First published by Romy Cerratti January 24th 2022
A German doctor saved my life when I was just over a year old. A joyous first family Christmas in Germany ended in me catching an infection from my cousin, sepsis and ICU. The doctor gave my fragile young body the best possible chance and I owe him much. Sadly many of my subsequent encounters with doctors and nurses have been the opposite and it is these that have left their mark. I was assaulted by an NHS doctor when I was 14 and desperately unwell with a complex mental illness. However it’s never been as ‘straightforward’ as dealing with the one horrific incident. Many months of bullying and threats preceded that assault. In the years that followed I went through unnecessary incarceration in inpatient units and damaging treatment therein, intimidation, lies, misdiagnosis, catching life threatening hospital infections and plain old incompetence. I have more often survived despite and not because of medical ‘care’ and have added PTSD to an already complex set of mental and physical health conditions. It is a great source of pain to me that I now approach all medical professionals with distrust, even fear.
However the prevailing British view of ‘our NHS heroes’ and ‘our amazing NHS’ could not be further from mine. The reverence of many Brits for their healers knows no bounds and most won’t tolerate criticism of their modern day saints. This even extends to when their health or the health of a loved one has been mishandled and damaged, sometimes even when the result is death. Just recently I read a newspaper report of the tragic cancellation of vital scans, due to NHS Covid policy, for a 15 yr old boy with a brain tumour. It struck me that the mother did not blame the NHS for this or even the doctors for missing the clear symptoms of a brain tumour earlier on. Heartbreakingly this poor lady almost blamed herself for not being ‘pushy’ enough! My mother encounters this regularly in the course of her job as a vicar looking after 8 rural parishes. Even when an avoidable death has occurred, people are reluctant to complain about their medical treatment. ‘I’m sure they did there best,’ or ‘it’s a problem of the management and resources not the doctors and nurses’ are the predictable responses. Such pervasive NHS worship can also scare would be complainents and whistleblowers into silence. I am often contacted privately on social media by those who want to tell me their story of medical mistreatment. Telling me is ‘safe’ because they know I will accept and empathise rather than judge or dismiss their NHS heresy. It is a heartbreaking privilege. Recently a Twitter follower shared both her story of doctors covering up the failings in her treatment and a link to the ‘Oliver McGowan Mandatory Training in Learning Disability and Autism video’. Oliver’s brave mother eloquently tells the heartbreaking story of the catelogue of errors and mistreatment that lead to her son’s death. It somewhat shocked me that even in a case where there was clear blame to be ascribed to individual physicians, she said ‘It’s not about pointing fingers, it’s not about blame.’ But is it?
It’s actually quite rare for people to make an official complaint against the NHS, even if they do feel wronged in some way. The intrepid who do embark on the official complaints process find their path beset with obstacles that can feel designed to make you give up.
‘Scandalous and shameful. If you’re looking for an outcome and you’re emotionally stressed, don’t waste your time with these corrupt individuals.’
This is a Trust Pilot review of the Parliamentary and Health service Ombudsman, (PHSO), the final and highest arbitrator of complaints against the NHS and its employees. It is indicative of pretty much every single review. Undeniably people who have had bad experiences are more likely to leave online feedback. However this near universal unbridled fury and distress, summed up in one review as ‘The PHSO is a vehicle for injustice,’ suggests a fundamental problem.
In 2016, after a scandal provoked a change of Ombudsman , chief executive at the Patients Association, Katherine Murphy said patients had ‘been failed by the PHSO for too long.’ However, the statistics, as well as patient feedback, suggest nothing has improved. In 2018/19 it was found that the PHSO upheld just 2.4% of all the complaints submitted. (It must be added that if resolution without investigation is taken into account this figure rises to 20% but also that ‘resolution’ is most often no more than a simple apology). This is a decline from the already paltry 3% in 2016/17 and even further from 4.7% 2015/16. The Ombudsman is theoretically held to account and monitored through the submission of annual reports to the Public Administration and Constitutional Affairs Committee, (PACAC), a parliamentary committee made up of cross-party members. However PACAC can’t review individual complainants cases and the Ombudsman’s verdicts can’t be challenged. Therefore the Ombudsman is not accountable in any meaningful sense. The only recourse available to a complainant is Judicial Review, a path that precious few citizens have the means to make use of. One rare example of a successful High Court challenge in the High Court was brought by two GPs in 2018. In the ‘Miller & Anor V Health Service Commissioner for England’, the judgement criticised all aspects of the investigation process including failure to consider all the evidence and an inadequate review process. Importantly it also highlighted the ‘lottery’ of the ‘clinical advisor’ selected for each case. When the PHSO investigates and scrutinises a case it uses but a single clinical advisor whose words are Holy Writ. Therefore one person’s opinion is basically all that matters and it is an NHS doctor reviewing one of their fellows. The NHS arguably acts as its own judge and jury.
‘It doesn’t matter what I say or what evidence I present you will simply stick to your narrative that bears no relation to the truth. I am powerless.’
This time these are my own words, taken from my response to the PHSO’s final report on one of my two complaints I submitted in late 2018. I had already gone through a long mentally draining process to get to this stage of utter despair. That involved having to first complain to the hospital and the NHS Trusts, several labyrinthine forms and some rather interrogatory face to face meetings. This smorgasbord was completed by a random, intimidating phone call from someone at the relevant NHS Trust trying to dissuade me from taking things further. Both complaints centred around the absence of psychiatric assessment, misdiagnosis and serious negligence in both psychiatric and physical healthcare. The consequences of the way I was treated have been profound and I am living with the terrible consequences daily. But those wounds were actually deepened by the complaints process I had hoped would bring some healing closure and justice. The fact that my records were lost, my complaints muddled up resulting in huge delay and my caseworker frequently went AWOL almost feels inconsequential to me now in the light of the whole process being a whitewash. The first question asked of the PSHO’s clinical adviser assigned to my case was:
‘Is there any evidence that Ms Cerratti should have been assessed by a psychiatrist during her admission/time as an inpatient?’
The Ombudsman actually questioned whether it is essential for someone with severe psychiatric problems to be assessed by a psychiatrist whilst in hospital. This gives a fair impression of the whole tortuous coverup of an ‘investigation’. I was left staring at a page of my medical records, on which was written a few notes of my medical history, dictated to a nurse by my mother, but on which the PHSO insisted was recorded a psychiatric assessment. One by one family members stared at the same page and we all started to wonder whether we’d fallen ‘through the looking glass’. Indeed my whole encounter with the PHSO had the bewildering feel of being in a shape shifting bonkers Wonderland.
‘“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean — neither more nor less.”’
They were in control and could weave whatever bizarre fiction they chose irrespective of what most would understand to be reality.
I have nothing but admiration for the amazing Mrs McGowan, the architect of the much needed Oliver McGowan Mandatory Training in Learning Disability and Autism programme. She has achieved more regarding NHS reform than I am ever likely to. I also respect her emphasis on improving the education of NHS staff. However improved training, although vital, can not alone solve the problem of NHS malpractice. In order to stop the rot we must get rid of rotten apples and that very much involves both blame and pointing the finger. It must involve holding individual medics to account, even criminally, and certainly striking off the worst offenders. In Oliver’s tragic case no amount of extra training could have prevented the arrogant disregard of his medical notes and ignoring his family’s and indeed his own wishes. In my friend’s NHS story, it was not ‘lack of training’ that made doctors falsify her medical notes to conceal their bad practice. In my own case there was an invisible psychiatric assessment, disregard of my previous trauma and the unwillingness to believe me or even listen to me, none of which was down to a lack of training.
The medical abuse I have suffered hasn’t just left me with a distrust of medics, it’s given me a deep rooted distrust of life. Ironically the process I hoped would help ease that, the NHS complaints process, actually reinforced it. I can only speak out to encourage other victims to do likewise and in the hope that our suffering will be acknowledged and provoke reform of the NHS, it’s culture and its complaints process.
1,500 more patients of jailed breast surgeon Ian Paterson recalled
https://www.theguardian.com/society/2023/feb/01/1500-more-patients-of-jailed-breast-surgeon-ian-paterson-recalled
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‘On Friday, the Nottingham University Hospitals (NUH) NHS Trust, which runs the QMC, was fined £800,000, the highest fine ever issued for failings in maternity care, after pleading guilty at Nottingham Magistrates’ Court on Wednesday to two charges relating to Wynter and Mrs Andrews of being a registered person who failed to provide care or treatment in a safe way resulting in harm or loss.’
https://www.dailymail.co.uk/news/article-11683715/NHS-trust-fined-800-000-systematic-failures-baby-death.html
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Daily Mail:
‘NHS Trust admits care failures over death of baby girl 23 minutes after she was born after inquest found she would have been saved if delivered earlier’
https://www.dailymail.co.uk/news/article-11675403/NHS-Trust-admits-care-failures-death-baby-girl-23-minutes-born.html
‘Gallbladder surgeon admits leaving two patients with life-changing injuries after botching operations’
https://www.dailymail.co.uk/news/article-11673149/Gallbladder-surgeon-admits-leaving-two-patients-life-changing-injuries-botched-operations.html
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Order revoked – not impaired
‘7. The 2022 Tribunal found that Dr Samra had put patients at unwarranted risk of harm, had brought the profession into disrepute and had breached a fundamental tenet of the profession by signing prescriptions without adequate regard to patient safety.’
Click to access dr-dalveer-samra-03-jan-23.pdf
Suspension revoked – not impaired
‘5. The 2021 Tribunal considered that Dr Vasistha’s dishonest behaviour in recording consultations that did not take place, in effect for financial gain, and then subsequently deleting some of those records would be regarded as serious misconduct by a reasonably informed member of the public. It noted that the public rely on doctors to act with honesty
and integrity.’
Click to access dr-amitesh-vasistha-03-jan-23.pdf
Restoration application refused. No further applications allowed for 12 months from last application.
‘The 2011 FTPP found that Dr Al-Daraji had breached the terms of his employment contract; falsified a number of emails; submitted a reference which he knew to be false in support of a job application; inflated his job title and experience on his CVs; published an article knowing that the images were not those of the patients described; and signed a copyright transfer form in relation to the publication of an article, knowing that a similar article had been published by him elsewhere. The 2011 FTPP found that a number of Dr Al-Daraji’s actions had been misleading and dishonest. In addition, he admitted to having dishonestly self-prescribed XXX.’
Click to access dr-wael-al-daraji-05-jan-23.pdf
Restoration application refused
‘4. The matters w4.hich led to Dr El-Badawi being erased by a Medical Practitioners Tribunal between 26-29 June 2016, (‘the 2016 Tribunal’), involved repeated and dishonest provision of false information. Between 1 September 2010 and 30 March 2015, Dr El-Badawi submitted a Curricula Vitae (CV) to two locum agencies (Locum Vision and ID Medical) containing information which was untrue and which he knew to be untrue. The untrue information included Dr El-Badawi stating that his work involved on-calls for Primary Percutaneous Coronary Intervention (PPCI) procedures; in particular, that he had taken part in the on-call rota at Papworth Hospital.’
Click to access dr-khalid-el-badawi-05-jan-23.pdf
Restoration application refused. No further applications allowed for 12 months from last application.
’11. The 2011 Panel found that Dr Yassin deliberately changed the marks awarded by her colleagues so as to give a better impression of her performance, and lied about and to colleagues to protect her own reputation, regarding this as a serious breach of professional
standards. The 2011 Panel determined that Dr Yassin’s repeated dishonesty and unprofessional behaviour amounted to serious misconduct, and that the gravity of her misconduct was aggravated by the fact that she continued to lie to the Panel, seeking to maintain her position and undermine the credibility of her educational supervisors
throughout her evidence. ‘
Click to access dr-anhar-yassin-05-jan-23.pdf
Restoration application granted. Restore to Medical Register.
1’4. The 2015 Panel determined that Dr Jenyo made additions to, and deleted parts of, Patient A’s clinical notes. The 2015 Panel concluded that the deletions were particularly serious, as they were intended to show symptoms in different areas to those reported by Patient A. For example, in the deletion of the term “mid-back pain” (entry 26 February 2007,
amended 27 May 2010), to remove reference to such pain early on in Patient A’s records, and the deletion of a note of a chest examination (entry 17 January 2007, amended 27 May 2010), to fit in with the clinical picture that Dr Jenyo wanted to present.’
Click to access dr-robert-jenyo-06-jan-23.pdf
Suspension revoked
‘6. The facts found proved at Dr Asif’s hearing can be summarised as a finding that between around 1995 and 9 March 2019, Dr Asif abused Ms A mentally in that on 9 March 2019 he attempted to forcibly enter XXX by climbing onto the roof and by banging on the windows. 7. Further, the September 2022 Tribunal found that he physically abused Ms A, in or around 2002/2003, in that he slapped Ms A across the face and also in or around 2002/2003, pulled all of the telephone cords out of their sockets when Ms A attempted to contact the emergency services, hitting her face with one of the wires. These facts were found proved in January 2022 and the Tribunal subsequently reconvened in August and September 2022’
Click to access dr-muhammad-asif-06-jan-23.pdf
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Shrewsbury maternity scandal: Payout over boy’s brain injury
https://www.bbc.com/news/uk-england-shropshire-64377732
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This article is spot on and speaks for so many of us. The UK is in an accountability and honesty crisis. My own experience with Derbyshire Healthcare NHS Foundation Tryst has many parallels. As soon as I raised a complaint, I became a problem, no longer a patient. What followed was a disturbing sequence of lies, abuse of power and official obfuscation as the individuals at DHCFT were prepared to go to any lengths to cover up to protect their own personal reputations and interests:
https://patientcomplaintdhcftdotcom.wordpress.com/
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‘Punch to the gut!
An investigation was carried out and the PHSO obtained independent clinical advice. Based upon that advice, the investigator told me she was going to uphold my complaint. She drafted a report in my favour and wrote to both me and DHCFT’s CEO, Mr Trenchard, putting us on notice to expect receipt of the draft report ‘any day now.’
8. Unexpectedly, following this, I was suddenly told the investigator had left the Ombudsman and my complaint was to be allocated to a new investigator. The draft report that upheld my complaint was destroyed and a new draft report was produced that no longer upheld any of my complaint…’
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So what’s new. I remember the ex policeman employed as a new broom at PHSO. He told me , ‘I know how to do a proper investigation’ . He disappeared off the screen when he showed tendencies of wanting to see justice done…
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GB News:
‘NHS pays £39M to girl who had limbs amputated after hospital mistake
The girl was initially discharged and given paracetamol before her parents brought her back to A&E just hours later’
https://www.gbnews.uk/news/nhs-pays-39m-to-girl-who-had-limbs-amputated-after-hospital-mistake/428528
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Very sad.
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Daily Mail:
‘Pregnant women and new mums are increasingly being abandoned by the NHS with many losing confidence in maternity services, a damning report reveals.
A major survey of 20,900 women by the care regulator found the number reporting a positive experience of pregnancy, labour and postnatal care has plummeted.’
https://www.dailymail.co.uk/health/article-11623585/Pregnant-women-abandoned-NHS-Nearly-40-mothers-struggled-help-labour.html
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The Guardian:
‘A “most accomplished fraudster” was paid between £1m and £1.3m by the NHS during the nearly two decades she posed as a qualified doctor after forging a degree certificate, a court has heard.
Zholia Alemi, believed to be 60 years old, worked as a psychiatrist in the UK for 19 years after claiming to have qualified at the University of Auckland in New Zealand, a trial at Manchester crown court heard.’
https://www.theguardian.com/society/2023/jan/10/fraudster-posed-as-nhs-doctor-for-19-years-court-hears
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Links:
Click to access miss-fawzia-ashkanani-20-december-2022.pdf
Click to access dr-wisam-ismail-21-dec-22.pdf
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Suspension, 6 months.
‘4. At the February 2020 hearing, Miss Ashkanani admitted the majority of the Allegation and the February 2020 Tribunal found proved that:
• On 12 December 2013, Miss Ashkanani failed to:
review Patient A’s medical records;
reassess whether Patient A required the surgery;
check that Patient A was taking Bisoprolol pre-operatively;
obtain an up to date assessment of Patient A’s blood test results prior
to surgery;
record having undertaken a number of clinical actions;
• Miss Ashkanani had inappropriately changed Patient A’s admission to a 23-hour stay when an inpatient admission was indicated;’
(there are a lot more failings included)
Click to access miss-fawzia-ashkanani-20-december-2022.pdf
Suspension revoked
‘8. The 2021 Tribunal determined that Dr Ismail had committed plagiarism to enhance his own career. The Tribunal took into consideration that members of the public and the profession would be appalled that someone at such a high level of study would copy the work
of others to pass off as their own. Members of the public and the medical profession would similarly be appalled by his actions thereafter, namely denying his actions to the University, submitting a complaint against the University, denying the Allegation before his regulator and seeking to pass blame to his research supervisors.’
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Suspension, 1 month.
’20. From December 2019 to June 2020 there was an exchange of emails between Patient A and the Trust. Patient A expressed within those emails her distress at the possibility of unauthorised access to her confidential medical records and claimed that someone had been
spreading derogatory rumours about her and about her health.
46. The Tribunal considered that inappropriately accessing a patient’s medical records, and then divulging that information, was a serious departure from the requirements of GMP and GMC Confidentiality Guidance as set out in the paragraphs quoted above.
47. The Tribunal was mindful of the number of occasions the records had been accessed. It had been submitted that this was an isolated act of misconduct. The Tribunal took the view that the accessing of medical records over four days, on multiple occasions, was difficult to
accurately characterise as “isolated” .’
Click to access dr-shwetali-ramdas-bhonde-12-dec-22.pdf
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BBC:
‘Metal forceps were left inside a patient in a so-called never event at a Worcestershire hospital.
The error occurred during a complex seven-hour abdominal operation at Alexandra Hospital on 23 November.
The patient spent the night in intensive care at the site in Redditch when the six-inch (15 cm) object could not be retrieved the same day.
The hospital trust has apologised unreservedly and said it would share the findings of an investigation.’
https://www.bbc.com/news/uk-england-hereford-worcester-64075014
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BBC
‘NHS Dumfries and Galloway has been ordered to apologise over its treatment of a patient who later took their own life.
A complaint was lodged with the Scottish Public Services Ombudsman (SPSO) against the health board.
A parent of patient A said the health board failed to properly assess the risk to life and the family had not been appropriately involved.
All aspects of the complaint were upheld and an apology was ordered.’
https://www.bbc.com/news/uk-scotland-south-scotland-64052309
SPSO Decision Report 202001745
https://www.spso.org.uk/decision-reports/2022/december/decision-report-202001745-202001745
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Suspension, 2 months.
‘4. Patient A was unhappy with the size of the excision made to her forehead to remove the BCC [Basal Cell Carcinoma]. She expressed her concerns on the day of the procedure and subsequently made a complaint to the Hospital. Patient A received copies of her clinical notes including consent form. She noticed that the words ‘LARGE Excision’ had been added to the
consent form where details of potential risks were listed, which did not appear on the carbonated copy she had been given and which she claimed had not been discussed with her.
5. It is alleged that Dr Varghese amended the hospital copy of the consent form after Patient A had signed it, knowing that he had not discussed this particular risk with Patient A and knowing that the amendment was not included on the copy given to her. It is alleged that in doing so, Dr Varghese acted dishonestly.
61. The Tribunal therefore did not find credible Dr Varghese’s evidence about why the amendment was made and the circumstances in which it was made. It found that it was much more likely that Dr Varghese added the comment to the consent form because of the reaction of Patient A.’
Click to access dr-jibu-varghese-01-dec-22.pdf
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Suspension, 2 months.
‘4. The misconduct matter relates to an allegation that on one or more occasions, including 26 January 2021, Dr Fearnley injected the medication, as outlined at Schedule 3, whilst at work and before and/or in between patient consultations.
50. The Tribunal determined that Dr Fearnley’s actions had the potential to put patients at unwarranted risk of harm. It noted that on the day in question, Dr Fearnley saw in excess of 20 patients and was not making wholly comprehensible notes which could have affected their ongoing care. Whilst there is no evidence of harm being caused to any patients, the potential for harm was significant.’
Click to access dr-james-fearnley-18-nov-22.pdf
Suspension, 6 months.
‘3. The Allegation that has led to Dr Hall’s hearing can be summarised as on one or more occasions between 28 December 2017 and 25 August 2020, Dr Hall issued several private prescriptions which he presented to a Boots store. It is alleged that these prescriptions, which were for XXX, were written using names other than his own, and this was dishonest.
6. At the outset of these proceedings, through his counsel, Mr Gledhill, Dr Hall made admissions to all paragraphs and sub-paragraphs of the Allegation’
Click to access dr-mark-hall-21-nov-22.pdf
Suspension revoked – Not Impaired
‘7. An investigation into an allegation that Dr Mehboob falsified documentation was launched by Pulse Jobs. The Trust undertook an investigation and the matter was referred to the GMC. The Allegation was found proved by the 2022 Tribunal.
8. The 2022 Tribunal found that Dr Mehboob’s conduct was serious, that his actions had brought the medical profession into disrepute and breached fundamental tenets of GMP. The Tribunal determined that Dr Mehboob’s dishonesty amounted to misconduct that was serious.’
Click to access dr-raheel-mehboob-25-nov-22.pdf
Conditions for 9 months
‘The 2021 Tribunal found that between 2014 and 2019, Dr Wetzler had prescribed medication (including controlled drugs) for a patient without informing the patient’s GP and without first ascertaining how much of such medication the patient was already being prescribed. In
addition, Dr Wetzler had prescribed medication at unlicensed dosage, and issued prescriptions to the patient on the advice of a complementary health practitioner, who was not a registered medical practitioner, without critically analysing their opinion.’
https://www.mpts-uk.org/hearings-and-decisions/medical-practitioners-tribunals/dr-michael-wetzler–nov-22
Suspension, 1 month
’44. The Tribunal has determined the facts as follows:
1. At a serious incident review meeting on 16 November 2018 with the Phoenix Hospital Group, you stated that your practice (London Bridge Plastic Surgery and Aesthetic Clinic) had informed the Care Quality Commission (‘CQC’) of a serious clinical incident which occurred on 7 August 2018 (‘the Incident’), or words to that effect. Admitted and found proved
2. You knew that, at the time of making the statement at paragraph 1, you/your practice had not reported the Incident to the CQC. Determined and found proved
3. Your actions as described at paragraph 1 were dishonest by reason of
paragraph 2. Determined and found proved’
Click to access mr-christopher-inglefield-28-nov-22.pdf
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Suspension, 12 months.
‘7. The October 2019 Tribunal found that Dr Conway’s actions in working whilst not licensed to practise amounted to serious misconduct and that her approach to her licence to practise was ‘cavalier’. It considered that Dr Conway did not fully recognise the potential ramifications for patient care of treating patients while not licensed to practise… ‘
Click to access dr-jacqueline-conway-18-nov-22.pdf
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Suspension to expire
’14. In respect of Patient B, the June 2022 Tribunal noted that Dr Volle had failed to identify the fracture/subluxation in the CT scan on 1 October 2016 and that it was subsequently identified on MRI imaging on 5 October 2016. It concluded that Dr Volle’s issuing of a final report, without either seeing all the images or giving a warning that all the
images had not been viewed, was behaviour which fell so far below the standard of a competent consultant radiologist that it amounted to serious misconduct.’
Click to access dr-eckhard-volle-08-nov-22.pdf
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‘A hospital was fined £60,000 after a heart patient died following a mix-up over scan results.
Luke Allard, 28, who had a heart disorder, was sent home after a doctor at the Queen Elizabeth Hospital (QEH) in King’s Lynn read an old CT scan.
The mistake was discovered two days later, but Mr Allard suffered a fatal heart attack on his return to the unit.’
The hospital pleaded guilty to failing to provide safe care and treatment, exposing him to risk of avoidable harm.
https://www.bbc.com/news/uk-england-norfolk-63904797
‘A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section.
For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster’s baby was to blame.
“It was just continuous lies,” the 34-year-old told BBC News.
East Kent Hospitals chief executive Tracy Fletcher promised “to ensure lessons are learned”.’
https://www.bbc.com/news/uk-63920920
‘The NHS has announced three major reviews of a hospital trust after a BBC Newsnight probe was told a climate of fear among staff put patients at risk.
Whistleblowers at University Hospitals Birmingham (UHB) NHS Trust alleged they were punished by management for raising safety concerns.
One insider told the BBC the trust was “a bit like the mafia”.’
https://www.bbc.com/news/uk-england-birmingham-63923425
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Tip of the iceberg. Our NHS is a mess.
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Conditions, 24 months
‘6. On 10 December 2015 Patient A underwent a second re-laparotomy (‘the Procedure’) and you:
a. inappropriately delegated the Procedure to Mr B; To be determined
b. did not attend theatre to oversee the Procedure of your own volition; To be determined
67. The Tribunal determined that paragraphs 6.a. and 6.b. are proved.
c. failed to:
i. communicate to the on-call team that following the Procedure Patient A may continue to bleed overnight; To be determined
ii. record any clinical notes, including the matters referred to in
paragraph; To be determined
70. The Tribunal therefore determined that paragraphs 6.c.i and 6.c.ii are proved.
64. The Tribunal also had regard to the DATIX Incident Review and Management Form completed by Mr I on 15/12/2015 in which he also confirmed that he asked Mr Marsh to attend approximately five times. In this he stated, ‘The consultant refused to come and reiterated that the middle grade should proceed.’
Click to access mr-peter-marsh-28-oct-22.pdf
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WARNING
‘2. The allegation that has led to Dr Bakhtiar’s hearing is that between 14 January 2014 and 28 November 2014, Dr Bakhtiar inappropriately transcribed, signed and issued 148 private prescriptions for third party patients (the ‘Patients’). The patients were based outside the UK and one or more of the patients named on the prescriptions did not exist…that he failed to adequately investigate or monitor the system of prescription requests used by the Pharmacy or Clinic and that he completed the Prescriptions based on insufficient information to allow for safe prescribing.
3. It is also alleged that Dr Bakhtiar failed to identify a number of ‘red flags’ relating to the Prescriptions;
4. It is further alleged that Dr Bakhtiar failed to keep adequate records;
8. At the outset of these proceedings, through his counsel, Ms Neair Maqboul, Dr Bakhtiar made admissions to all paragraphs and sub-paragraphs of the Allegation’
Click to access dr-mohammad-bakhtiar-14-oct-22.pdf
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Suspension 3 months
‘4. It is alleged that Dr Wells had dishonestly completed MCCD stating that he had seen the patients on specific dates prior to death when he knew that he had not seen the patients on those dates.
5. It is further alleged, that during a telephone call with the Deputy Registrar, Ms H (referred to as Mrs F in the Allegation), Dr Wells had dishonestly indicated that he had last seen Patient E alive on a specific date when he knew that he had not seen Patient E on that
date.
8. At the outset of these proceedings, Dr Wells made admissions to all the paragraphs and sub-paragraphs of the Allegation’.
Click to access dr-mark-wells-14-oct-22.pdf
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Not Impaired – Suspension to expire
3. Dr Sheikh’s hearing took place in October 2021. At that hearing, a differently constituted Tribunal (‘2021 Tribunal’) found proved that Dr Sheikh had failed to disclose that she had been convicted in April 2012 in Romania of a criminal offence that involved her ‘being concerned in supplying controlled drugs.’ It was also found proved that Dr Sheikh provided false information to the Trust and the GMC regarding the details of her conviction, namely she sought to say that she passed money with no knowledge that it was connected to a drugs transaction, when in fact she had been directly involved in drugs transactions. It was also found proved that she failed to disclose her conviction to the GMC until 15 January 2018 and maintained a false position as to the facts of her conviction. The 2021 Tribunal found that these actions were dishonest
Click to access dr-farina-sheikh-20-oct-22.pdf
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BBC:
‘The chairman of an NHS trust that runs a mental health unit where patients were filmed being mistreated has quit.
A BBC Panorama investigation found a “toxic culture of humiliation, verbal abuse and bullying” at the Edenfield Centre in Prestwich near Manchester.’
https://www.bbc.com/news/uk-england-manchester-63678727
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Suspension, 3 months
‘3. The allegation that has led to Dr Saha’s hearing can be summarised as that, on 11 May 2021, whilst undertaking Paper 2 of the Royal College of Physicians (UK) Part 1 online written examination, Dr Saha accessed external web pages in order to research examination questions and check and/or amend her answers to the questions. It is alleged that she knew she was not permitted to access web pages during the examination and that her actions in so doing would give her an unfair advantage in the Examination. It is alleged that by reason of that knowledge, her actions were dishonest.
51. The Tribunal was of the view that Dr Saha’s conduct in effectively cheating while undertaking the examination was particularly serious and was at the highest end of the scale.’
Click to access dr-abhishikta-saha-27-oct-22.pdf
ERASURE
‘2. The Allegation against Dr Peters relates solely to his practice of issuing private prescriptions whilst working for The Provider Services Partnership. The Provider Services Partnership provides clinical reviews for overseas patients who were not registered with a GP in the UK. It is alleged that Dr Peters inappropriately prescribed medication to a number of patients and failed to take reasonable steps to contact the clinician who had previously prescribed for the patients. It is further alleged that Dr Peters failed to ensure he had the appropriate registration for prescribing to patients in Egypt and indemnity insurance to do so.’
Click to access dr-peter-peters-26-oct-22.pdf
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BBC:
Almost 600 patients received “suboptimal care”, an inquiry into the clinical practice of a urology consultant has been told.
The public inquiry concerns the work of Aidan O’Brien at the Southern Trust between January 2019 and June 2020.
…
Lead counsel to the inquiry Martin Wolfe KC said “deficiencies of care had been identified in a number of cases” leading to nine serious adverse incidents (SAIs) being launched.
He said 400,000 pages of evidence had been “scrutinised”.’
https://www.bbc.com/news/uk-northern-ireland-63547948
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‘A doctor accused by a public inquiry of a cover-up following the death of a child has been found guilty of dishonesty by a fitness to practise tribunal.
Retired consultant paediatrician Dr Heather Steen has been found guilty of a raft of charges by the Medical Practitioners Tribunal Service (MPTS).
During a brief hearing this afternoon, MPTS panel chair Sean Ell said they had found “most of the facts proved”, including “the dishonesty allegation”.
The panel will now consider whether Dr Steen’s actions following the death of nine-year-old Claire Roberts amount to misconduct and how they affect her fitness to practise.’
https://www.belfasttelegraph.co.uk/news/northern-ireland/retired-paediatrician-found-guilty-of-dishonesty-by-fitness-to-practise-panel-over-death-of-child-42125041.html
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‘Liz Smith, MSP for Mid Scotland and Fife, has written to health secretary Humza Yousaf calling for an independent inquiry into the former head of neurosurgery at NHS Tayside, Professor Sam Eljamel.
He was ordered to pay £2.8 million in compensation to a woman who was left with life-changing injuries as a result of his medical negligence.
According to the BBC, Jules Rose discovered in 2013 that Prof Eljamel had removed her tear gland instead of a tumour in her brain.’
https://www.scotsman.com/health/public-inquiry-urged-into-disgraced-scottish-neurosurgeon-3904589
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‘Three young women died after a catalogue of failures at an “unstable” and “overstretched” mental health hospital, an inquiry has found.
Christie Harnett and Nadia Sharif, both 17, and Emily Moore, 18, died under the care of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).
All three were treated at West Lane Hospital in Middlesbrough, where two of the girls took their own lives.’
https://www.bbc.com/news/uk-england-tees-63472700
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Very sad and all too common.
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Restoration application refused
‘4. Dr Ishaque’s case was considered by a Fitness to Practise Panel in 2012. The following allegations were found proved:
On 10 September 2010 you submitted a curriculum vitae to the GMC in which you stated that you held qualifications which you did not have namely:
i. MRCP1 – The Royal College of Physicians, UK Jan 2009
ii. FRCR1 – The Royal College of Radiologists, UK May 2009
iii. FRCPath1 – The Royal College of Pathologists, UK Nov 2009
iv. MSc (Policy Analysis and Management) – Carnegie Mellon University (USA) 2010
Paragraph 2b
• You failed:
i. The examination for the Royal College of Physicians in January 2009.
ii. The examination for the Royal College of Radiologists in June 2009’
Click to access dr-muhammad-ishaque-13-oct-22.pdf
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BBC:
‘The families of three patients who all died after undergoing the same specialised endoscopy procedure have accepted damages from an NHS trust.
The patients all died after a procedure called an endoscopic retrograde cholangiopancreatography (ERCP) at Nottingham University Hospitals NHS Trust.
Following their deaths, a coroner issued a report calling for changes.’
https://www.bbc.com/news/uk-england-nottinghamshire-63328932
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‘Two out of five maternity units in England are providing substandard care to mothers and babies, the NHS watchdog has warned.
“The quality of maternity care is not good enough,” the Care Quality Commission (CQC) said in its annual assessment of how health and social care services are performing.’
https://www.theguardian.com/society/2022/oct/21/maternity-units-england-substandard-nhs-care-quality-commission
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The Guardian:
‘The deaths of at least 45 babies could have been avoided if nationally recognised standards of care had been provided at one of England’s largest NHS trusts, a damning inquiry has found.’
https://www.theguardian.com/society/2022/oct/19/east-kent-nhs-trust-might-have-avoided-45-baby-deaths-with-better-care-inquiry-says
‘A family calling for a public inquiry into a health trust following the deaths of three teenage girls have handed in a petition at Downing Street.
The trust is to be prosecuted by the Care Quality Commission over the youngster’s death as it had “failed to provide safe care and treatment”.’
https://www.bbc.com/news/uk-england-tees-63180419
ERASURE
‘4. On 24 February 2021 at the County Durham and Darlington Magistrates’ Court you were convicted of three counts of making false representations between 25 February 2019 and 11 September 2019 with a view to procuring the burning of human remains, namely that you had truthfully answered the questions of the Cremation Form 5, contrary to section 8 of the Cremation Act 1902. Determined and found proved (p8)
23. In relation to his conviction, the Tribunal bore in mind that Dr Kyaw Htin had been convicted of a dishonesty offence and that it involved both untruthfully completing Cremation 5 Forms and failing to consult the original medical practitioner who originally signed the medical certificate relating to the deceased. The Tribunal considered that the Cremation 5 Form was an important legal document which required a high level ofresponsibility reflected in the inclusion of a Statement of Truth. The conviction incorporated three counts of such conduct, while 27 other instances were taken into consideration. ‘
Click to access dr-kyaw-htin-25-aug-22.pdf
ERASURE
‘3. The Allegation that has led to Dr Alshafey’s hearing can be summarised as failures in relation to obtaining adequate training before carrying out an abdominoplasty and failing to provide adequate care to two patients:He had decided to practise well beyond the limits of his own competency and experience in undertaking an abdominoplasty without adequate training, skill or supervision;’ p66
Click to access dr-haitham-alshafey-22-sep-22.pdf
ERASURE
‘2. The Allegation that has led to Dr Chiam’s hearing can be summarised as follows. Dr Chiam is alleged to have dishonestly carried out private work, contrary to his job plan with the Trust, on 28 occasions between 12 March 2018 and 9 January 2019. It is alleged that his conduct in that regard was financially motivated because he was paid, on those occasions, both by the Trust and by the private company to whom he was providing his services. Dr Chiam is also alleged to have been dishonest on 30 May 2018 by claiming to be unavailable for work at the Trust due to his children being unwell on that day, when he was in fact conducting private work at Barlborough Hospital. 4. At the outset of these proceedings, Dr Chiam made admissions to all paragraphs and sub-paragraphs of the Allegation,’
Click to access dr-patrick-chiam-29-sep-22.pdf
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Restoration following disciplinary erasure
‘The 2014 Panel made the following findings of fact:
4. You falsified ePortfolio entries in that:
a) You caused to be completed and submitted a DOPS assessment dated 1 February 2011 relating to a renal biopsy in the name of ‘A’, Found proved
c) On 9 May 2011 you caused to be completed and submitted
assessments in the name of Dr C namely:
i. ACAT, Found proved
ii. CbD, Found proved
iii. MiniCEX. Found proved
5. You knew the assessments at paragraph 4 were false because:
a) The doctors who were purported to have carried out those
assessments had not
8. The 2014 Panel concluded that Dr Radha’s dishonesty was extensive, persistent and covered-up, as well as a particularly serious departure from the principles set out in GMP. ‘
Click to access dr-schwann-radha-02-sep-22.pdf
Restoration following disciplinary erasure
‘4. The 2016 Panel found proved allegations of violent and controlling behaviour XXX. The 2016 Panel also found proved that Dr Aly submitted an email, purportedly from Ms B, during court proceedings. Ms B disputed that she had written this email and reported the issue both
to the GMC and to the police. The 2016 Panel found Dr Aly’s actions to be dishonest.
The 2016 Panel found it proved that Dr Aly, whilst on his career break, had engaged in paid employment in Bahrain between September 2012 and October 2013, which was in breach of the Trust’s Special Leave Policy. The 2016 Panel also found it proved that Dr Aly had falsified documents relating to that activity and made several denials of the truth to the Burton Trust both orally and in writing.’
Click to access dr-essam-aly-02-sep-22.pdf
‘A bereaved Co Down mother is to receive “substantial” undisclosed damages to settle legal action over alleged failures in her hospital treatment and the care provided to her tragic baby, it was announced today. ‘
https://www.belfasttelegraph.co.uk/news/courts/co-down-mum-to-receive-substantial-undisclosed-damages-over-alleged-failures-in-hospital-treatment-and-care-for-her-tragic-baby-42027153.html
‘HSIB’s investigation was prompted by a series of reports in the Guardian in 2020 about inadequacies in 111 operations in the initial weeks of the pandemic, and claims by the Covid-19 Bereaved Families for Justice that many callers with Covid received inadequate advice and died after being wrongly told to stay at home.
HSIB’s 15-month investigation uncovered an array of failings, including some key flaws in the Coronavirus Response Service (CRS), a telephone triage service set up on 5 March 2020 to which 111 call handlers were to transfer queries from anyone concerned about the virus.’
https://www.theguardian.com/society/2022/sep/29/nhs-111-failures-led-to-early-covid-deaths-investigation-finds
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Daily Mail:
‘A law student died after wrongly being denied a face-to-face GP appointment, the NHS has admitted.
…
Recordings of his four calls were obtained by BBC Newsnight and will be broadcast tonight, with the permission of his family.’
https://www.dailymail.co.uk/health/article-11261791/NHS-officials-ruled-student-died-denied-face-face-appointment.html
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BBC – 28/9/22:
‘Humiliated, abused and isolated for weeks – patients were put at risk due to a “toxic culture” at one of the UK’s biggest mental health hospitals, BBC Panorama can reveal.
An undercover reporter at the Edenfield Centre filmed staff using restraint inappropriately and patients enduring long seclusions in small, bare rooms.’
https://www.bbc.com/news/uk-63045298
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‘The healthcare watchdog praised bosses of a mental health hospital after visiting during the weeks when the BBC filmed patients being mistreated.
According to a report to governors at the trust which runs the Edenfield Centre, the Care Quality Commission noted its “strong, motivated leaders”.’
https://www.bbc.com/news/uk-63095331
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None so blind as those who do not wish to see.
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The Guardian:
‘Almost 6,000 people harmed by prescription errors in NHS last year’
https://www.theguardian.com/society/2022/sep/26/almost-6000-people-harmed-by-prescription-errors-in-nhs-last-year
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BBC:
‘Up to 600 patients are to be recalled by a hospital after concerns were raised about shoulder operations.
Some patients have lost the use of their arm after surgery by Mian Munawar Shah at Walsall Manor Hospital
…
The MPTS has not commented on its decision not to take Ms Aldridge’s 2016 complaint further. It said the High Court had extended interim measures on Mr Shah that had been imposed in 2021.’
https://www.bbc.com/news/uk-england-birmingham-63007107
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Not Impaired
‘3. Dr Shafi’s case was first heard by a Medical Practitioners Tribunal (‘MPT’) in April 2016 (‘the 2016 Tribunal’). The 2016 Tribunal found Dr Shafi’s fitness to practise to be impaired by reason of deficient professional performance whilst employed by Birmingham and Solihull
Mental Health NHS Foundation Trust (‘the Trust’) between 2012 to 2014 as a CT1 core trainee in psychiatry.
4. The 2016 Tribunal found a number of deficiencies in Dr Shafi’s performance including inappropriate prescribing, an inability to summarise findings and an inability to draw conclusions in relation to Mental Health Tribunal reports.
5. The 2016 Tribunal also found that in 2014 Dr Shafi fell asleep in meetings, demonstrated inadequate techniques in basic hygiene, preparing for physical examinations and phlebotomy, keeping clinical records and demonstrated poor clinical judgement for her level of training.
6. The 2016 Tribunal further found that Dr Shafi failed to review a patient when requested to do so and failed to understand the risk regarding head injury.’
Click to access dr-afsa-shafi-21-april-22.pdf
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Voluntary erasure
‘7. Dr Lakshminarayana was referred to the GMC on 25 June 2019 by Dr B, Responsible Officer for locum agency Cygnet Healthcare (‘Cygnet’). It was alleged that Dr Lakshminarayana had failed to disclose certain health conditions, XXX, while completing pre-employment checks. According to Dr B’s statement dated 6 May 2021, staff at the Cygnet unit where Dr Lakshminarayana was working raised concerns XXX. His affiliation with Cygnet was terminated in July 2019.
8. As a result of the concerns raised by Dr B, the GMC obtained a copy of the medical questionnaire completed by Dr Lakshminarayana in February 2019 and ascertained those matters relating to XXX that, it is alleged, had been inaccurately completed.
25. The Tribunal had regard to the examples set out in the VE Guidance where, except in exceptional circumstances, it would not be in the public interest to allow voluntary erasure; these include cases involving allegations of dishonesty. However, the VE Guidance also sets out examples of exceptional circumstances where it is appropriate to allow voluntary erasure, prior to the conclusion of a fitness to practise process, even if a case was of a type where a voluntary erasure application should, usually, not proceed. Such exceptional circumstances include cases where XXX.’
Click to access dr-cheedella-lakshminarayana-30-march-2022.pdf
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Restoration application granted. Restore to Medical Register.
‘This prompted the following allegations which were found proved at the 2017 hearing:
1. On 30 January 2015 you were sent an email from Pro-Medical Personnel Limited (‘Pro-Medical’) requesting that you provide an up to date mandatory training certificate.
2. On or around 31 January 2015 you created a new mandatory training
certificate dated 31 January 2015 (‘the Certificate’).
3. On 31 January 2015 you sent an email to Pro-Medical attaching the Certificate.
4. You submitted the Certificate to Pro-Medical despite knowing that:
a. you had not completed the up to date mandatory training;
b. the Certificate was falsified.
5. You actions in respect of paragraphs 2-4 above were:
a. dishonest;
b. misleading.’
Click to access dr-hosam-elseknidy-06-sep-22.pdf
ERASURE
‘8. The Tribunal identified the following aggravating factors:
• Dr Swidan’s actions demonstrated a pattern of dishonest misconduct spanning a period of three months, involving 15 claims for payment to which Dr Swidan was not entitled;
• Dr Swidan’s dishonest scheme involved a significant number of his consultant colleagues, he abused the trust they had placed in him to be open and honest;
• Dr Swidan’s actions left the Trust with inaccurate records as to which doctors had worked the shifts in issue’ (p17)
Click to access dr-ayman-swidan-12-sep-22.pdf
Suspension for 12 months
‘6. On 8 November 2021, the GMC received information from an anonymous whistle-blower, stating that they had concerns about XXX. They stated that Dr Ahmed had been dismissed from a number of locum posts and had demonstrated medical incompetence on a number of occasions.
39. The Tribunal concluded that, given the seriousness of the concerns raised and the non-compliance with the order for a performance assessment, conditions would not be sufficient to satisfy the three limbs of the overarching objective.’
Click to access dr-azhari-ahmed-08-sep-22.pdf
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