“(1A) The over-arching objective of the [GMC] in exercising their functions is the protection of the public. (1B) The pursuit by the [GMC] of their over-arching objective involves the pursuit of the following objectives— (a) to protect, promote and maintain the health, safety and well-being of the public, (b) to promote and maintain public confidence in the medical profession, and (c) to promote and maintain proper professional standards and conduct for members of that profession.”
“The original symptoms have gone and he's extremely well, so all that’s left are his chest x-ray changes. These are typical for somebody who worked with asbestos a long time ago, and it sounds as if he probably did when he was working as a plumber after leaving school for 10 years. They are of no significance and would not be expected to affect his lung function which in fact is excellent. After all he hasn't smoked for many years. This explains the nature of these minor chest x-ray changes which can be ignored, and I've discharged him.”
“His previous investigations include a chest CT scan, which showed no clinically significant lymphadenopathy but multiple calcified pleural plaques and some incidental calcified granulomata, in keeping with asbestos exposure. It also revealed some renal simple cysts.”
“I would be grateful if you could see this gentleman who came to see me after seeing his haematologist for his myelodysplasia check up. He complained of a vague central chest pain that has been there the last 4-5 weeks. It is there most of the time but at times gets worse. He denies it being worse on exertion. He denies radiation, vomiting or sweating. He denies any cough or respiratory symptoms either. He was sent by the haematologist to A+E whereby he had an ECG which showed a sinus arrythmia as his pulse was irregular. His troponin was mildly raised at 17. They suggested his symptoms may be other angina related or gastritis related. I have started him on omeprazole but in view of his raised troponin and his ongoing chest pain I would be grateful for your urgent help. He is hypertensive which is well controlled. He is also an ex-smoker. I hope that you can help with his further management.”
“I would be very grateful if you could see this gentleman acutely today. Mr Loder presented to us in February after having presented to his haematologist with chest pains (he is under their care for myelodysplasia). His haematologist sent him to A+E and he had serial ECG and troponin which was normal. They advised that he may have stable angina or gastritis and was advised GP follow up. He came to see me and he described his pain as not that bad and not that frequent. But he had a lot of belching at the time, I suggested that we start a PPI and refer him to rapid access CP clinic. He was seen in the clinic and was advised to have a cardiac CT done. Unfortunately due to a mix up, he has then been asked to have stress echo in May. Unfortunately he and his wife have come to see me today and his pains are getting more frequent. It is central to the right side and is occurring multiple times. He is getting extremely worried about this pain. He is not taking aspirin due to his stomach side effects, PPI made no difference to his pain. BP is 129/72, pulse 80. I would be grateful if you could rule out unstable angina and perform serial ECG/troponin again, I also suspect there may be some anxiety related effects as he and his wife are extremely concerned about this pain.”
“With regards to his painful chest symptoms, if a cardiological underlying cause has been excluded, then I would suggest consideration of a respiratory opinion, due to the background history of pleural calcification on a background of asbestos exposure. I would be grateful if you considered this.”
“I would be very grateful if you could see this gentleman in your clinic. Mr Loder suffers hypertension, myelodysplasia and chronic rhinitis. He presented to his routine haematology follow up in February whereby he was complaining of mild right sided chest pain and he was found to have an irregular heart rhythm. He was sent to A+E whereby they stated he either had gastritis or stable angina. He was asked to see us for follow up. The pain is in the right side of the chest, it is now radiating to the right arm. It is there all the time now and is causing him a lot of distress. He denies any respiratory symptoms but he has a background history of asbestos exposure. We arranged a CXR and referred him to the rapid access cardiology clinic. They organised a stress echocardiogram which he has been told was normal. His 24th ECG showed several runs of supraventricular ectopics and the cardiologist has suggested a small dose of beta blocker. However he is still in a lot of pain. He and his wife are extremely concerned about the pain as they have no answer to it and it is getting worse. He saw his haematologist who suggested a referral to you to at least rule out a respiratory cause for his pain. I believe that his pain may be neuralgic with a high degree of anxiety (which is very odd because when the pain started in February, he was not bothered by it at all and it is ever since we started investigating it, his anxiety levels seem to be rising). He has rejected analgesia all this time because he did not want to take any but has finally agreed to trialling some gabapentin.”
“Problem Chest pain (Review) History ongoing CP. pt feels is getting worse. discussed whether anxiety may be partly causing his pain and also whether there may be a neuralgic element to his pain. long discussion with patient and wife. suggested may trial short course diazepam to see if it helps him relax. Examination O/E – blood pressure reading 138/72 mmHg Medication Diazepam 5mg tablets One To Be Taken Twice A Day 6 tablet Comment Plan 1. agreed to trial diazepam short course 2. discussed massage/acupuncture 3. Refer CIMS also as physio may help if there is a neuralgic cause for his pain”
“[19.] Victor and I discussed Dr Patel’s substandard care and dismissive attitude and he said he wanted to register with a different GP. We also wanted to know what Dr Patel had recorded on Victor’s medical records as neither of us were confident that medical papers and records would be lost, or altered. Because we knew Dr Patel had been informed of the cancer diagnosis and he had not contacted Victor. We decided to ask for the medical records as a Subject Access Request (SAR). …… [21.] The SAR was submitted on8 September 2015 and …….. passed to Dr Patel to action…. [22.] ….. I was notified on23 September 2015 that the full records were available to collect, which I did on the same day……. [23.] We went through the documents and identified many things which gave rise to concerns or were untrue. In particular Dr Patel recorded some conversations which did not take place. He stated, “also patient felt doesn’t feel like it is his lungs causing symptoms” and “patient denies any respiratory symptoms.”
“[4.] Whether there is a manner in which retrospective amendments ought to be done Sometimes changes are needed to a patient’s medical record - for example if wrong information has been recorded. Such alterations should be shown as additions to the notes recording when the new note is being added, and why the change is necessary. The key is that the original record and the new information are shown as separate entries in the medical record. ………….. To quote from [MPS An essential guide to medical records 6.7.2020 (accessed 29.3.22)], “Original – notes should not be retrospectively amended without making clear when the amendments have been made and why. In the event that you have made a factual error, do not obliterate the entry that you wish to correct. Instead, run a single line through it so it can still be read and add the correction including the date and your signature. Failure to do so could lead to allegations of dishonesty, attempting to pass amendments off as part of the original record. Amendments to electronic records can be tracked by audit trail and should be clearly marked on the file.”
“Dr Patel was frankly not thinking forensically at all when making the amendments to the records he did. He is a diligent General Practitioner who was in receipt of a surprising and rare diagnosis. He wished to review the records to see if there were any lessons which could be learned and in doing so was concerned that the notes that he had made of the two consultations in question did not come to the high standards he sets himself in relation to record keeping. It is submitted that medical records are there to record the consultation and the salient features of what occurred during the consultation. They are also there as a space within which a practitioner may record their thought processes. Dr Patel did not feel that the notes that he made contemporaneously adequately reflected either the extent of the discussions that he had with VL and his partner (which were extensive) but also importantly his thought processes in particular in relation to the referral for a respiratory opinion. The additions that he made were made in order to better reflect what had happened. They were not made for any other forensic reason. The additions were made some 5 or 6 days following the receipt of the diagnosis and there was of course at that time no intimation of any allegations of failing of care. ……….. It is accepted that Dr Patel made the amendments alleged. It is also accepted that the manner in which he did so was inappropriate and with the benefit of hindsight Dr Patel recognises that the proper way to make any such amendment is by way of separate dated entry. We submit that this is an uncharacteristic lapse of concentration on Dr Patel's behalf. Indeed he will say that he was not fully cognisant of the fact that such amendments were not fully transparent in an electronic system. We are instructed that when viewing the entries on the live computer system the entries show an icon which indicate that the entry has been amended however the reality is that that was far from Dr Patel's mind at the time he made the amendment. He simply did not consider the possibility as he was not thinking in a forensic manner at all. He has reflected and learned about this matter. We submit that this is an isolated lapse in an otherwise unblemished career and it is certainly a lesson that Dr Patel will have taken to heart and it will not be a mistake that is repeated in the future. It is therefore an error which is capable of remediation, and has been remediated and therefore the chances of repetition are remote.”
“[(2)] (a) the decision may be materially flawed (for any reason) wholly or partly; or (b) there is new information which may have led, wholly or partly, to a different decision”
“Allegation 3 It is alleged that additions made by Dr Patel to the notes of the consultation of26 May 2015 were untrue. We consider all the additions, and the evidence available as to whether they were true or not: ‘patient has had previous history of asbestos exposure. 2 chest XR's done in Feb and April does not show any acute pulmonary lesions. pleural plaque on left side which is stable from previous films.’ From the evidence available to us, and while it is not our role to make findings of fact, it seems clear that this addition is factually correct. The information is not disputed that Mr Loder did have a previous history of asbestos exposure. The records also corroborate what Dr Patel added in respect of the chest x-ray reports from February and April 2015. Ms Rogers states that Dr Patel did not discuss these points with Mr Loder during the26 May 2015 consultation, while Dr Patel disagrees and says the previous history of exposure to asbestos was discussed, indeed it was the reason why he referred Mr Loder to the respiratory physician. For the purposes of considering this allegation, it is not necessary to resolve this conflict of evidence. This is because the addition makes no mention of any discussion with Mr Loder about these matters, it simply states Mr Loder’s medical history, and the history is in itself accurate. ‘also patient denies any respiratory symptoms now as cold previously settled. denies any cough/haemoptysis/weight loss/shortness of breath.’ There is a conflict of evidence in respect of this addition. Ms Rogers stated that Mr Loder did not deny respiratory symptoms, in fact he had repeatedly reported to Dr Patel that he had coughed up blood (haemoptysis) and was short of breath. He also reported pain, reduced mobility and fatigue. Dr Patel, while accepting that Mr Loder had reported haemoptysis and shortness of breath previously, said Mr Loder did not report those symptoms on26 May 2015 . In fact he reported that he had recovered from a previous cold, which had been noted in an earlier consultation. It is not our role to seek to resolve substantial conflicts of evidence. However, we are able to assess the weight, if any, we should give to a particular piece of evidence in deciding whether there is a realistic prospect of proving the relevant allegation. We are mindful that the GMC must prove the allegation on the balance of probabilities; the doctor does not have to prove anything. With regard to Ms Rogers’ account that Mr Loder repeatedly reported haemoptysis and shortness of breath to Dr Patel, we note that in her statement for the GMC she did not detail on precisely which occasions Mr Loder reported these symptoms. It is clear from the records that Mr Loder had reported such symptoms on other occasions. If this matter was before a tribunal, it is likely that Ms Rogers would be asked to provide further comment on how she knew these symptoms were discussed on this specific occasion. As to Dr Patel’s account, a tribunal might be expected to give weight to the doctor’s contemporaneous records. The evidential value of the record of the GP consultation in this case is undermined because it was made several months after the event. That said, there is a contemporaneous record in the form of Dr Patel’s letter referring Mr Loder to the respiratory clinic. In this letter Dr Patel stated that Mr Loder ‘denies any respiratory symptoms but he has a background history of asbestos exposure’. This letter provides support for Dr Patel’s evidence that, on the day of the consultation, it was Dr Patel’s understanding that Mr Loder did not report any respiratory symptoms. The tribunal would also be likely to take into account that, when Mr Loder was seen by Dr C less than a week later, on1 July 2015 , Dr C recorded a history that Mr Loder had ‘no associated cough, wheeze or sputum’. Having carefully considered all the evidence, we conclude that there is no realistic prospect of a tribunal finding on the balance of probabilities, this addition to be untrue. ‘also patient felt doesn't feel like it is his lungs causing symptoms’ Again, there is a conflict of evidence in respect of this addition. Ms Rogers stated that Mr Loder did not say he didn’t feel his lungs were causing his symptoms, in fact she and Mr Loder did not know what was causing the symptoms. Dr Patel, however, said Mr Loder and Ms Rogers were up to that point concerned primarily about a cardiological cause for the symptoms. Previous records made reference to the personal and understandable reasons for their concerns. There is no contemporaneous record to support Dr Patel’s account over that of Ms Rogers. However even if it could be proved that Mr Loder did not hold the view reported by Dr Patel, we believe it would not be possible to prove that this was not Dr Patel’s understanding of Mr Loder’s views, in light of the previous history of cardiology referrals and tests. ‘4. agreed to refer to respiratory clinic for patient for rv’ It is evident that Dr Patel did agree to refer Mr Loder, and he wrote the referral letter the same day. This statement therefore appears to be accurate.”
“As discussed above, we do not believe a tribunal would find, more likely than not, that the additions made by Dr Patel to the record of the consultation on26 May 2015 were untrue. It therefore follows that the allegations of dishonesty, and intention to avoid criticisms of care, would fall away; allegations 4 and 5 would not be capable of proof.”
“misleading because the additional entries made on19th August 2015 are added to the existing record and so appear to be part of the contemporary record when in fact they are later amendments and additions. This modifies the original contemporary record rendering it unreliable as evidence. It means that we cannot now rely on either the original or the amended record since the accuracy of both is called into question.”
“Dishonesty [46] Evidence a doctor has been dishonest can represent a very serious breach of our professional standards and pose a risk of confidence in the medical profession. [47] Good medical practice provides that doctors must be honest and trustworthy, and must make sure that their conduct justifies their patients’ trust in them and the public’s trust in the profession. [48] Examples of dishonesty in professional practice can include: …….. • Improperly amending patient records” [48] Examples of dishonesty in professional practice can include: • Improperly amending patient records”
“[14] The case examiners will apply the following test at the conclusion of the investigation stage: The investigation committee or case examiner must have in mind the GMC’s duty to protect the public which includes promoting and maintaining the health, and safety and well-being of the public; public confidence in the profession; and, proper standards and conduct for doctors, in considering whether there is a realistic prospect of establishing that a doctor’s fitness to practise is impaired to a degree justifying action on registration.”
“We find that there is a realistic prospect of allegations 1 and 2 being found capable of proof. These relate to Dr Patel inappropriately making retrospective amendments to medical records. The amendments were inappropriate because he did not make clear when the addition was made, by whom, and why it was made. We accept the expert’s opinion that this fell seriously below the standard expected of a reasonably competent GP because it undermines the credibility of the record. We also note the expert’s view that the additions, in themselves, appear to be helpful clinical additions. Furthermore we note that there is no dispute about the accuracy of some of the comments added by Dr Patel, which reflected Mr Loder’s clinical history and Dr Patel’s management plan. Where there was a dispute, we have explained that we do not believe the addition can be proved to be inaccurate and the disputed addition did not materially affect Mr Loder’s ongoing care. When considering whether Dr Patel’s admitted departure from the standards expected in respect of his record keeping, on a single occasion on19 August 2015 , is sufficiently serious to require action on his registration, we must keep in mind that the primary purpose of the GMC’s fitness to practise proceedings is to protect the public against future harm from those who are not fit to practise, rather than to punish a doctor for past misdoings. We must decide whether there is a realistic prospect of establishing that the doctor’s fitness to practise is currently impaired: this decision looks forward to what a doctor may do now or in the future, rather than to actions committed in the past. This means we should take into account whether the doctor’s failings are easily remediable, whether they have been remedied (and to what extent), and whether they are likely to be repeated. This incident took place seven years ago, and Dr Patel’s Responsible Officer and employers report no concerns since about Dr Patel’s conduct. Dr Patel has been fully registered with the GMC since 2006 and he has no fitness to practise history. With regard to his record keeping failing, Dr Patel has acknowledged the failing and expressed his regret for it. He has provided evidence that he has refreshed his knowledge of the standards required in respect of record keeping by completing relevant professional development courses. We have been informed of no other concerns, before or since, about his records. In these circumstances, we are of the view that there is no realistic prospect of demonstrating that the doctor poses an on-going risk to patient safety and is not currently fit to practise. Further, in the absence of evidence that the doctor displayed a reckless disregard of his clinical obligations, we do not consider that there is a realistic prospect of a finding of impairment solely in order to maintain public confidence in the profession.”
“[79] An isolated lapse from high standards of conduct – such as an atypical rude outburst – would not normally, in itself, suggest that the doctor’s fitness to practise should be in question. The sort of misconduct….. which may however, indicate a lack of integrity, an unwillingness to practise ethically or responsibly or a serious lack of insight into obvious problems of poor practise will bring a doctor’s registration into question.”