“It is not a function of this Committee to determine whether the regime of treatment instituted by you in the case of Mr M was or was not correct treatment for his addiction. The Committee’s concern is that in your prescribing of diamorphine for him there was a lack of care in record keeping and also a lack of supervision involving improper delegation to a person who is not a registered medical practitioner of functions requiring the knowledge and skill of a medical practitioner. The Committee also consider that you would be well advised to amend your method of charging professional fees, which savours of script selling to an extent which the Committee cannot condone. The Committee have, however, carefully considered the representations which have been made on your behalf. They are prepared to believe that, as a result of these proceedings, you will carefully review and improve the manner in which you conduct your medical practice in relation to the treatment of patients who are addicted to drugs.”
“2. TA came to the Trust from a local GP practice and had been with the Options for approximately 2 years. Options had been prescribing him with methadone elixir (1mg/ml) at a dose of about 100mg/day. He also had a chronic benzodiazepine dependency and so Options had established him on a low diazepam detoxification programme over several months. His most recent dose was 12mg/day. 3. On17th January 2006 , a pharmacy liaison police officer advised the Trust that they had discovered three prescriptions for TA with the same West Sussex address. Apart from the Trust’s prescription for methadone elixir 100mg/day and diazepam/12mg/day, he was also getting a prescription from another local GP for dihydrocodeine and more diazepam. The police also notified the Trust that TA was also taking a private script to Boots Pharmacy in Horsham issued by a Dr S(athananthan) at the Mayday hospital. According to the police, the scripts from Dr Sathananthan had been occurring for approximately one year and were for methadone (physeptone) tablets 250mg daily and diazepam 60mg daily. The script was dispensed weekly making a total of 350 x 5mg tabs methadone and 42 x 10mgs tabs diazepam per pick up. 4. After receiving this information, the Trust called TA to clarify things and he admitted that he had been receiving the medication in the totals identified. The conversation was heard and noted by an associate specialist, Dr Harry Waters, and Dr Keating on31 January 2006 . According to TA, in early 2005, he was offered some Physeptone (methadone) and ampoules “from a friend”, which he said he injected. He said that his friend then introduced him to Dr Sathananthan who said that he would need a referral. Unknown to the Trust, TA had accessed another GP in West Sussex. He apparently told her that he was not involved with Options and (without liaison to confirm this), she wrote the referral to Dr Sathananthan and also prescribed Dihydrocodeine and Diazepam. 5. TA informed the Options that he had met Dr Sathananthan “in a clinic near the baby unit at the Mayday Hospital”
“11. A patient of the Crawley Substance Misuse Services, K… C…, with diagnosis of borderline personality disorder and multiple substance dependence, including in particular cocaine and benzodiazepines as well as opiates, had a markedly pathological relationship with both her parents, especially her mother who often bought her cocaine. This patient posed considerable challenges to the Crawley Substance Misuse Team’s ability to encourage her to put limits on her own behaviour. The concerns of the Crawley Substance Misuse Team related to the fact that during a hiatus in KC’s engagement with the team, her mother went to Dr Sathananthan to request a prescription for buprenorphine (subutex) as an opiate substitute medication. Dr Andrew Fullerton, the Staff Grade doctor within the Crawley Team, subsequently reassessed her on6 December 2005 and KC told Dr Fullerton that Dr Sathananthan had issued a week’s prescription for subutex and nitrazepam to her mother for her, without seeing the patient. 12. There was clearly no attempt by Dr Sathananthan to assess the patient’s level of substance dependence or her mental state. Nor was there any attempt to contact any other treating agency, despite the fact that KC’s mother was very likely to have made it clear that the Crawley Team was involved. The patient’s mother only asked Dr Sathananthan for the prescription as the Team had temporarily suspended her prescription due to the medication not having been used as directed, poor motivation to change and increasing use of illicit drugs, as well as erratic attendance on the part of the client. 13. Dr Jackson stated that the Crawley Team had no information about the precise dosage of the prescription, as it was apparently held by KC’s mother who dispensed it to KC without revealing to her the dosage or total quantities of the supplier. No formal complaint from the patient’s mother has been received regarding this matter. 14. Dr Sathananthan was believed to have assessed Ms KC on a previous referral. Unfortunately, the Crawley Team had not been able to obtain any written information about the treatment previously offered. However, Ms KC also told Dr Jackson that Dr Sathananthan had tried hypnotherapy, which only succeeded in aggravating her traumatic childhood memories. 15. Dr Jackson stated that the Crawley Team did realise that the case described was characterised by challenging and limited testing as well as splitting behaviour on the part of the patient. He stated that the information available about this case was very incomplete and not supported by any formal dissatisfaction on the part of the patient or her mother.”
“16. On7 June 2006 the GMC received a letter from PC Steve Goodens (Horsham Police Station), Controlled Drugs Inspector of the North Downs Division of Sussex Police, stating that during one of his routine inspections on6 January 2006 at Boots the Chemist in Horsham, West Sussex he came across a patient who was in receipt of a private prescription issued by Dr Sathananthan. The prescription was for 350 x 5mg of Physeptone tablets and 40 x 10mg Diazepam tablets per week. Details of the patient, (known as TA), and the prescription were recorded for comparison with other Chemists. On this occasion, comparison of details was carried out on12 January 2006 and the patient’s name was recognised as being in receipt of a methadone prescription issued by Dr Waters of Options. 17. Options was contacted and informed of the situation. They informed the police that they were unaware of the dual prescribing and were taking steps to remedy the situation by meeting with the patient. 18. The police had an informal meeting with Dr Sathananthan on7 February 2006 at his clinic. This was an informal meeting to establish the circumstances surrounding how the patient was both referred to and taken on by the clinic. 19. During the meeting Dr Sathananthan stated that TA was referred by his GP, Dr Bailey, during March 2005 and was first seen by Dr Sathananthan on17 March 2005 . Dr Bailey was advised by letter that he had been taken on by the clinic a couple of weeks later. After the first visit, TA was deemed to be stable and further appointments were made at four weekly intervals. The police asked Dr Sathananthan whether he had asked the patient whether he was receiving treatment from another source. Dr Sathananthan stated that upon initial appointment, patients were told to seek employment, not to get into trouble with the police, not to double script and advise if they were seeking or obtaining medication from elsewhere. Approximately 3 months after commencing the programme for TA, Dr Sathananthan was informed by another patient that TA was obtaining a script from elsewhere. TA was apparently confronted with this allegation, which he denied. Dr Sathananthan stated he thought there was no foundation to the allegation and it was possibly a malicious rumour between clients. No further action was taken with regard to this and TA’s GP was not notified. Dr Sathananthan stated that in his opinion TA was entirely plausible. He state that upon learning from Options of the double scripting, he had ceased prescribing. A message had been left on TA’s answer phone to that effect. 20. The police noted that correspondence was available between the clinic and the GP regarding the referral. Dr Sathananthan informed the Police that his secretary would hold all these documents. However, because it was not a formal interview, documents were not viewed or seized. A record of the information discussion was made as a brief note in the policeman’s book.”
“The Panel first considered whether an interim order is necessary. In the light of the information from Options Drug and Alcohol Service and Horsham Police regarding your prescribing of controlled drugs to Mr A without assessing or monitoring him adequately and the information from the Crawley Substance Misuse Team concerning your prescribing for Miss C without seeing her in person, the Panel is satisfied that an interim order is necessary. The Panel has noted the favourable testimonials relating to your NHS work. It notes that you were appraised satisfactorily in March 2006 in relation to your post as an NHS Consultant Psychiatrist. The Panel is concerned, however, that your private practice was not included in any appraisal. The Panel notes that you no longer intend to work in your private clinic. The Panel is concerned to note that, although there was no finding of serious professional misconduct in July 1985, the GMC’s Professional Conduct Committee voiced their concern about your lack of care in record keeping and lack of supervision in relation to your treatment of a drug addict. These are similar matters to those being investigated by the GMC at present. In accordance withsection 41A of the Medical Act 1983 , as amended, the Panel has determined that it is necessary for the protection of members of the public, in the public interest and in your own interests to make an order imposing conditions on your registration for a period of 18 months. The conditions are as follows: 1. You must not treat or prescribe for drug addiction. 2. You must confine your medical practice to posts within the National Health Service and not undertake any private practice. 3. …”
“ Re. Dr Sathananthan The PCT is most concerned about its failure to ensure the safety of patients given controlled drugs by Dr Sathananthan. The issues are known to the GMC but are briefly summarized below. We understand that the panel will shortly be making decisions about this case and it is important that the PCT outline its concerns at this time. Croydon Controlled Drug Prescribing During the PCT’s routine monitoring of controlled drugs (CD) prescribing, we identified serious concerns about Dr Sathananthan's CD prescribing during July - Oct 06. The CD prescribing is summarized in the following table. Total Croydon clinic CDs Jul - Oct 06 (Restrictions imposed 18 Aug) Diamorph HCL (S) ? powder Heroin 87 (? Units) Diamorphine 100mg ampoules 28 Diamorphine 10mg tablets 1792 Morphine sulphate 100mg tablets 84 Methadone ampoules 1498 Methadone tablets 5628 (one ppn was for 1176 tablets) Methadone mixture ml 8760 The PCT is very concerned about this prescribing for the following reasons. • Methadone tablets are inappropriate as they can be crushed and injected. Tablets are not part of a methadone maintenance regime. • One prescription was written for 1176 methadone tablets. This quantity is likely to find its way onto the street and injection of crushed tablets does put lives at risk. • Methadone ampoules are not part of a normal methadone maintenance regime. • Diamorphine (Heroin) powder is not prescribed for patients with addiction problems. • Previous DoH advice is that injectable heroin or morphine is rarely appropriate and should only be prescribed by a consultant in substance misuse. • The strength of the diamorphine ampoules (100mgs) is enormous. The quantities of these drugs seem excessive in relation to the number of patients. • The diazepam and temazepam prescriptions were not reviewed but if combined with methadone, heroin or morphine, it could be lethal. • In Jan 06 Dr Sathananthan was prescribing potentially lethal quantities of methadone, diazepam and temazepam to a patient who subsequently took an overdose. (see original complaint and summary of clinical concerns below). Possible Breach • Four prescriptions (that we know about) were written the day before the GMC restrictions were imposed when he would have suspected that this would happen. • These prescriptions contained several other postdated prescriptions enabling future prescriptions for CDs to be dispensed weeks after the restrictions were imposed. (see appendix) • He did not subsequently inform the pharmacist of the restrictions. He therefore ensured these predated prescriptions would continue to be dispensed for weeks after the restrictions were imposed. • He did not inform the pharmacists of the restrictions. Had he done so, the prescriptions dated for the future weeks would not have been dispensed. This appears to be a breach of these restrictions. Does the GMC consider this to be the case? Local investigation When the above concerns were sent to the GMC a formal request was made for the PCT to undertake a local investigation of these concerns. This has been impossible as Dr Sathananthan has refused to be investigated in relation to these concerns. (see letter). Previous Clinical failures In Jan 06, the consultant in substance misuse identified the following: • Dangerous lack of assessment of substance dependence. • No assessment of co-existing mental health problems or mental state. • Failure to identify or liaise with other services involved. • Undermining long term strategies of other substance misuse services. • Important non-prescribing component of treatment entirely absent. • Lethal daily doses of methadone. • No titration of methadone to safe initial dosage. • Dangerous drug combinations very high risk of overdose and respiratory depression. (250mgs methadone daily, diazepam 60mg daily and temazepam 20mg daily is evidence of potentially lethal prescribing. In fact this patient had taken an overdose. • Diazepam should have only been prescribed as part of a reducing plan. • Prescribing methadone tablets inappropriate (risk of injecting if crushed). • Did not inform patient's GP what he was prescribing. • Use of IV diamorphine and IV morphine inappropriate (only in exceptional circumstances and only prescribed by consultant in substance misuse.) • Dangerous quantities of drugs e.g. one ppn for 1176 tablets of methadone. • Failure to examine, do tests, counsel patients, keep adequate records. All these are outlined in the complaint sent to the GMC Jan 06 which formed the basis of the decision to restrict his prescribing. Further serious concerns about Dr Sathananthan's clinical performance were identified by Dr Rob Jackson (Addictions Service Clinical Director) and referred to the GMC in March 06. These also identified the following failures. • No assessment of level of substance dependence • No assessment of mental state. • No attempt to contact other agencies • Unable to obtain any written information from Dr S about her treatment when requested by NHS specialist in substance misuse treating the same patient. GMC response These serious clinical performance deficiencies are the same as those identified in the GMC professional conduct hearing in 1985. This concluded that “Dr Sathananthan abused his professional position by issuing in return for fees and in an irresponsible manner, prescriptions for diamorphine. There was lack of care in record keeping, lack of supervision, and improper delegation to a patient of tasks requiring the knowledge and skill of a medical practitioner.”
“The concerns in this case relate to Dr Sathananthan’s prescribing for drug addiction and the conditions deal with those concerns. There are no concerns, as far as I can see from the paperwork, that suggest that Dr Sathananthan’s NHS work is problematic or is unsafe and, indeed, the letters that I submitted last year from Dr Holloway and others … supported by Dr Holloway’s recent email, suggests that Dr Sathananthan’s work at the NHS is well regarded and on that basis there is … a public interest in allowing Dr Sathananthan to continue with that work so that he can see patients within that speciality. Doing that work will not involve any contact with patients requiring treatment for drug addiction and … Dr Sathananthan has no interest in pursuing that specialisation any further. In my submission, that is all that is necessary here. Conditions should continue and it would be disproportionate to suspend Dr Sathananthan today. If you are concerned and wish to take further action, you could consider making the conditions more restrictive …”
“One prescription alone for 1172 tablets of methadone could put many lives at risk if distributed for injection purposes.”
“… it is in general necessary for these matters to be dealt with as speedily as is reasonably possible. Interim orders mean what they say, they are interim and must be approached on that basis.”