [Miss A’s] care under that provided by Dr Masters and his team at Highfield. I have today spoken with Dr Masters and he is aware of the position.”
‘I understand that you do not want Doctor Cheetham to have any professional contact with your daughter, or any professional involvement with her medical treatment. Also you do not want the South Buckinghamshire NHS Trust to block a referral to a paediatrician outwith the Trust.’
“Reason for review This was the first child protection conference in respect of Miss A. There has been growing concern expressed by health professionals at Highfield surgery regarding Miss A’s health and well-being, this concern has been heightened because the parents have had difficulties in finding a mutually acceptable way forward regarding the treatment and care of Miss A……… Background information Miss A has a chronic fatigue type illness with symptoms consistent with ME. She is now bed-bound and needs assistance with all basic activities. Miss A does nor attend at school and at present is too weak for home tuition. There have been misunderstandings and differences of opinion regarding her treatment and [her father] has little trust in the professional system thus the family are isolated. Views put forward by parties involved Viv Dacre, social worker, presented her social work report to the conference (see attached). She reiterated that she had not been able to see Miss A as [her father] did not want her to…… Dr Nigel Masters, GP, then addressed the conference giving the history of his involvement. He described it as an overwhelming case. He stated that Dr Maxim began to see Miss A six weeks ago. She had been seen by Dr Earley (consultant paediatrician) ay Wycombe General Hospital but no further diagnosis was made. Miss A got progressively worse being confined to her bed eventually. During which time she was visited by Dr Cheetham (consultant paediatrician). He explained that his main concern was to keep the channels of communication open and that he had referred Miss A to the Brakespeare Hospital but Bucks Health Authority would not fund it. No firm diagnosis had actually been made however Dr Masters believed the illness to be some form of sommetisation disorder or chronic fatigue disorder. [The father] felt that this was not the correct diagnosis and while Miss A needs psychological support she is not suffering from some sort of psychiatric disease. Tests have been carried out by Dr Munro which he felt would reveal the cause of the illness……. Dr Nigel Masters, GP, advised the conference that he had ascertained that Dr Prendergast, consultant psychiatrist at the Great Ormond Street Hospital specialises in the diagnosis and treatment of children with this kind of disorder. In that context he is in a position to call on the advice and intervention of other specialists within the hospital as appropriate……… [The father] after discussion with his wife agreed that Miss A should be referred to Dr Prendergast at Great Ormond Street Hospital.”
“SUMMARY Adrian Collin, Conference Chair summarised the conference as follows: ‘This afternoon’s child protection conference was attended by both parents. The situation is one of a twelve-year-old girl who has been bed-bound for approximately 2 months further to a protracted period of illness which started with investigations by Dr Earley approximately a year ago. Social Services have been unable to complete an assessment but were aware that there was conflict between [Miss A’s] parents and various medical practitioners regarding the management of her illness and appropriate therapy. The outcome of this afternoon’s discussion was an undertaking given by [Miss A’s] parents that they would support Dr Nigel Masters’ referral to Dr Prendergast consultant psychiatrist at Great Ormond Street Hospital. On taking advice from conference members the chair was of the opinion that Miss A is at risk of significant harm if this course of action is not pursued. In view of this an adjourned initial child protection conference has been arranged for Wednesday 27 August at 4 pm in the Chiltern Social Services office in Room 1. This will go ahead if the proposed referral of Miss A to Great Ormond Street Hospital does not go ahead or the process is complicated in any way that holds up urgent attention of her current situation. DECISION The Conference were in agreement that Miss A’s name should not be put on the Buckinghamshire child protection register.”
“We believe that the composition of the conference was heavily biased and that opinions had already been formed by those present at the conference. Had all invitees attended the conference we would have been outnumbered 19:2. The only representative that could support our position about the hitherto management of our daughter’s condition, namely Dr Munro, had been refused payment of her fee after Social Services originally agreed to it. Our only requested representation had therefore been denied us. The minutes of the conference are peppered with references to Dr Munro as the ‘complimentary medicine doctor.’ For the record I would like the following facts to be recorded: Dr Jean Munro MB, BS, MRCS, LRCP, FAAEM, DIBEM, NACOEM Dr Jean Munro is a qualified doctor and medical director of the Brakespeare Hospital. The hospital has an excellent reputation specialising in the treatment of Allergy in Environmental Medicine. Some 75% of all patients attending the Brakespeare are referred by Health Authorities all over the United Kingdom on a fully funded basis. We refer to the question of the purported complaint against Dr Cheetham which is minuted. We reaffirm that we have made no formal complaint against Dr Cheetham and we have a written acknowledgement from South Bucks NHS Trust to this effect. However we would confirm that according to the statements made to us by Ms Suggate and Dr Masters, Dr Cheetham had actually blocked Social Services and other medical services when Miss A first became acutely ill and the family were in severe difficulties. We do not understand why he did this, and we still think it was a strange act. This was one of the reasons why there had been so much tension between the family and Dr Cheetham, and which subsequently led to us asking him not to be involved with the case. Dr Masters confirmed to the conference Dr Cheetham had indeed blocked these services, but this important information is not recorded in the minutes. It is all the more important to put this on record, since recent correspondence from Dr Cheetham to Dr Speight attempts to discredit Dr Speight’s report, and at the same time, the character of [the father] with some of the most bizarre and inconceivable statements.”
“It is incorrect that we agreed for Miss A to be treated at Great Ormond Street Hospital without qualification. Our agreement was predicated on the treatment that would be offered. We said on a number of occasions that that before finally agreeing to this we would have to agree the treatment. The minutes do not reflect this. We continue to assert that we believe that our daughter’s illness is organic and as such it would be inappropriate for treatment to take place in a psychiatric unit. We believe that her illness (which has been diagnosed as ME/CFS) should be managed in primary care since there is no medically defined curative treatment for the condition. In terms of physiotherapy in the form of graded exercise, we again confirm that we originally requested Dr Earley to enrol Miss A in a ME rehabilitation course conducted at Amersham General Hospital. Miss A reacted very badly to exercise (this is not a critical statement of those physiotherapists involved whom we are sure do gentle exercise) but more of a reflection of her particular physical state at the time. We have a completely open mind about physiotherapy at an appropriate time in the future, but fear that at this precise moment further attempts at physiotherapy might actually be harmful. There is much written to substantiate these views (see quotation and references). We have absolutely no objection for Miss A to be under the care of a consultant paediatrician who is sympathetic to the belief that her illness is primarily organic.”
“My belief for what it is worth is that Miss A is a reasonably classic case of ME/CFS and that this is as already stated a genuine organic and extremely unpleasant condition. Starting from this viewpoint, I have to say that the evidence for psychological disturbance in either Miss A or her parents is extraordinarily thin. They strike me as a normal family with normal inter-relationships, with the parents acting in a normal protecting manner to care for a daughter who is really quite ill. I do not see any indication for referral to child psychiatry, especially to a child psychiatrist who disbelieves in ME as an organic entity. I certainly do not think that to attempt to enforce child psychiatry on this family against their wishes is likely to be a constructive course of action and I would regard further steps down the child protection road as entirely inappropriate. Regarding management I have already stated that I start from a position of basic therapeutic nihilism. Having said that, amitriptyline can be quite rewarding in many cases. Occasionally I find fluoxetine helpful in the very severe cases. I am basically agnostic on much of the alternative medical therapies as recommended by Dr Munro et al. I usually tell my patients that I have no objection to them shopping around alternative therapists as long as they don’t waste too much of their money. I am always delighted when someone else cures my patients! As you can see from the above, I think it will be in everyone’s interests if the recent conflict can be damped down and defused. Certainly the parents are happy to cease hostilities. I think Miss A deserves the care of a consultant paediatrician in her own area for the next year or two. The family were quite happy with Dr Earley’s initial involvement and it might be that they could be brought together again. Naturally it would be inappropriate for me to be the main source of support for this family in view of distance but naturally I would be happy to discuss her with anyone at any stage if this would be helpful. I wish you luck in her further management and hope that she had a nice summer holiday. I enclose a brief handout I have written on this condition for your interest.”
“The effect of the case as alleged in para 4(a) is that Dr Cheetham sought to influence the course of Miss A’s clinical management after11 June 1997 when he was no longer Miss A’s doctor and that such conduct was improper by virtue of para 4 (b) (i) to (iv) [ - of the Charge list - ]” “In relation specifically to Dr Cheetham’s letter of13 August 1997 to Dr Speight an alternative approach to the question of justifiable intervention arises under Section 47 of the Children Act.”
“Miss A was under no risk of significant harm and therefore removed any justification for intervention after that date” and it was asserted that: “Any possible justification undersection 47 of the Children Act 1989 is limited to co-operation with the body charged with dealing with the concerns (here the social services authority). Once the concerns in question have been considered (and rejected as groundless) by that body, there could be no justification for the doctor in question seeking to influence matters as Dr Cheetham did here.”
“SUMMARY Adrian Collin, Chair, summarised the conference as follows. This afternoon’s reconvened initial child protection conference went ahead according to the proviso made at the meeting on 21 July that if the plans made at the July meeting were not followed through, or if any problem arose the conference would be re-convened. This happened because the original plan for referral of Miss A to Great Ormond Street Hospital was overtaken by an initiative promoted by [Miss A’s father] to involve Dr Speight, paediatrician with a specialist interest in ME. He has now seen Miss A and inter alia advises continued management of her care at home with advice from a local paediatrician. With regard to the latter there is a problem. Although it was reported that there is some obvious improvement in Miss A’s condition she is nevertheless still bed-bound and removal from the bed to use the commode involves great effort and discomfort. With regard to the possible risk of significant harm, and its implications for registration, the conference members were agreed that in this case registration would be inappropriate. Nevertheless, a co-ordinated and multi-disciplinary approach to Miss A’s situation was called for and after careful discussion was agreed, with the support of [the parents] that Social Services should play a particular role in co-ordinating this process. The ownership for medical management of Miss A’s condition clearly rests with Dr Nigel Masters the family GP. The planning process should increasingly involve Miss A as part of her rehabilitation. There are a number of medical issues to be addressed including the diagnosis and treatment of urinary symptoms, planning for appropriate physiotherapy in manageable stages etc etc. Appropriate educational input needs to be planned further to the home tuition anticipated with Mrs Egerton. The Sir William Ramsay School was considered a placement to be geared to and experienced in the support of children with special needs. Concern also focussed on securing appropriate social stimulation for Miss A from her own peer group. REGISTRATION/DECISION The conference members were agreed that Miss A’s name should not be included on the Buckinghamshire Child Protection Register.”
“Dr Cheetham saw [Miss A] in June 1997 when she had been bed-bound for three weeks. He advised intensive investigation, and a hospital admission, and a programme of rehabilitation, which the family could not accept. Dr Munro from the Brakespeare Hospital was invited to give an opinion and she defined a number of abnormal pathological results, most of which are not available to us. She has told us that she believed that Miss A’s condition was due to the excessive numbers of courses of antibiotics that she had. She also felt that inappropriate homoeopathic treatment had caused deterioration in Miss A’s symptoms. Dr Speight a consultant paediatrician in Durham was involved and said that Miss A had chronic fatigue syndrome. He advised bed-rest and the involvement of a local paediatrician in helping with the problem. Because [the father] did not wish local staff, other than the GP or his district nurse to become involved there are limited objective records as to what has happened in the intervening 21 months. A number of staff, particularly community nurses, were very anxious that a child should be at home for a long period of time, unable to do anything and yet there should be no specialist referral treatment. This was deemed to be inappropriate action by [the father] and Social Services were informed, and after an interval a case conference was convened. This conference said that if Miss A had specialist treatment at Great Ormond Street Hospital that there would be no case to answer. The conditions of the case conference were not fulfilled. Dr Speight was consulted and no further medical intervention, or investigation, was instituted. Miss A’s case was closed by the Social Services. Miss A has now been at home, bed-bound, for 2 years. Initially incontinent for a long time she can now sit on a commode to pass urine. She has contact with her parents and grandparents and occasionally nurse volunteer babysitters. She has no contact with contemporaries. She has tuition once a week from a private tutor, but no other formal schooling. She has no specialist medical supervision. It is likely that this state of affairs is seriously harmful to her. The prolonged bed-rest is likely to have caused permanent weakness to her muscles and bones and the longer that it continues the greater this damage will be. The lack of any contact with children of the same age will have a profound effect on her ability to relate to others. Schooling consisting of private tuition for one hour a week is a very poor education. Accepted medical interventions in a child with this degree of disability will include specialist assessment and a planned programme of rehabilitation, which would be consistently monitored. Such a programme has not been instituted. It is urgently necessary that there is an independent examination and assessment of Miss A by a doctor or team experienced in children who have been diagnosed as having serious chronic fatigue. This ‘accepted medical intervention’ would be the recommendation of a major report by the Royal College of Physicians, Psychiatrists and General Practitioners (1997). Chapter 10 of this report is devoted to the condition in children.”
“The issue for the Court is thus: did the PCC understand the relevant law and give effect to it?”