The Director of Proceedings charged that the Doctor was guilty of professional misconduct.

In summary, the charge alleged the Doctor failed to undertake and/or record an adequate assessment of a patient on four occasions, namely 10 October 2003, 2 November 2003, 9 December 2003 and 24 February 2004. It also alleged the Doctor prescribed Duromine without undertaking an adequate assessment of the patient.

The Tribunal was satisfied the Director of Proceedings had proven several particulars of the charge and that when those proven particulars were viewed cumulatively, they constituted professional misconduct.

The Doctor is a general practitioner. It was alleged the patient presented to the Doctor on 10 October 2003 with a bloated stomach and suffering abdominal discomfort. The patient’s condition failed to improve over the time of her subsequent visits to the Doctor. Ultimately, the patient underwent surgery on 16 March 2004 at which time a large mucinous cystadenocarcinoma of the ovary was removed. The cyst weighed 14.7kg.

The Tribunal considered it was important to emphasise from the outset the Doctor was not charged with failing to diagnose the cyst. The evidence before the Tribunal was that even large cysts of this nature are notoriously difficult to diagnose. The Director of Proceedings did not criticise the Doctor for failing to identify the cyst in his patient. Instead the focus of the Director of Proceedings’ case was upon the alleged inadequate examinations and steps taken by the Doctor when consulted by his patient.

There were 34 particulars, sub particulars and sub sub particulars set out in the notice of charge. The Tribunal found the Doctor breached the duty of care he owed the patient (Ms L) in 12 respects identified in the notice of charge. In all 12 instances he failed to adhere to the standard of care reasonably expected of a general practitioner in his position.

The Tribunal was satisfied that it was necessary for the Doctor to conduct an abdominal examination on Ms L when she presented to him on 10 October 2003. It was not appropriate for the Doctor to have relied on the abdominal examinations he performed 11 and 9 months previously when assessing his patient’s condition. At the very least the Doctor should have performed a thorough abdominal examination.

The Tribunal considered that ideally a rectal examination should have been carried out. However, the Tribunal did not believe the Doctor breached his duty of care to Ms L by not offering a rectal and/or vaginal examination to his patient on this occasion. As no abdominal examination was carried out the Tribunal could not be satisfied whether or not there was good reason to carry out a rectal and/or vaginal examination. Therefore, the Doctor’s lack of an abdominal examination deprived the Tribunal of any evidence upon which to judge whether or not a rectal and/or vaginal examination was necessary.

The Tribunal was in no doubt the Doctor breached his duty of care to Ms L by failing to calculate her BMI and record that figure before prescribing Duromine.

If Duromine is to be prescribed to persons with a BMI of less than 30 then there must be sound medical reasons for doing so. In this particular case the Doctor did not take the fundamental step of ascertaining whether Ms L was clinically obese and/or otherwise met the standard criteria for Duromine. Ms L was not obese, nor did she meet any of the other clinical criteria normally associated with those who are prescribed Duromine where their BMI is less than 30.

Before prescribing Duromine the Doctor should have taken and recorded Ms L’s pulse and blood pressure. This was particularly important in the case of Ms L because of her history of arrhythmia. The Tribunal categorised this omission as only a minor departure from appropriate standards because the Doctor had recorded Ms L’s pulse/blood pressure on several occasions and her pulse/blood pressure appeared to be stable.

The Doctor’s records of his consultations contain a very bare statement of the patient’s recent history, but did not disclose the sorts of inquiries the Tribunal would like to see from a general practitioner in the Doctor’s circumstances. However, the Tribunal’s overall assessment is that the Doctor’s effort to obtain and record Ms L’s clinical history on 10 October 2003 was barely adequate, but not a failure to adhere to the standards reasonably expected of a general practitioner in his circumstances.

The Doctor’s failure to have carried out an abdominal examination deprived the Tribunal of sufficient evidence to conclude he should have requested an ultra sound scan and/or blood tests. Thus, although the Doctor’s failure to request an ultra sound and/or blood test was not particularly satisfactory, his omissions in this regard did not meet the threshold of falling below the standards reasonably expected of a general practitioner in his circumstances.

When Ms L presented to the Doctor on 7 November she explained that her stomach was no smaller, and that she remained concerned about the way her weight appeared to be distributed only in her abdomen. This concern should have alerted the Doctor to the need for an abdominal examination. His failure to do so, constituted a failure to adhere to the standards reasonably expected of a general practitioner in his circumstances.

The Doctor’s failure to undertake a rectal and/or vaginal examination on 7 November did not constitute a breach of the duty of care he owed Ms L for the same reasons as the 10 October consultation.

When Ms L presented to the Doctor on 7 November the Tribunal considered he should have made thorough inquiries about and recorded the effects Duromine had upon Ms L during the previous month. The Doctor’s failure to make inquiries constituted a failure to adhere to the standards reasonably expected of a general practitioner in his circumstances.

Before re-prescribing Duromine the Tribunal considered the Doctor should have taken and recorded Ms L’s pulse and blood pressure. His failure to do so, constituted a failure to adhere to the standards reasonably expected of a general practitioner in his circumstances.

Whilst taking such steps would have been ideal, the Doctor’s failure to adhere to an ideal standard does not expose him to a finding of failure to adhere to the standards reasonably expected of a general practitioner in his position.

The consultation on 9 December 2003 simply involved Ms L telephoning the Doctor’s surgery and asking for a repeat prescription of Duromine. This was the third 30 day prescription of Duromine for Ms L.

The Tribunal was concerned that yet again the Doctor prescribed Duromine without checking Ms L’s pulse and/or blood pressure when he should have done so in light of her history of arrhythmia and was a failure to adhere to the standards reasonably expected of a general practitioner in his circumstances.

When Ms L presented to the Doctor on 24 February 2004 she was in considerable discomfort and concerned about the fact that her abdomen was unusually large.

The Doctor failed to perform and record any type of physical examination. In the Tribunal’s view it was incumbent upon the Doctor to at least carry out a full and comprehensive abdominal examination. By this time Ms L had been consulting the Doctor for over four months about her bloated stomach and abdominal discomfort. The Doctor’s failure to carry out even the most basic abdominal examination on 24 February 2004 compounded his earlier errors when he failed to perform any abdominal examination. The Doctor’s decision not to perform an abdominal examination constituted a serious departure from the standards reasonably expected of a general practitioner in his circumstances.

The Doctor’s failure to undertake a rectal and/or vaginal examination did not constitute a breach of the duty of care he owed Ms L for the same reasons as the 10 October and 7 November consultations.

While the Tribunal believed it would have been desirable for the Doctor to have arranged blood tests and/or an ultra sound scan on 24 February, and that he should have been considering the need for such tests by this time, his failure to do so did not constitute a breach of the duty of care expected of a general practitioner in his circumstances. The Tribunal’s reasons for this conclusion are the same as its reasons for reaching the same conclusion in relation to the consultations on 10 October and 7 November 2003.

The Doctor’s failure to perform an abdominal examination and make appropriate inquiries about his patient before issuing further Duromine was a serious departure from the standards expected of a general practitioner in his position.

The Tribunal found a number of deficiencies in the Doctor’s treatment and management of his patient. These deficiencies each constituted a failure to adhere to the standards reasonably expected of a general practitioner in the Doctor’s circumstances. When viewed cumulatively, the Doctor’s acts and omissions were well short of the standards which the Tribunal reasonably expects of a general practitioner in his circumstances.

The Tribunal was concerned that the Doctor was a sole practitioner working in an environment which places a number of demands upon him. During the course of the hearing the Doctor showed many signs of an overburdened practitioner who could benefit from professional support and assistance. The Tribunal considered the Doctor could particularly benefit from instruction on how to improve the effectiveness of his practice from both a clinical and commercial perspective.

The Tribunal ordered: