“a long way short of the requirement of a consultant undertaking a post in paediatric neurology. ...Despite this fact Dr Holton soon found himself dealing with an ever increasing paediatric neurology workload. … Dr Holton therefore found himself under-trained, overworked and working in professional isolation. The CSAC believes this is a significant mitigating factor in relation to the main findings of this report. To compound these difficulties it is clear that neurophysiology resources in Leicester are under-resourced. There is often a wait of many weeks for a child to have a standard EEG recording and we found at least one case of a child having to wait over 12 months for a 24 hour EEG recording. Dr Holton therefore found himself having to rely on his own clinical judgment far more than would be generally acceptable in a department dealing with many children with epilepsy.”
“The expectation, therefore, is that up to 4 out of 10 children with intractable seizures who are not being reviewed by a trained paediatric neurologist who has access to specialist neurophysiology facilities may be wrongly diagnosed. This is in direct concordance with the percentages identified in this review. That is, of the 214 children reviewed at stage 2, 78 (36%) in the view of CSAC members, felt it by far more likely than not that they did not have epilepsy. In our view 67 (31%) of the children we saw were over-treated.”
“Generally, professional colleagues who worked with Dr Holton on an equal level … found him supportive and effective and considered his advice to be sound.”
“Dr Holton was described by some staff variously as obsessive, arrogant, opinionated, irrational, unwilling to listen (some staff and parents), moody, angry and as giving unrealistic expectations to parents. These views were almost always as a result of conflict over patient management and a questioning of Dr Holton’s clinical practice.”
“The gulf between the two sets of opinions concerning Dr Holton were striking and there appears to be no middle ground. For each opinion supporting Dr Holton it was possible to find an opposing view. Overall it would appear that those who are not in any disagreement with him found him polite, supportive and helpful, while those that found themselves in disagreement with him found him difficult to deal with.”
“A few letters have been reviewed in which expressions of gratitude and praise in the strongest terms have been described. No attempt has been made to invite additional letters of support, but anecdotally it is understood from some witnesses that several parents continue to speak in support of Dr Holton and his care of their children. Some parents who had concerns nevertheless expressed their admiration for his hard work and dedication.”
“Many parents describe being made to feel belittled and as if they had no right to question Dr Holton if they did air concerns or questions with him. Many witnesses considered that Dr Holton gave overly-optimistic expectations to parents of their child’s likely improvement under his clinical management. As the child’s progress failed to achieve the initial promises and where parents became concerned at levels of drug prescriptions, or side effects and raised these issues with Dr Holton, the parent’s views changed to observations of dominance, failing to listen and arrogance.”
“Whatever the rights and wrongs of Dr Holton’s clinical practice, he was on the one hand well respected by many professional colleagues and by his junior doctors, but on the other hand was unable to convince professional colleagues who took issue with him on the subject, of the rationale of his approach. While many staff interviewed would be happy to work with Dr Holton again, there are members of medical, nursing, and administrative staff who consider that the conflict of personalities are (sic) such that professional relationships with Dr Holton have broken down irretrievably.”
“their opinion on such of the following matters as appears to them to be relevant, that is to say whether- (a) the standard of the practitioner’s professional performance has been seriously deficient; (b) the standard of the practitioner’s professional performance is likely to be improved by remedial action; (c) the practitioner should limit his professional practice, or cease professional practice; (d) no further action needs to be taken on the Report and in each case the Panel’s reasons for their opinion.” (a) the standard of the practitioner’s professional performance has been seriously deficient; (b) the standard of the practitioner’s professional performance is likely to be improved by remedial action; (c) the practitioner should limit his professional practice, or cease professional practice; (d) no further action needs to be taken on the Report and in each case the Panel’s reasons for their opinion.”
“This means that the GMC will question a doctor’s registration if it believes that the doctor is, repeatedly or persistently, not meeting the professional standards appropriate to the work that the doctor is doing – especially if the doctor might be putting patients at risk. This could include failure to follow the guidance in the GMC’s booklet “Good Medical Practice.”
“The job description implied that candidates who were not trained might wish to apply for the post, and that opportunities for training would exist after the successful applicant had taken up the appointment and started to work. The lay reader would be entitled to be taken aback at the concept of a doctor being appointed to a post for which he or she had not been trained. The implication was that an incompletely trained candidate could “pick up” the necessary additional training after starting work in the post. This was somewhat akin to saying that an ordinary motor car driver could start work driving HGV lorries without any training in driving a lorry. However at the time of Dr Holton’s appointment it was by no means unique for job descriptions for Consultant posts to allow for the appointment of untrained or incompletely trained applicants. What happened in Leicester was no different in this regards from other places in the UK. What was possibly different about Dr Holton’s case was that the employing authority apparently took no responsibility for the training provided after Dr Holton’s appointment. There appears to have been no formal training plan, no clear educational aims identified, and no goals or end-points established. No-one was appointed to supervise the process. There was no mechanism to ensure progress was being made, and there was no mechanism to ensure that adequate training had been achieved. Worse still, Dr Holton’s opportunities to receive the necessary training were curtailed because of the increasing pressures from his work.”
“Accordingly, the view of the Assessment Panel is that the standard to be expected of Dr Holton’s professional performance should be that of a Consultant Paediatrician who, although untrained in paediatric neurology had, by dint of his special interest, accumulated experience in neurology, almost entirely self-taught and almost totally unsupervised, practising neurology in isolation and in the face of immense difficulties and obstacles to clinical practice, difficulties which must all be taken into account.”
“It is self-evident that any assessment of Dr Holton’s performance must take into account all the background factors that could have affected his performance, including those listed above.”
“Acceptable means that the evidence demonstrates that the doctor’s performance is consistent with the performance described in Good Medical Practice. Cause for Concern means that there is evidence that suggests performance may not be acceptable but that there is not sufficient evidence to suggest seriously deficient performance.”
“3. Providing or arranging treatment Overall assessment: Cause for concern 349. It is a fact that some patients who had been diagnosed as having epilepsy, whether this diagnosis was correct or incorrect, were inappropriately treated. In relation to the assessment of epilepsy, the Assessment Panel identified a number of features: • Once epilepsy had been suspected, it was sometimes found that a patient would be left on anti-convulsant medication even if the response to treatment was poor. Whereas in some cases this lack of response was followed by cessation of treatment and re-evaluation of the case, in some patients a sequence of events was set up whereby one or more additional anti-convulsants were introduced. • There was a tendency in some patients to add in multiple anticonvulsant drugs without withdrawal of agents that had not proved beneficial on their own. • There was an unusual readiness to use prednisolone in high dosage, which was regarded as clinically inappropriate. 350. Concern about treatment applied to only a minority of cases that were studied in the Performance Assessment. The Assessment revealed plenty of cases in which Dr Holton’s treatment of epilepsy had been acceptable. 351. The Assessment revealed no general concerns regarding Dr Holton’s treatment of general neurology patients with the exception of his use of certain untested or unproven therapies. 352. The Assessment provided little data on Dr Holton’s treatment of general paediatric disorders, by the limited data available indicated acceptable treatment. 353. Data obtained from clinical colleagues in third party interviews suggested that in general Dr Holton’s treatment of patients was acceptable. 354. It became clear to the Assessment Panel that Dr Holton had fully and freely recognised the erroneousness of his treatment of certain patients with suspected epilepsy. During the case based discussions it was evident that he had corrected these errors, and that they would not be repeated. As when discussing Dr Holton’s performance in the area of patient assessment, the Assessment Panel’s view is that the problems of treatment of epilepsy were largely not of Dr Holton’s making, and that it would be quite unreasonable for him to take all of the blame. 355. However there were two other areas of treatment that caused the Assessment Panel some concern. This related to the treatment of patients with other neurological disorders, including those with various encephalopathies, for example after a head injury or after an episode of cerebral hypoxia. The first concern was that it was noted that Dr Holton had a tendency to use vitamin E supplementation in clinical situations (e.g. Charcot Marie Tooth disease – hereditary sensorimotor neuropathy; facial palsy) for which there was no objective evidence that this treatment would be of any value. During the case based discussions, Dr Holton was willing to concede that there was no controlled trial evidence to support the use of vitamin E in the clinical situations in which this agent had been deployed. Dr Holton was also willing to accept the point that when using an unproven and unconventional treatment it would have been highly desirable for the parents to have been given a full explanation as to the unlicensed and unproven status of the drug, and given a choice as to the drug’s use. The Assessment Panel nevertheless felt that Dr Holton’s residual enthusiasm for the use of this drug in neurological disorders was uncritical and unusual. 356. The second concern was Dr Holton’s use of the drug desferrioxamine. Desferrioxamine is an iron-chelating agent, licensed for use in paediatrics to treat acute iron poisoning and to treat patients with chronic iron overload as in for example, thalassaemia. In patients with thalassaemia the need for regular blood transfusions eventually leads to a toxic accumulation of iron in the body. The drug is also used to treat acute iron poisoning in children who have ingested iron compounds. Dr Holton’s use of this drug came to the Assessment Panel’s attention in a patient on the intensive care unit in whom a CT scan had shown no evidence of intercranial bleeding. Dr Holton nevertheless believed that despite the CT scan findings there might have been intercranial bleeding. This is technically possible; a CT scan does not always detect certain types of intercranial haemorrhage. Dr Holton’s concerns, as explained to the Assessment Panel during a case based discussion, was that a hypothetical haemorrhage might have in turn released elemental iron, which in turn might have proved toxic to the brain, and that this warranted treatment with desferrioxamine. Dr Holton was under the impression that there was evidence to support this theory, and that this drug was being routinely used for this purpose in certain centres in the USA. The medical members of the Assessment Panel have investigated these claims. Discussion with paediatric intensive care specialists in the UK and USA indicates that desferrioxamine is not in routine use in acute neurological situations either in the UK or the USA, although colleagues were aware of a few individuals who had been known to use this drug. An examination of the scientific and medical literature indicates that the basis for the use of this drug appears to be some old (>10 years) animal data, unsupported by any controlled studies in human patients. The Assessment Panel felt that Dr Holton’s continuing enthusiasm for this unlicensed and untested treatment was uncritical and misplaced. 357. Dr Holton indicated to the Assessment Panel that he acknowledged that there is now a far greater emphasis on evidence based medicine, and the need, where possible, for treatment to be based on controlled studies, The residual concern of the Assessment Panel was the impression, admittedly based on only two drugs, that Dr Holton was fundamentally uncritical about the use of these drugs and was overly enthusiastic about their possible value. One can only speculate, but it is possible that his uncritical streak was a chink in Dr Holton’s armour that may have fostered his enthusiasm for a rather over-vigorous and uncritical approach to the drug therapy of epilepsy. The limitations to this conclusion are: • It is based on the use of only two drugs • It is speculative • It fails to take into account the background to Dr Holton’s clinical practice, and in particular the fact that he was untrained in paediatric neurology. It is highly likely that had Dr Holton been exposed to proper supervised clinical training in paediatric neurology, then any tendencies to over-value particular approaches would have been exposed to scrutiny and down-regulated. 358. Taking all these matters into account, the Assessment Panel concluded that “Cause for concern” was the appropriate overall assessment for Dr Holton’s provision of treatment.”
“386. Dr Holton was regarded by his health professional colleagues as very caring and showing great respect for patients and parent, including respect for the need for confidentiality, and the Assessment Panel was provided with ample positive data on these aspects. There was one negative observation, from Sister Brown, who reported that medical records had been left in the corridor outside the clinic room sometimes – she made a habit of putting the notes away if she found them. 387. Set against a suggestion in the complaints of parents that Dr Holton was unwilling to refer patients for a second opinion, the review of the medical records showed that in fact Dr Holton did indeed refer patients for a second opinion when this was appropriate. There is also information to show that he sometimes volunteered to arrange a second opinion when he sensed that a family was unhappy with his care.”
“take into account a doctor’s individual circumstances and the environment in which he or she works”
“It would appear that the Performance Assessors are now being instructed to disregard the GMC guidance. The Performance Assessors reiterate that they feel that this represents a significant and inappropriate deviation from the GMC Performance Assessment procedures.”
“Thus in one sense what the report did in fact (at least in part) satisfied the second instruction, concerning disregarding the formal job title, though it did take into account the various circumstances and factors which directly affected Dr Holton’s performance. … The Assessment Panel’s response to these matters is that by excluding certain important factual data from consideration, bias is introduced, and any resulting opinion ceases to be objective and the whole process of Performance Assessment loses integrity. Whilst it is plain that the Assessment Panel is of the view that the stated preconditions to the 6 questions are flawed, the Assessment Panel recognises that ultimately its duty is to assist the CCP, and with the preceding caveats in mind the 6 questions are answered as follows… .”
“Q1. What would the Panel’s assessment be of the 15 specified categories of Good Medical Practice? Of the overall gradings of the 15 categories of the Good Medical Practice, the overall grading would remain unchanged for 14. However, for “providing or arranging treatment” the overall grading would change from “Cause for Concern” to “Unacceptable”
“If it is the view of the GMC that the remit of the assessment should be changed in this very fundamental way, then the answer is that which is contained in the answers to questions 1 and 2, namely: • For “Providing or arranging treatment” the overall grading would change from “Cause for Concern” to “Unacceptable”. • Under Ruled 13, the answer to question 1 “Has the standard of the practitioner’s professional performance been seriously deficient?” would change from “No” to “Yes”
“The position is that Dr Holton has already recognised and accepted the problems relating to his previous approach to epilepsy, and the Performance Assessment demonstrated that he has already taken the necessary remedial action.”
“85. Although at the time Dr Holton was practising there was a lack of evidence to support certain aspects of his approach, recently published research now offers scientific support for one aspect of what he did. The Performance Assessors refer to the following paper, which is exhibited as “Exhibit Pressler et al 2005”: “Pressler RM, Robinson RO, Wilson GA, Binnie CD. Treatment of interictal epileptiform discharges can improve behaviour in children with behavioural problems with epilepsy. Journal of Pediatrics 2005; 146:112-117.” 86. This research comes from a prestigious unit and was published in what is arguably the most highly regarded paediatric medical journal. The work comprised a double-blind, placebo-controlled, crossover study. The conclusions were (i) that suppressing inerictal discharges can improve behaviour in children with epilepsy and behavioural problems, particularly partial epilepsy and (ii) that focal discharges may be involved in the underlying mechanisms of behavioural problems in epilepsy.” “Pressler RM, Robinson RO, Wilson GA, Binnie CD. Treatment of interictal epileptiform discharges can improve behaviour in children with behavioural problems with epilepsy. Journal of Pediatrics 2005; 146:112-117.”
“The Panel noted that the Assessors in setting their standard for your post had included the adverse factors which complicated and at times impeded the quality of your performance. However, the Panel considered that these factors were more appropriately taken into consideration after decisions had been taken as to the quality of your performance.”
“1. The Assessment Panel did not apply the correct standard for the job you were doing, that is, Consultant Paediatrician with a special interest in Neurology 2. The Assessment Panel made a flawed decision in deciding not to take account of the proportion of time spent by you on epilepsy in particular when considering your overall performance. 3. The Assessment Panel mistakenly considered that your current understanding of your areas of deficiency, which reflects hindsight, justified them awarding you a more positive grading. 4. It heard evidence that the comments from parents in the Third Party Interviews were not taken into consideration by the Assessment Panel when they considered their grading.”
“ii. On your admission you spent most of your clinical time (1997-2001) assessing/managing patients with epilepsy. Many were complex and difficult cases. Even if you made errors in only a significant minority of cases the consequences for those children and their families were substantial. iii. This Panel does not accept the Assessment Panel’s argument that, because in clinical areas other than epilepsy your skills were satisfactory, an overall grading of “Acceptable” is justified. iv. You made mistakes in a central area of your practice on a number of occasions with adverse consequences to some children and their families. The fact that in 2003 you recognised and acknowledged the seriousness of these mistakes, and would now act differently, does not excuse them. The essence of a performance assessment is not what you would do now, but what happened then. In summary, the Panel endorses the Assessment Panel’s conclusions about your failings in the assessment of epilepsy. It considers them to be serious, of sufficient frequency, and of sufficient consequence to cause harm to patients. It rejects the argument that epilepsy formed only a small part of your work. It has no doubts from the Assessors’ own individual ratings from their medical record review that this area of your practice was Unacceptable.”
“In evidence Dr Rosenbloom commented that they had seen no criticism of your management expressed by tertiary referral centres to which you had referred some patients. However, this Panel noted evidence from statements to the Trust by two consultants that they had expressed concern regarding your treatment of epilepsy but you had been unwilling to alter your views which is consistent with the findings of the Department of Health (2003 – Bamford) Report. It also noted that the Community Paediatricians had expressed concern to the Trust about your practice and their concerns were drawn to your attention well before your suspension in May 2001. The Panel considers that your inappropriate and uncritical treatment of, albeit a small proportion of patients, to be serious, of sufficient frequency and potential harm to regrade your performance in this area to Unacceptable.”
“When considering this issue of your relations with patients under the headings both “Communication” and “Respect” the Panel concluded that the Assessors had given too much weight to the evidence obtained in the artificial conditions of Phase 2 of the performance assessment. They disregarded the conclusive evidence from numerous sources that the Trust was receiving a steady stream of letters detailing patient complaints about your behaviour. The report prepared for the Trust by the Royal College of Paediatrics and Child Health and the Behaviour Report, also provide evidence of actual incidents involving unsatisfactory behaviour.”
“The Panel considered each of these subheads separately and endorses the view of the Assessment Panel that the issues of patient confidentiality, referral and accessibility offered no cause for concern. Nevertheless, the Panel concluded that there was ample evidence from a variety of sources that you did not always treat patients or their relatives with the politeness and respect to which they were entitled. In the Third Party Interviews for example, the Assessors themselves graded 48 out of 99 responses as either giving “Cause for Concern” or “Unacceptable” in terms of “Respect for Patients”
“The Panel notes the Assessment Panel’s opinion in their Supplementary Report that the Assessors would have considered your professional performance to have been seriously deficient (with some caveats) if they had applied the same standard that this Panel now has adopted. The Panel has decided that the standard of your professional performance has been seriously deficient.”
“1. You shall confine your practice to working as a Specialist Registrar in the approved higher Medical Training programme in Neurophysiology in the West Midlands Deanery to which you were appointed in 2003; 2. You must obtain satisfactory ongoing assessments and obtain a satisfactory annual performance review (RITA) and you must provide the GMC with copies of the reports on your performance and progress; 3. You shall draw up, in conjunction with the Regional Postgraduate Dean or his nominated deputy, a written Personal Development Plan which addresses the following areas of deficiencies identified by this Panel: a. Developing a reflective approach to your practice. b. Skills in communication, and respect for patients. c. Developing good relationships with colleagues and working in teams; a. Developing a reflective approach to your practice. b. Skills in communication, and respect for patients. c. Developing good relationships with colleagues and working in teams; 4. You shall forward a copy of your Personal Development Plan to the GMC within three months of the date in which these conditions become effective; 5. You shall meet with the Regional Postgraduate Dean or his or her nominated deputy, on a six monthly basis to discuss your progress towards achieving the aims set out in your Personal Development Plan; 6. You shall agree to the appointment of a mentor, approved by the Regional Postgraduate Dean or nominated deputy, who shall not be your programme director or a workplace supervisor; 7. You shall allow the GMC to send to the Regional Postgraduate Dean a copy of the report of the assessment of your professional performance and of this determination. You shall permit the Dean to disclose this information to any other person involved in your supervision or retraining; 8. You shall allow information about the standard of your professional performance any remedial action which you have taken in relation to your performance, to be exchanged between the GMC and any person who assists you in complying with these conditions; 9. You shall allow the GMC to obtain information from the Postgraduate Dean or his/her nominee and any other relevant person about the standard of your professional performance and any remedial action you have taken in relation to your performance.”
“Where does responsibility for the deficiency lie? Although you were not fully trained as a Paediatric Neurologist, you had read widely and taken opportunities to expand your knowledge. The Panel is satisfied that despite your relative isolation there was no good reason why your understanding of what diagnosis and treatment of epilepsy was appropriate should not have been on par with that of consultants in comparably designated roles at that time. The Panel heard convincing evidence about your very heavy workload and some of the resource constraints, such as delays in getting letters typed. It is aware that you campaigned for an expression of consultant staff in Paediatric Neurology for several years and were only successful in 2000. The Panel has noted written evidence you made no attempt to argue that your failings were due to your workload or stress. The prime responsibility rests with you. Perhaps because you were the lead consultant with responsibility for epilepsy, or because of your academic approach, or because of the intensity with which you approached clinical work, you failed to take adequate note of clinical presentations and clues. You did not show a reflective approach to the diagnosis and treatment of some of your patients with epilepsy. You did not always listen to parents and children or to concerned colleagues. Some parents and professional colleagues considered your approach to be an arrogant one. As a consequence the service you provided patients was not always reliable. The Panel has heard evidence that professional colleagues attempted to raise concerns about your approach sometime prior to your suspension, but with no constructive response. The ability to reflect and refine diagnosis and treatment approaches in difficult areas of clinical practice, in the context of feedback from patients, parents and colleagues is an essential component of good medical practice. This is at the core of our seriously deficient performance. It is likely that most of the problems in relation to communication and respect stem from an inappropriate response to challenge rather than a lack of professional skills in working with patients. You performed well in the clinical competency tests undertaken by the Assessment Panel.”
“1. You shall confine your practice to working as a Specialist Registrar or Consultant in Neurophysiology.”
“2. You must obtain satisfactory reviews of your clinical and academic progress in your current Specialist Registrar training programme and you must provide the GMC with copies of the reports on your performance and progress.”