IN THE FAMILY HEALTH SERVICES APPEAL AUTHORITY Case No: 10447
Dr S Ariyanayagam Professional
BETWEEN
and
__________
__________
1.
This
is an appeal pursuant to section 49M(3) Health and Social Care Act 2001 against
the decision of the City & Hackney Primary Care Trust (the PCT) to remove
Dr Khazne from the medical list in the interests of the efficiency of the
service. The appeal is by way of re-determination of the decision of the PCT to
remove Dr Khazne from the list.
2.
To
facilitate the hearing of the case directions were made on 15 April 2003, 9 May
2003, 1 October 2003 and 14 October 2003.
3.
On
10 October 2003 Dr Khazne’s solicitors requested by letter that the hearing be
adjourned. This request was
refused. The reasons were:
The appellant’s solicitors
rely on two reasons to justify seeking an adjournment: late receipt of the respondent’s evidence
which does not give them enough time to prepare the appellant’s case, and the
ill health of the appellant.
The respondent’s evidence
was served late – that is not according to the timetable set (and subsequently
amended) by the FHSAA. The evidence is
now available in accessible and comprehensive form. Bundles were made available to the appellant’s then advisers on
or about 30 September 2003. Much of the
evidence is known to the appellant, including the NCAA assessment. The new documentary evidence and statements
amplify the details of the NCAA assessment.
The panel’s view is that the appellant has had sufficient time following
service of the documents to discuss those with his professional advisers and
prepare his case.
The appellant also relies on
a medical certificate dated 24 September 2003 (from his GP Dr Rizk) referring
to him suffering from depression, anxiety and hypertension. Dr Rizk recommends the appellant refrain
from work for three months. This
certificate has any only limited relevance to the real issue, which is the
appellant’s ability to properly participate in the hearing of his appeal.
These proceedings should be
dealt with as speedily and expeditiously as possible. To delay further at this stage, without good reason, would cause
all parties significant cost and inconvenience. The panel also took into
account the impact that prolonging the hearing of the case may have on the
appellant’s conditions as described in the medical certificate.
4.
The
application for an adjournment was not renewed when the hearing commenced on
Friday 17 October 2003.
5.
The
substantive hearing of the case took place at the Kings Fund Centre on Friday
17 October 2003, Monday 20 October 2003, Tuesday 21 October 2003, Wednesday 22
October 2003 and Thursday 23 October 2003.
At this hearing the parties were represented as follows: Dr Khazne by Mr Greg Chambers of counsel
instructed by Geo Dowse & Co and the
PCT by Mr William Edis instructed by Bevan Ashford.
6.
The
written material available to the Panel was collated by the PCT and was made
available in several paginated loose-leaf bundles. The index to the various bundles is annexed to this
decision. All the references in this
decision in [ ] are to these bundles, unless otherwise stated.
7.
The
following witnesses gave oral evidence at the hearing:
Director of Primary Care and
Community Service for the Respondent PCT
Director of Quality and
Service Improvement (Nurse Director) for the Respondent PCT
GP and NCAA assessor
GP and member of PCT’s
Clinical Governance Team
GP and locum medical advisor
to East London and City HA
Psychologist and NCAA
behavioural assessor
GP and NCAA assessor
Formerly HR Director of NHS
Trust and NCAA Lay Assessor
Chief Executive of the
Respondent PCT
8.
At
the start of the hearing on Friday 17 October 2003 a preliminary application
was made on behalf of Dr Khazne that the hearing take place in private. This application was on the basis that as Dr
Khazne was under stress, and the case against him was prejudicial to his
reputation. In refusing the application
the panel took into account Rule 39(1) Family Health Services Appeal Authority
(Procedure) Rules 2001 which states that ‘all hearings by a panel shall be in
public except where a practitioner..has asked for the hearing to be in private
and the panel considers it is
reasonable in all the circumstances for that hearing to be held in
private.’ The panel concluded that the
public interest in having an open hearing outweighed the reasons given by Dr
Khazne for wanting the hearing to be in private.
9.
Dr
Khazne is aged 53. (His date of birth
is 28 October 1950.) Dr Khazne
qualified in medicine at Zaragoza in Spain in 1992. Prior to that he had worked as a qualified nurse. Following medical qualification in Spain he
worked there for a year as a Senior House Officer. He then travelled to the United Kingdom where he worked as a
locum in various hospitals for about a year.
He then returned to Spain. On
return to the United Kingdom in 1997 he joined Dr Rizk’s general practice. He worked with Dr Rizk for a year. He then joined Dr Satar for some sessional
work and at the same time started sessional work with the Dr Lloyd’s practice. When Dr Lloyd retired in April 2000 Dr
Khazne took over Dr Lloyd’s practice.
10.
The
case against Dr Khazne did not arise from complaints from any of his
patients. Rather it arose out of
mounting concerns following successive clinical governance visits by the PCT to
Dr Khazne’s practice. The clinical
governance visits took place on the following dates: 13 March 2001, 28 June
2001, 20 September 2001 and 1 February 2002.
11.
The
PCT decided at the conclusion of the last visit to suspend Dr Khazne from
practice, pending further assessments of his performance. On 12 March 2002 a further assessment of Dr
Khazne’s practice was undertaken by Dr Kheraj. Dr Kheraj recommended to the PCT that Dr Khazne be referred to
the NCAA for more detailed assessment. [256]
12.
The
NCAA is a special health authority established in April 2001. The function of the NCAA is to help NHS
organisations, such as PCTs, to handle concerns about the performance of
doctors. [290] This function was met in Dr Khazne’s case by
assessing him. ‘The purpose of an NCAA
assessment is to clarify any areas of concern and to make recommendations for
how those may be addressed.’ [290] Components of the NCAA assessment
included: an occupational health
assessment, a behavioural assessment and assessment of clinical performance.
13.
When
the NCAA submitted their final report to the PCT in October 2002 they
recommended that the PCT consider the measures necessary to protect patient
safety. As Dr Khazne was by this time
suspended, the recommendation was to consider ‘the options of continuing the
suspension from the referring body’s list of practitioners and referral to the
GMC.’ [116]
14.
The
PCT provided written evidence covering all the clinical governance visits and
the NCAA assessment. This was the core
of the PCT’s case. The witnesses who
gave evidence included two of the clinical governance assessors, Dr Kheraj and
Dr Patel. The PCT relied heavily on the
NCAA assessment in arriving at its decision to suspend Dr Khazne from the list. Three witnesses who were involved in this
assessment gave evidence. These
witnesses were: Dr Mower, Dr Bowden and Molly Anderson.
15.
There
were a number of areas were there were irreconcilable factual disputes between
Dr Khazne and the various witnesses called by the PCT. In relation to every significant area of
dispute the panel preferred the evidence of the PCT’s witnesses. They found the witnesses credible, balanced
and free of bias. They communicated
clearly and qualified their views as appropriate; they also appeared to be
determined to be fair to Dr Khazne. The
panel’s impression of Dr Khazne was different and is set down in more detail
below. In general terms the panel did
not always find Dr Khazne a credible witness.
This was only in part due to deficiencies in his communication skills,
but also for other reasons. He appeared
at times to be deliberately evasive.
The rigidity of his thinking was reflected in his answers to many
questions. Where there was conflict he
tended to rely on dogmatic response rather than reflective reasoning. This was unfortunate as it made it more
difficult for the panel to take into account the sometimes valid points he, and
his representative, were making.
16.
Dr
Bowden regarded the notes as acceptable.
‘I was not overly concerned with regard to Dr Khazne’s practice
following my review of these medical records.’ [325]
17.
Dr
Kheraj conducted a review of forty one (41) sets of notes supplied by Dr
Khazne. His overall conclusion was that
the quality of the notes was good ‘both in terms of their physical structure
and also in their clinical content’ [262]
18.
The
panel were provided with eight (8) sets of anonymised notes which were
analysed. The panel were aware of Dr
Khazne’s list size. (1844 as at 1
January 2002 [97]) The panel also took
into account the shortcomings in the patient care demonstrated in three (3)
sets of these notes against the summary
analysis of Dr Kheraj and Dr Bowden referred to above. The panel did not regard the content of the
other five (5) sets of notes as demonstrating particular areas of concern.
19.
Patient
A was a hypertensive patient on co-tenidone.
Although his condition needed monitoring there were no blood results in
the last two years. Dr Khazne asserted
that this was because the patient was needle phobic, and as evidence in support
of this assertion referred to the patient refusing an influenza
vaccination. There was no record in the
notes to indicate that the patient was in fact needle phobic. Refusal of
vaccination is not synonymous with being needle phobic and Dr Khazne appeared
to be unable to comprehend this difference when questioned, nor did he display
the area of knowledge requisite of a practitioner in the management of
hypertension.
20.
Patient
C was a diabetic patient. There was no
evidence that Dr Khazne conducted the appropriate blood monitoring to identify
the level of HbA1C (Glycosylated Haemoglobin) in the patient’s blood. The notes indicated she was regularly
attending Moorfields Eye Hospital. Dr
Khazne's told the panel that he assumed that Moorfields Eye Hospital screened
blood as routine and would only alert the practitioner if the screening
detected some abnormality. The panel
considered that this demonstrated a deficiency in Dr Khazne’s practice in that
he had not checked the practice at Moorfields Eye Hospital, and accepted no
responsibility for making contact with the hospital and chasing results.
21.
The
Panel took the view that as diabetes is a multi-system disorder, it is
incumbent on the practitioner to be aware of the extent of the patient’s
control of his/her condition. From Dr
Khazne’s evidence it appeared to be the case that he was reliant on finger
prick testing alone as a means of monitoring for diabetes. Furthermore at no stage during the hearing
did Dr Khazne acknowledge that good practice entailed the recording of HbA1C
readings in the patient’s notes.
22.
Patient
D was apparently misdiagnosed as suffering from diabetes. ‘At diabetic clinic was told to stop all his
medication.’ [Medical records bundle
65] This was the information Dr Khazne
recorded on 13 October 2000. Dr Khazne
took the patient’s word for this former misdiagnosis and did not check the
information with the hospital.
23.
The
panel regarded this as an example of Dr Khazne’s inability to reflect upon, and
deal with information. He asserted that
his management of patient D was reasonable, as patient D would not go to
hospital. In support of this contention
Dr Khazne relied on a letter from the hospital dated 6 August 2001 [Medical
records bundle 73d] referring to patient D’s failure to attend for an
outpatient appointment. Dr Khazne
failed to understand the point repeatedly made by the panel that the October
2000 meeting he referred to in his notes followed a visit the patient
apparently made to the hospital prior to 13 October 2000. The patient’s condition could therefore have
been investigated in 2000 - either by telephoning or writing to the
hospital. The particular area of
concern identified by the panel in relation to this case is as follows: if a
patient asserts that they have been misdiagnosed, this assertion needs to be
carefully checked in the interests of the patient’s safety.
24.
A
detailed analysis of Dr Khazne’s clinical skills was afforded by the use of
simulated surgeries during the NCAA assessment. Dr Khazne was dismissive of the exercises criticising their
superficiality. Simulated surgeries
were the chosen format, as Dr Khazne was of course supended from practice at
this stage. The panel heard evidence
from Dr Bowden that the use of simulated surgery is generally regarded as an
effective way to test practitioner’s clinical skills, and there is no body of
published evidence to criticise the efficacy of the system.
25.
The
panel attached considerable weight to the reports of the simulated
surgeries. They are an accepted and
effective way of determining the quality of a practitioner’s consultation
skills, covering not only clinical knowledge but also communication
skills. The conditions presented by the
simulated patients were as follows [120]:
Case 1. Bereavement and depression presenting as
insomnia
Case 2. New pregnancy presenting for antenatal care
Case 3. Request for antibiotics for recurrent cough
Case 4. Poorly controlled maturity onset diabetes
Case 5. Back pain probably due to lumbar disc
Case 6. Phone call from the mother of a feverish
child with purpuric spots
Case 7. Chest pain which could be new angina or
myocardial infarct
Case 8. Mother asks for her 18 year old daughter’s
cervical smear result
26.
In
Case 7 the topic in the simulated surgery was to evaluate the practitioner’s
skill in diagnosing, and managing, resting chest pain which may be angina or
myocardial infarct. The evaluation from
both assessors was that on the basis of the professional actor’s clinical
presentation the management plan put forward by Dr Khazne was unsafe. Dr Mower did not consider that Dr Khazne was
alert to the significance of resting chest pain and in particular he did not
advise the patient to go straightaway to hospital. Although Dr Khazne maintained he did advise the patient to go to
hospital he did not give any indication of appreciating the urgency of the
situation as presented to him – for example by arranging for an ambulance to
take the patient to hospital. Dr Mower
also considered that Dr Khazne over-reassured the ‘patient’ and demonstrated
poor technique in taking this patient’s blood pressure.
27.
The
panel noted that Dr Khazne’s record for this case [477] which was completed at
the time of the simulated surgery contained no reference to possible resting
chest pain although ample information was provide by the actor. In addition important information provided
by the actor ‘Father died at the age of
52 from a heart attack whilst sitting in a chair- he died within
minutes’ [477] was not recorded by Dr Khazne.
Dr Khazne totally denied that his approach, and his practice, in this
case was in anyway defective. The panel preferred the evidence of Dr Mower. The
panel concluded that Dr Khazne had retrospectively appreciated the failure of
his approach to this simulated case study and modified his evidence
accordingly.
28.
In
case 6 the actor was playing the part of the mother of a 14 month old child who
had been unwell. The actor spoke to Dr
Khazne on the telephone and provided information. The purpose of the simulation was to analyse the practitioner’s
skill in the diagnosis and management of children with who may be suffering
from a serious life threatening condition - meningitis. The evaluation of both clinical assessors,
that is Dr Bowden and Dr Mower, was that Dr Khazne was not aware of the
significance of non-blanching rash. He
falsely reassured the ‘mother’ thereby inhibiting her providing vital
information. Dr Khazne in his evidence
said that he told the mother to bring the baby to the surgery and he ‘offered a
home visit’. The record for this case
completed by Dr Khazne at the time of the simulated surgery [471] gives no
indication that Dr Khazne was alert to the possible seriousness of the child’s
condition. Furthermore there is no
reference in these notes Dr Khazne offering a home visit. The panel concluded that by the time Dr
Khazne gave his evidence he had realised his failings during this simulated
consultation and simply embellished his evidence to give the impression that at
the time he had considered it to be serious.
Dr Khazne was also unaware that a meningitis injection does not protect
against all causes of meningitis and as a consequence inappropriately reassured
the mother in the case study.
29.
In
case 8 the simulated surgery was configured to test Dr Khazne’s understanding
of confidentiality issues. The
instruction to the actor who played the part of the patient’s mother is as
follows: ‘Your daughter, Anna Brown, who is aged 18 years old, gets a letter
from the surgery to attend for a test result.
You inadvertently opened the envelope since you both have the same
initials. Having opened the letter you
are worried as to what the test is about and the result. Your daughter has not seen the letter yet as
you don’t want to worry her.’ [482]
30.
The
point of the case, as described by Dr Bowden, was to identify whether the
practitioner can retain patient confidentiality and at the same time not
alienate the patient’s mother
31.
Dr
Bowden gave evidence that Dr Khazne firmly and unequivocally asserted that the
patient’s mother had a ‘right to know’ confidential information about her
daughter’s health and when Dr Khazne was challenged by the assessors he did not
accept that there alternative ways of handling the exchange of confidential
information. Molly Anderson described
Dr Khazne ‘launching in’ and giving the patient’s mother confidential medical
information about her daughter, including the fact that her daughter was on the
pill.
32.
As
with other instances there was a major factual dispute between Dr Khazne’s
version of what he said in this simulated surgery, and what the assessors heard
and observed. The Panel preferred the
evidence of the assessors. Dr Bowden, Dr
Mower and Molly Anderson impressed the Panel as experienced and conscientious
assessors. They demonstrated a sound
grasp of the details of the assessment exercises they were undertaking and the
purpose of the exercises. Dr Khazne on
the other hand was inconsistent and unconvincing. Under cross-examination he stated that the NCAA assessors were
accusing him and were ‘one million percent’ exaggerated in what they said.
33.
The
panel concluded that Dr Khazne had an entirely misconceived understanding of
the basic principles of medical confidentiality. During the process of the
appeal it also appeared that Dr Khazne
re-formulated his own position on confidentiality. The Panel have no doubt that the position
that the NCAA assessors observed Dr Khazne adopting was that the patient’s
mother was fully entitled to be given
confidential details of her daughter’s medical history. Dr Khazne, following a similar path observed
above in relation to cases 6 and 7,
retrospectively recognised the failure of his approach and when he gave
evidence he took up a new extreme position that his patients were entitled to
absolute confidentiality. Dr Khazne
then demonstrated his inflexibility when he was not able to consider any
circumstances that his patient’s right to confidentiality might have to be
qualified. He was not aware of the availability of any General Medical Council
(GMC) guidance on confidentiality issues.
34.
The
other case studies used by the NCAA assessors also displayed deficiencies in Dr
Khazne’s clinical and communication skills.
Case 2 was the only case where Dr Khazne acknowledged he might have
dealt with a consultation differently.
He made an opening remark to a newly pregnant patient presenting for
antenatal care ‘Do you want to carry on with the baby or have an abortion’
[303]. He did not deny making this
remark. The panel accept that Dr Khazne
may have been making what he regarded a friendly gesture. This however was an age inappropriate introduction given that the
‘patient’ was described as 32. Generally
the panel regarded his opening remarks as insensitive and likely to deter a
patient from communicating openly with the practitioner.
35.
In
case 1, the 56 tabs of amitryptilline prescribed to a patient suffering from
depression demonstrated a failure in prescribing methods. Dr Khazne’s failure to seriously engage with
the potential risk to the patient, and his bland explanation that he was tied
to prescribing a number of pills because of the way the pills were packaged,
indicated to the panel that he had not grasped the issues involved. He further chose to try and support this by
stating as a fact that a pharmacist will never provide a lower number of pills
than the pre-packaged amount.
36.
In
simulated case 5, a patient presented at the surgery with back pain. According to Dr Bowden the consultation was
'noted to be of low challenge' [327] Dr Khazne made what was regarded by Dr
Bowden and Dr Reed an inappropriate secondary referral. Dr Khazne asserted that all cases of disc
prolapse should be referred to hospital and simply disagreed with the NCAA
assessors that any other course of action was possible.
37.
Other
shortcomings in Dr Khazne’s clinical practice were identified by the NCAA
assessors. The panel heard evidence
that Dr Khazne would not always examine patients with vaginal discharge, but he
would prescribe. Similarly he would
sometimes prescribe for patients with incontinence without examination. [314]
Although the Panel accept that
it may be appropriate to prescribe without examination particularly on
the first visit of the patient, Dr Khazne failed to qualify and justify when
this approach could be necessary. Dr
Khazne told the NCAA assessors [314], and repeated in his evidence, that an
ultrasound scan is the diagnostic method for endometriosis. In doing so he displayed a lack of basic
gynaecological knowledge which would be reasonably expected from a
practitioner.
38.
Dr
Khazne maintained that a high vaginal swab would allow a diagnosis of genital
chlamydia to be made. [314] The Panel
regarded his knowledge in this area as
inadequate. Chlamydia swabs should be
taken from the cervix, not the high vagina. The consequence of using an
inadequate technique is that chlamydia may be missed, potentially resulting in serious long term complications
for the patient such as Pelvic Inflammatory Disease.
39.
There
were a number of areas concerning Dr Khazne’s practice where irreconcilable factual disputes between Dr
Khazne and the various PCT witnesses occurred. In particular the panel heard
evidence around Dr Khazne’s use of refrigerated storage, his conduct of
gynaecological examinations and his use of the thermometer.
40.
Dr
Khazne confirmed that over the winter of 2001 he stored influenza vaccinations
in medical fridge. He had clearly
accepted by September 2001 that his existing fridge was inadequate as he had
agreed to purchase a new medical fridge. [51]
This had not been purchased by February 2002, the date of the last
clinical governance visit. [57] The
panel concluded that Dr Khazne was not
sensitive to the fact that his refrigeration system was unsafe and he
simply did not recognise that he had no
safe storage system for medication which required storage in conditions of
controlled temperature.
41.
Dr
Khazne described to Dr Patel an unsafe procedure for vaginal examination. Dr Khazne allegedly stated that ‘I part the lips and then look’.
[246] When he was first challenged about this by Dr Patel and others, he
claimed he was joking. When he gave
evidence he denied completely making this statement at all. The panel saw no reason to doubt Dr Patel’s
account.
42.
It
was alleged that Dr Khazne was re-using medical instruments without properly
sterilising them. [58][251] It was also
alleged that there was one thermometer
that Dr Khazne would use in the mouth, armpit and in the rectum of
children. This he would clean with a
medi-swab. [108] [310] The panel set Dr
Khazne’s denial of only having one thermometer against the evidence of both Dr
Patel and Dr Mower and concluded that Dr Khazne’s recall was inaccurate. In any event even if Dr Khazne’s recall was
accurate, and he had three or four thermometers as he asserted when he gave
evidence the method of sterilisation that he relied on - use of antiseptic and
medi-swab - represented an inadequate and unsafe system of infection control.
43.
Generally
in relation to the environment in Dr Khazne’s surgery the panel relied on the
evidence from the written and oral evidence of those involved in the various
clinical governance visits. The panel
gave little weight to the findings of the NCAA’s evaluation of the environment
within the surgery. This was because Dr
Khazne was being assessed about his surgery ergonomics at a time when he was
not in charge of the surgery. The panel query the value of bringing a suspended
doctor back to his work place at a time when he cannot be expected to be in touch with the surgery.
44.
There
were two other matters that the panel identified as being particularly relevant
in weighing up the evidence as to the safety of the patient environment that Dr
Khazne was responsible for maintaining.
These were the availability of speculae and disposable paper rolls for
the examining couch.
45.
Dr
Khazne stated that he did use speculae and although he stored the speculae in a
separate room to his consulting room he always had some available before
examining a patient. The panel accepted
his evidence in that regard and considered that the discrepancy between the PCT
clinical governance witnesses, and Dr Khazne, was due to a misunderstanding. The misunderstanding centred on the
availability of the speculae - that is they were kept in a separate room not
within the consulting room itself. This
meant that if Dr Khazne wished to have use of speculae, he need to leave the
consulting room and collect the instruments.
46.
In relation to the use of disposable couch
covers Dr Khazne stated that he did not have disposable couch covers, but used
a sheet that was changed after every patient consultation. This evidence conflicted with the evidence
of Dr Patel [246] and Mary Clarke [251] and the panel preferred their evidence
in that respect.
47.
Dr
Khazne’s emergency equipment did not allow him to provide safe emergency
care. He did not have appropriate drugs
to deal with severe pain such as could be encountered in some cases of renal
colic. His stated reliance on co-codamol and paracetamol as a means of pain
relief for renal colic was unsatisfactory. Good practice requires that the
practitioner must possess, and have immediately available, more potent
analgesics even if the practitioner is dependent on hospital admission on these
occasions. Dr Khazne’s justification for not carrying certain medications was
not credible, nor did he see any requirement for improving in the future.
48.
He
did not have drugs to effectively ameliorate the effects of a severe asthma
attack. Dr
Khazne was unable to comprehend that his management of ‘status asthmaticus’
would vastly improve if he had access to a nebuliser, even if he did not carry
one. The evidence that he gave that he
would administer oxygen in an emergency case of asthma was irrelevant and
inappropriate.
49.
He
did not have a single drug available to deal with meningococcal meningitis, a
condition that would require immediate treatment with penicillin. In his evidence Dr Khazne failed to
demonstrate he was aware that the possession of parenteral penicillin in the
emergency bag could provide vital life saving treatment.
50.
The
panel were provided with a graphic illustration of Dr Khazne’s lack of grasp of
basic issues in relation to confidentiality.
When the subject of chronic disease registers was being discussed Dr
Khazne, with no warning to his representative or the PCT, produced plastic bags
containing boxes of card files which he claimed were the manually maintained
chronic disease registers maintained by his predecessor, Dr Lloyd. When challenged about this Dr Khazne did not
understand that these documents contained confidential patient information.
51.
The
panel did not attach great weight to the fact that Dr Khazne spoke to patients
when he went to the surgery for the NCAA assessment. [317] Dr Khazne appears
to be popular with his patients and it seemed unremarkable that they he would
talk to them. The fact that they chose
to talk to him about their medical conditions was outside Dr Khazne’s
control. The criticism that has
validity, however, is that Dr Khazne was not aware of the need to maintain
confidentiality and chose to discuss his former patients’ conditions with them
in a public place.
52.
The
panel took as a starting point that the maintenance of up to date chronic
disease registers is essential to allow a competent practitioner to actively
manage chronic disease.
53.
Dr
Khazne maintained on a number of occasions that due to his patient’s records
being transferred from a manual to a computerised recording system he was
unable to introduce disease registers as recommended by the clinical governance
assessors. The panel were not able to
accept that this was an adequate response.
The panel considered that it was Dr Khazne’s responsibility to maintain
an adequate manual system pending the introduction of computerised
records. In addition Dr Khazne did not
demonstrate any real understanding of the active management of chronic
disease. From maintaining a position
that his attempts to introduce chronic disease registers were being hampered by
the process of computerisation, Dr Khazne without notice or warning, produced
during the course of the hearing papers which he maintained represented
adequate and up to date chronic disease registers. Apart from the concerns that this immediately raised in relation
to patient confidentiality, the panel concluded that this demonstrated Dr
Khazne’s complete inability to constructively engage with those professionals
who had been working with him to improve his practice in this area.
54.
Dr
Kheraj noted that there was no clear system for repeat prescribing in existence
in Dr Khazne’s practice. [65] Dr Bowden, in his evidence, stated that the
system was hopeless from the point of view of patient safety. The system that was in existence was
simple. All requests for repeat
prescriptions were routed through the receptionist, who wrote down the
medication requested by the patient and then passed the request to Dr Khazne
for formal prescription. The panel
identified that this meant there were at least two areas of weakness in the
system:
a. This system was so laborious and time inefficient (Dr
Khazne gave evidence that it could take him around two hours an evening) that
it contained potential for human error.
b. The system was dependent on the reliability of the
receptionist receiving accurate information from the patient and then
communicating it accurately to the practitioner.
55.
Dr
Khazne asserted that his personal involvement made any mistakes impossible
without any acknowledgement of the weaknesses and risks in the system. Another inherent weakness was demonstrated
when Dr Khazne’s practice came to be managed by agency staff. The existing system was then [106] modified
on safety grounds.
56.
The
panel regarded much of the information contained in Dr Khazne’s practice
information leaflet as seriously misleading and deliberately created an
unrealistic expectation of the range of services offered by the practice. The leaflet reads [263-267]:
The surgery runs nine
clinics:
·
Blood
pressure
·
Well
person
·
Family
Planning
·
Diabetic
·
Travel/General
Immunisation
·
Asthma
·
Dietary
Advice
·
Antenatal
Care
·
Baby
Clinics
57.
At the second clinical governance visit Dr
Khazne was advised to immediately amend his practice leaflet to show a true
reflection of the services he provided. [44]
Dr Khazne when giving evidence stated that ‘I did not do general
immunisations.’ Dr Khazne also stated
that when he wrote the copy for the leaflet he intended to run all the
specialist clinics described, and since he had got the leaflets printed he
might as well use them. He later
contradicted this evidence by suggesting that his individual patient
consultations amounted to ‘specialist clinics.’
58.
There
appeared to be general consensus amongst those that gave evidence to the panel
that Dr Khazne was liked by his patients.
It was unfortunate that the NCAA were not able to present data from the
patient questionnaires as they were not able to rely on their validity. [297]
The NCCA should revise this component of their assessment if it is to be
used in the future.
59.
Dr
King referred to the way Dr Khazne is affectionate about his patients and staff
which was reflected in the way he talked about his practice. [352]
60.
In
relation to Dr Khazne’s approach to staff training, the panel considered that
his response to suggestions that his
staff should be trained in basic resuscitation methods indicated a failure to
avail himself of an opportunity to improve the provision of safer systems of
care for his patients. Both Dr Khazne’s response to the initiative to
place de-fibrillators in surgeries and
his entirely negative response to the benefits of team training were, in
the panels’ view, symptomatic of his
lack of flexibility, his inability to think laterally or to place patient
safety at the centre of his thinking. [313 and 329]
61.
The
panel noted the views of Dr Khazne’s colleagues, and in particular the view of
Dr Sattar [238] The Panel did not take
into account the anonymised ‘colleague’ questionnaires which were sent out by
the NCAA to assist the assessment of Dr
Khazne’s clinical performance. The
questionnaires were contradictory and their programme of selection was
unclear. In any event, the
questionnaires were not relied upon by the NCAA assessors in coming to their
conclusions. The panel did not consider
that this system of seeking anonymous opinions was an appropriate way of
gathering information and should be revised in the light of these proceedings.
62.
The
panel took into consideration that Dr Khazne demonstrated low scores in the
knowledge tests. These tests were undertaken by Dr Khazne and organised and
facilitated by the NCAA as part of their overall assessment. He scored 57% on the Multiple Choice
Questions (Peer scores average 78.48%) and 43% on the Patient Management Problems
(peer scores average 71.45%) [105]
63.
The
panel read a statement [347-352] and report from Dr King [273-280] She also
gave evidence. Her behavioural
assessment of Dr Khazne formed part of the NCAA assessment.
64.
The
panel regarded it as significant that when Dr Khazne was questioned about the
tabular presentation of his strengths and weaknesses contained in the NCAA
report [98-101] he resolutely refused to accept that he had any significant
weaknesses.
65.
The
panel were impressed by the evidence of Dr King. She has relevant experience in exploring the ways behaviour and
personality contribute to doctor’s performance. She acknowledged that Dr Khazne could have been in an anxious and
worried state when he undertook the evaluation but saw no evidence of this
being apparent when he underwent the psychometric testing. [283-285]
Because of concerns that Dr Khazne's cultural background could have
impacted negatively on his response to the tests, Dr Field confirmed that the
tests were fully validated in relation to different cultures and languages.
66.
She
was asked to comment on the likelihood of Dr Khazne successfully being
retrained. She gave evidence that the
conditions that need to be present before a practitioner embarked on retraining
were self-reflection, self insight and motivation to change. The panel did not consider that Dr Khazne
gave the impression of possessing any of these attributes. She gave evidence that Dr Khazne could not
see the deficiencies in his practice.
This was also the impression the panel gained from observing Dr Khazne
giving evidence. Given that the deficiencies in his practice will put his
patients at risk, this is a significant deficit.
Dr Khazne.
67.
The
medical certificate (dated 24 September 2003) submitted by Dr Khazne’s
solicitors in support of an adjournment stated that he should refrain from work
for three months due to ‘depression, anxiety and hypertension.’ Whilst the panel took this into account the
Panel also took into account that the psychiatric report that Dr Khazne
submitted on the second day of the hearing (dated 15 October 2003) made no
reference whatsoever to any of these conditions. [235d-235e]
68.
He
attributed his low scores on the clinical tests to be partly due to the
language difficulties. When he gave
evidence on particular disputed facts, therefore, the panel took care in making
sure that his evidence was understood.
69.
When
Dr Khazne gave evidence he appeared at times to have problems understanding the
meaning of particular words. English is
not his first language. His use of
English words could sometimes confuse.
For instance he often stated that his approach was ‘perfect.’ When
questioned by the panel what he meant by this he said he meant right/OK/good/acceptable
but not the ideal.
70.
The
difficulties that the panel observed in relation to Dr Khazne’s communication
appeared, however, not only to be related to his language skills. When Dr Khazne gave evidence he appeared to
be verbose but non attentive in the way he mumbled ‘mmm’ and then respond with
statements such as ‘perfect’ and ‘never’.
The panel considered that this type of communication could lead to
misinterpretation, particularly on the telephone. This would have an impact on
his ability to properly diagnose.
71.
Dr
Khazne also demonstrated a tendency to ‘jump’ to responses. He interrupted
counsel, and the panel members, before questions were concluded. This indicated to the panel that Dr Khazne
would find reflective listening difficult.
(This was also noted by Dr King in her assessment.[350]) The ability to listen is, of course, a key
skill necessary for the practice of primary care.
72.
The
PCT acknowledge that Dr Khazne is not a wholly bad doctor. They accept he demonstrates a commitment to
patients and works long hours [Respondent’s opening observations paragraph 19.]
73.
The
panel also took into account a number of factors including the following: Dr Khazne had taken over a practice with a
high degree of over prescription, he was working single handed and he was
providing a service in a geographic area of high social deprivation.
74.
The
evidence justifying Dr Khazne’s removal from the medical list is comprised of a
range of concerns, some more significant than others. An inescapable pattern
however emerged from the totality of the evidence; that is Dr Khazne was not
competent in a number of key areas of general practice. Cumulatively these concerns represent major deviation from good medical
practice. The panel concluded that
whilst there were some areas of Dr Khazne’s practice which were of an
acceptable standard, there were substantial areas in which he failed to meet
acceptable minimum standards of competence. This puts his patients at risk, and
justifies his removal from the list.
75.
Section
49M Health and Social Care Act 2001 allows a practitioner removed from the list
of medical practitioners by a Health Authority to appeal against that decision
to the FHSAA. Section 49M(4) provides
that the FHSAA, on an appeal, may make any decision that the Health Authority
could have made. This allows the FHSAA to remove a practitioner from the list
contingently, that is by imposing such conditions on his inclusion in the list
with a view to removing any prejudice to the efficiency of the service.
76.
The
panel therefore gave consideration as to whether to direct contingent removal
with requirements that Dr Khazne undergo an extensive period of retraining.
77.
The
panel concluded that it was not reasonable to expect the PCT to embark upon a
retraining programme for Dr Khazne because the outcome would be so
uncertain. In reaching this conclusion
the Panel particularly took into account Dr King’s assessment : ‘Dr Khazne
displayed no willingness to look critically at his own behaviour or
professional conduct, no genuine interest in learning new communication or
clinical skills and no understanding of the allegations against him.’ [352]
This analysis was reflected in the panel’s assessment of Dr Khazne’s
performance throughout the hearing.
78.
An
essential part of the process of retraining must be some acceptance on the part
of the person to be retrained that the process has some value. The panel saw no evidence that Dr Khazne
perceived this to be the case. It was
not until Dr Khazne gave evidence that he evinced any commitment to
retraining. The panel concluded that
this was simply a tactical concession on Dr Khazne’s behalf.
79.
The
panel were made aware that the Interim Orders Committee of the GMC had imposed
conditions on Dr Khazne’s registration requiring him, inter alia, to undergo a
cognitive assessment. The function of
such an assessment would be to identify if Dr Khazne had the capacity to be
retrained. The panel were also made
aware that Dr Khazne had been requested on many occasions to have this
assessment and had been dilatory in his response.
80.
The
panel gave consideration to delaying a decision about a contingent removal
until the cognitive assessment had been undertaken. The panel decided not to adopt this course for the following
reasons: because of Dr Khazne’s expressed reluctance to undergo such an
assessment and also the fact that the cognitive assessment is only one
component in identifying whether he should be retrained. The panel noted (ante) that Dr King’s
primary concerns were around Dr Khazne’s capacity for self-reflection and his
motivation to change, not his cognitive capacity.
81.
The
panel will hear representations as soon as practicable as to whether Dr Khazne
should be subject to national disqualification pursuant to section 49N Health
and Social Care Act 2001. The panel
will also decide whether this decision should be sent to the Spanish medical
authorities.
82.
Either
party to these proceedings has the right to appeal this decision under and
by virtue of Section 11, Tribunals and Inquiries Act
1992.
Dated this day of 2003