13941 - DR RAM SEWAK PRASAD and MERTHYR TYDFIL LHB - Appeal against removal from the Performers List
| Judgement Number | 13941 |
| Court | First-tier Tribunal (Health, Education and Social Care Chamber) |
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IN THE FAMILY HEALTH SERVICES APPEAL
AUTHORITY CASE 13941
Professor M Mildred - Chairman
Dr R Rathi - Professional Member
Mr AJ Lloyd - Member
BETWEEN
DR RAM SEWAK PRASAD
(Registration Number 2238870)
Appellant
and
MERTHYR TYDFIL LOCAL HEALTH BOARD
Respondent
DECISION WITH REASONS
Background
1. The appellant (“Dr Prasad”) is a general medical practitioner who began work in the
Merthyr district in 1983 and was in 1994 joined by Dr Satyendra Nath Jha (“Dr Jha”) in
practising from surgeries in Aberfan and Troedyrhiw in the district of the respondent Health
Board (“the LHB”). After a hearing of a Performance Panel established by the LHB on1
October 2004 he was suspended from the Performers List (“the List”) for one month during
which he attended a computer training course and worked under supervision at an Advanced
Training Practice for 11 days.
2. The LHB also referred Dr Prasad to the GMC whose Interim Orders Panel (“IOP”) imposed
six conditions on his registration on 8 December 2004. Those conditions included supervision
by Professor Jonathan Richards or another medical practitioner nominated by the LHB. Dr
Prasad gave undertakings to the GMC in November 2005 amended in May 2006 to take
account of his transfer to salaried status on 1 April 2006.
Procedural history
3. On 31 July 2006 both doctors were suspended by a Reference Panel of the LHB. This
suspension was extended by a different Panel of the FHSAA. Dr Prasad was suspended on
the grounds of a significant risk to patient safety, major gaps in his clinical knowledge and
failure to undertake any significant personal development. Dr Alan Cuthill was commissioned
to investigate and report on these issues. In March 2007 Dr Prasad was given notice of a
hearing on 2 April 2007. This continued on 17 May and 2 July 2007.
4. By letter dated 12 July 2007 Dr Prasad was informed of his removal from the List on the
ground that his continued inclusion would be prejudicial to the efficiency of the services
provided by those on the List. The letter referred to adverse findings in relation to record
keeping, management of referrals, monitoring of prescriptions, failure to obtain consent and
limited implementation of procedures, policies and protocols.
5. Dr Prasad appealed against this removal by a Notice dated 2 August 2007 on the basis of
unfairness in the investigation and hearings, in particular that the LHB had unfairly withheld
information relied on by it from Dr Prasad and his advisers, and that there was no explanation
why removal, as opposed to contingent removal, was warranted. Directions were given by
this Panel on 2 November 2007 for exchange of evidence and fixing the hearing to begin on
28 January 2008. It was ordered that this appeal be heard together with that of Dr Jha (Case
13942).
6. We were invited to rule upon the standard of proof to be applied to the burden on the LHB
to prove its case in relation to the efficiency ground. By a decision dated 4 January 2008 we
ruled that we were not bound by authority or the practice of any other regulatory body to
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adopt a criminal standard and accepted that a fair balance of the competing interests
rendered it appropriate that we should adopt a flexible approach to the civil standard of proof.
The hearing
7. The hearing took place at the Angel Hotel, Cardiff from 28 January to 1 February 2008.
The LHB was represented by Ms Fenella Morris instructed by Messrs Morgan Cole and Dr
Prasad by Mr Ranald Davidson instructed by Messrs RadliffesLeBrasseur. All members of
the Panel confirmed that they had no conflicts of interest in hearing the appeal. It was
accepted on all sides that the LHB should call its evidence first. Numbers in square brackets
in this decision refer to page numbers in the hearing bundle.
The LHB’s evidence: Dr Cuthill
8. The first witness was Dr Alan Cuthill, a GP from the Medical Centre, Taffs Well and a part-
time investigator for the Primary Medical Care Advisory Team (“PMCAT”) of the National
Public Health Service for Wales. He was charged by the LHB with investigating the practices
of Drs Jha and Prasad and he reported to the Reference Panel in July 2006. He was taken
through his criticisms of the two Appellants by Ms Morris, beginning with those of Dr Jha and
then turning to those of Dr Prasad.
9. Dr Cuthill withdrew a previous criticism of the treatment of patient KT in relation to her
potassium levels. In the records for 13 March 2006 there was no reference to her low
potassium level on 24 May 2005. The test should have been repeated for and mentioned at
the medications review. There was no clinical record of the consultation on 21 March 2006.
10. The medication prescribed (Indipamide) was inappropriate according to guidelines of the
British Hypertension Society (“BHS”) which advise prescription of an ACE inhibitor or a beta-
blocker in a patient under 55. The British National Formulary (“BNF”) has a warning that
indipamide can cause lowered potassium levels.
11. The Aberfan surgery notes had no case summaries – a standard GP requirement since
the 1980s.
12. Patient JA was treated for a bloody discharge from a nipple with antibiotics and
reassurance despite this being a red flag signal for breast cancer, especially in a patient with
a strong familial history of breast cancer. Dr Prasad treated this as a case of mastitis. There
was no record of an examination before referral to a consultant in May 2000. In addition there
were no records of consultations at various appointments with Dr Prasad.
13. Dr Prasad’s referral letter for patient AL to a breast surgeon was inadequately basic with
no family history, no suggestion of urgency and no description of the duration of her
symptoms. In fact she should have been referred on the pro-forma that would have ensured
she would have been seen in two weeks. The consultant was clearly critical of the referral
[1814].
14. Dr Prasad should have referred patient CM to a consultant dermatologist rather than
making a partial excision of what turned out to be a malignant melanoma on 10 June 2005.
Good practice required referral where, as here, the possibility of a melanoma was strong. His
action could have damaged the specimen, was by an inappropriate technique and could have
caused the disruption and even spread of the melanoma. Dr Prasad should have known all
this from undertaking a minor surgery course with five-yearly refreshers. In addition there
was no written consent or any note of an oral consent by the patient who was extremely
lucky, in view of a referral delayed by over a year, that her melanoma had not developed
further.
15. Dr Cuthill criticised Dr Prasad’s monitoring of the thyroid function of Patient JG. He was
treated with carbimazole, a thyroid suppressing drug, with no monitoring of his levels even
though the medication review of 28 November 2005 should have picked this up. On this
regime six-monthly thyroid function tests and six to twelve-monthly liver function tests are
recommended by the NICE Guidelines. The fact that a patient is also under the care of a
hospital does not relieve a GP of responsibility for his patient’s care.
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