Daniel Ravindra Sundar Veeravalli v General Medical Council
| Jurisdiction | England & Wales |
| Judge | Mrs Justice Lang |
| Judgment Date | 31 March 2022 |
| Neutral Citation | [2022] EWHC 747 (Admin) |
| Docket Number | Case No: CO/3464/2021 |
| Court | Queen's Bench Division (Administrative Court) |
[2022] EWHC 747 (Admin)
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT
Royal Courts of Justice
Strand, London, WC2A 2LL
Mrs Justice Lang DBE
Case No: CO/3464/2021
Jonathan Caplan QC and Miles Bennett (instructed by Russell Cooke LLP) for the Appellant
Peter Mant (instructed by GMC Legal) for the Respondent
Hearing date: 10 March 2022
Approved Judgment
The Appellant appeals under section 40 of the Medical Act 1983 (“MA 1983”) against the decision of the Medical Practitioners Tribunal (“the Tribunal”), made on 3 September 2021, that his fitness to practise was impaired by misconduct, and that conditions were to be imposed on his registration for a period of 12 months.
Factual summary
The Appellant was, at all material times, employed as a Consultant in Obstetrics and Gynaecology at Tameside General Hospital (“the Hospital”) by the Tameside and Glossop Integrated Care NHS Foundation Trust (“the Trust”).
The General Medical Council's (“GMC”) fitness to practice proceedings concerned the Appellant's management of Patient A whilst she was in labour. Patient A was admitted to the hospital at 06.50 on the morning of 8 March 2017. Labour had begun and she was experiencing strong and regular contractions. By 07.25, she had full cervical dilation.
Patient A's baby (Patient B) was in the breech position, and so delivery was complex. After counselling, she decided to proceed with a vaginal delivery. Progress in the second stage of labour was slow. Administration of the labour-augmenting drug syntocinon (Oxytocin) commenced at 09.11. Patient B's left leg delivered spontaneously at 09.43. The delivery was difficult. Patient B was delivered at 10.28, but showed no signs of life and was pronounced dead 30 minutes later.
In July 2018, the Inquest into the death of Patient B recorded that the cause of death was osteo-diastasis of the occipital bone on a background of hypoxia.
The Tribunal found that the Appellant had overall responsibility for Patient A's care. At a staff handover meeting, he recommended the administration of syntocinon (a drug to augment contractions in labour) in Patient A's case, without direct clinical review. On later reviewing Patient A, he failed to obtain informed consent for continuation of syntocinon, and failed to identify the suspicious baseline heartrate correctly. He also failed to formulate, and obtain consent for, a safe management plan, in discussion with Patient A and her partner.
It is important to make it clear that the GMC did not allege, and the Tribunal did not find, that the Appellant's acts or omissions caused Patient B's death.
The Allegations made against the Appellant are set out below, with the Tribunal's determination in respect of each one:
“ The Tribunal's Overall Determination on the Facts
132. The Tribunal has determined the facts as follows:
1. At all material times you were the Consultant with overall responsibility for Patient A's labour of Patient B. Determined and found proved
2. On 8 March 2017 between the hours of 07:50 and 09:11 you:
a. recommended the commencement of syntocinon without direct clinical review of Patient A; Determined and found proved
b. failed to:
i. obtain consent for the commencement of syntocinon, in that you did not:
1. discuss your recommendation for the administration of syntocinon with Patient A; Not proved
2. explain the:
a. benefits of syntocinon; Not proved
b. risks of syntocinon; Not proved
3. take into account Patient A's views of syntocinon;
Not proved
4. obtain verbal consent from Patient A for the commencement of syntocinon; Not proved
ii. maintain adequate records, in that you did not:
1. record the reasons to justify your recommendation of the commencement of syntocinon as set out at paragraph 2. a.; Not proved
2. formally prescribe syntocinon in the drug chart. Not proved
3. On 8 March 2017 at or around 09:15 you reviewed Patient A and you failed to:
a. in the alternative to paragraph 2. b. obtain consent for the continuation of syntocinon, in that you did not:
i. engage in a discussion with Patient A regarding the continuation of syntocinon; Determined and found proved
ii. explain the:
1. benefits of syntocinon, including achieving adequate contractions with a view to aim for vaginal delivery of Patient B in breech presentation; Determined and found proved
2. risks of syntocinon, including hyper stimulation of the uterus which could lead to fetal compromise; Determined and found proved. Amended under Rule 17(6)
iii. 3. take into account Patient A's views of syntocinon; Determined and found proved Amended under Rule 17(6)
iv. 4. obtain verbal consent from Patient A for the continuation of syntocinon; Determined and found proved Amended under Rule 17(6)
b. recognise high risk features, including:
i. full cervical dilation since 07:25 with active pushing since 08:12; Not proved
ii. breech presentation; Not proved
iii. persistent fetal tachycardia for approximately one hour; Not proved
c. adequately interpret Patient A's cardiotocographic trace (‘CTG’), in that you did not:
i. assess all features of the CTG; Determined and found proved
ii. regard take into account the whole clinical picture and progress of labour, including the factors set out at paragraph 3. b.; Determined and found proved
Amended under Rule 17(6)
d. follow NICE guidelines, in that you did not undertake a systematic assessment of Patients A and B; Not proved
e. communicate your overall impression of the CTG to the delivery team; Not proved
f. take appropriate action, including:
i. discussing the interpretation of the CTG findings with:
1. Patient A; Not proved
2. the midwifery team; Not proved
ii. undertaking a systematic assessment of Patient A by: 1. assessing:
a. the maternal early warning score; Not proved
b. maternal hydration; Not proved
c. excluding possible causes of tachycardia including sepsis; To be determined
2. excluding possible causes of tachycardia including sepsis; Not proved
Amended under Rule 17(6)
4 3. investigating persistent fetal tachycardia by:
a. checking maternal observations; Not proved
b. recommending hydration; Not proved
3 4. formulating a safe management plan in discussion with Patient A and her partner; Determined and found proved
g. stop the use of syntocinon and offering a caesarean section, in light of:
i. a suspicious CTG; Not proved
ii. in-coordinate uterine contractions and slow descent; Not proved
iii. the factors as set out at paragraph 3. b.; Not proved
h. obtain consent for:
i. Patient A's management plan , and ensuring shared decision-making, in that you did not discuss with Patient A the: Amended under Rule 17(6)
1. suspicious CTG; Determined and found proved
2. factors as set out at paragraph:
a. 3. a. i; Determined and found proved
b. 3. a. ii. 1. and 2.; Determined and found proved
c. 3. b.; Determined and found proved in relation to 3bi and 3bii but not proved in relation to 3biii
ii. vaginal examinations; Not proved
i. maintain adequate records, in that you did not sign the CTG or ensure it was signed on your behalf. Not proved
4. In the alternative, you failed to record discussions that took place with Patient A with regards to consent as set out at paragraph:
a. 2. b. Not proved
b. 3. a. Not proved”
Appellate jurisdiction
Section 40 MA 1983 provides for a right of appeal to the High Court from decisions of tribunals where they have, amongst other things, directed suspension from the medical register. Under section 40(7), the court may on such an appeal:
a) dismiss the appeal;
b) allow the appeal and quash the direction appealed against;
c) substitute for the direction appealed against any other direction or variation which could have been given or made by an MPT; or
d) remit the case to the Medical Practitioners Tribunal Service to dispose of the case in accordance with the directions of the court.
The appeal is governed by CPR part 52 and PD 52D. Under CPR 52.21(3), the question for the court is whether the decision of the Tribunal is “wrong” or “unjust because of a serious procedural or other irregularity in the proceedings in the lower court”.
Although appeals under section 40 MA 1983 are by way of rehearing, by virtue of paragraph 19. 1 PD 52D, they are not conducted as rehearings in the full sense where the appellate court hears evidence and reaches a decision unconstrained by the conclusion of the lower court. Save in exceptional cases, the court will not hear evidence and it will accord appropriate respect to the primary findings of fact made by the first instance panel which heard the witnesses give evidence.
In Meadow v General Medical Council [2007] QB 462, Auld LJ said at [197]:
“On an appeal from a determination by the GMC, acting formerly and in this case through the FPP, or now under the new statutory regime, whatever label is given to the section 40 test, it is plain from the authorities that the court must have in mind and give such weight as is appropriate in the circumstances to the following factors:
(i) The body from whom the appeal lies is a specialist tribunal whose understanding of what the medical profession expects of its members in matters of medical practice deserve respect.
(ii) The tribunal had the benefit, which the court normally does not, of hearing and seeing the witnesses on both sides.
(iii) The questions of primary and secondary fact and the overall value judgment to be made by the tribunal, especially the last, are akin to jury questions to which there may reasonably be different answers.”
In Raschid v General Medical Council [2007] 1 WLR 1460, which was an appeal against sanction, Laws LJ said after reviewing the authorities:
“19. … the fact that a principal...
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