PUBLIC RECORD. Record of Determinations. Medical Practitioner s name: Dates: 07/06/ /06/2018, 19/09/ /2018 & 28/09/2018

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1 PUBLIC RECORD Dates: 07/06/ /06/2018, 19/09/ /2018 & 28/09/2018 Medical Practitioner s name: Dr Hasan AFTAB GMC reference number: Primary medical qualification: Type of case New - Misconduct MB BS 1999 University of Karachi Outcome on impairment Impaired Summary of outcome Suspension, 12 months. Review hearing directed Immediate order imposed Tribunal: Legally Qualified Chair Lay Tribunal Member: Medical Tribunal Member: Mr James Newton-Price Mrs Jennifer Portway Dr Stephen Duxbury Tribunal Clerk: Mrs Sam Montgomery (7 June 2018 & June 2018) Miss Chloe Ainsworth (8 June 2018) Ms Dee Montgomery/Miss Emma Saunders (14 June 2018) Miss Emma Saunders/Mr John Poole (15 June 2018) Ms Elly McQuinn (21 September 2018) Mr Sewa Singh (19 20 & 28 September 2018) 1

2 Attendance and Representation: Medical Practitioner: Medical Practitioner s Representative: GMC Representative: Present and represented Mr Len Furlong, Counsel (directly instructed) (7 June 2018 to 21 September 2018 only) Mr Paul Williams, Counsel Attendance of Press / Public In accordance with Rule 41 of the General Medical Council (Fitness to Practise) Rules 2004 the hearing was held partly in public and partly in private. Overarching Objective Throughout the decision making process the tribunal has borne in mind the statutory overarching objective as set out in s 1, Medical Act 1983 (the 1983 Act) to protect, promote and maintain the health, safety and well-being of the public, to promote and maintain public confidence in the medical profession, and to promote and maintain proper professional standards and conduct for members of that profession. Determination on Facts - 21/09/2018 Background 1. Dr Aftab qualified in 1999 in Karachi, Pakistan. He came to the UK in Prior to the events which are the subject of the hearing Dr Aftab worked in the NHS and has worked as a locum consultant in Emergency Medicine since At the time of the events Dr Aftab was practising as a locum consultant in Emergency Medicine at the Betsi Cadwaladr University Health Board (the Health Board). 2. The allegation that has led to Dr Aftab s hearing can be summarised as follows: Patient A: On 19 February 2015, Patient A, a trauma patient, was referred via the emergency bleep system to the Glan Clwyd Hospital, North Wales ( the Hospital ). Patient A presented with a significant mechanism of injury, was semi-conscious, and had abrasions/contusions over the right hypochondrium and pelvis. Dr Aftab was the Trauma Team Lead on duty at the time of Patient A s admission. Following an assessment of Patient A, the Trauma Team agreed that Patient A should undergo a full CT scan which would include the head, neck, chest and pelvis. After this decision was made, Dr Aftab consulted with Dr C, Consultant Radiologist (Dr C). Dr Aftab s case in his Rule 7 letter was that Dr C advised him that a full CT 2

3 scan was not necessary and therefore Dr C refused Dr Aftab s request for a full CT scan of Patient A. Dr Aftab s case at this Tribunal hearing was that Dr C asked him to re-evaluate whether a full CT scan was necessary and that he, Dr Aftab, decided on reflection, to request only a CT scan of the head and neck. Later the same day, Dr B, Consultant Anaesthetist in the Intensive Care Department, attended the Emergency Department. He discovered that a full CT scan had not been carried out. It is alleged that when Dr B asked Dr Aftab why a full CT scan had not been carried out, Dr Aftab informed Dr B that the Radiologist had refused his request to carry out a full CT scan. When Dr B spoke with Dr C regarding this matter, he was informed by Dr C that Dr Aftab had only requested a head and neck scan and that Dr Aftab had told Dr C a full body scan was not necessary. Dr C s evidence at this hearing was that he would often ask a doctor to re-evaluate the need for a full CT scan but that he would not have refused the request if the doctor maintained his view that a full CT scan was necessary. It is alleged that Dr Aftab made untrue statements to Dr B regarding Dr C s refusal of a full CT scan and that his actions in this regard were dishonest. Patient D: On 29 June 2015, an assistant in the Dispensary at the Hospital received a telephone call from New Life Pharmacy in Glasgow regarding a request it had received for a botulinum toxin injection ( Botox ) from the Hospital. The assistant spoke to Ms F, Pharmacy Operations Manager, at the Hospital. As the request submitted to New Life Pharmacy did not have an official order or order number, it was not an official request made by the Hospital. Ms F contacted New Life Pharmacy and established that the Hospital s contact details were on the request. Ms F established that the request had been made by Dr Aftab and included card details to allow payment to be taken, and the patient for whom the injection was intended was named as Patient D, a XXX family member of Dr Aftab. Ms F did not appreciate at the time that Dr Aftab was a doctor working at the hospital. The Tribunal noted that Medics Direct, of which New Life Pharmacy is a part, is a company that procured medicines on behalf of doctors. Following a recent inspection, the company had tightened up its procedures and therefore asked for records of patient consent with requests for Botox. Subsequently, Dr Aftab contacted the pharmacy at the Hospital and asked a Medicines Information Pharmacist ( MIP ) (Ms I) if he could prescribe Botox, whether the pharmacy would dispense it, and how he might obtain it. Ms I asked about the purpose of its use and Dr Aftab allegedly told her that it was for cosmetic reasons. Ms I told Dr Aftab that the pharmacy could supply Dysport which is effectively the same medication as Botox under a different brand name. Ms I became suspicious and referred Dr Aftab to Ms F. Ms F asked Dr Aftab whether his request for Botox was to treat private patients to which, apparently, Dr Aftab had replied it was not and that it was for an NHS patient. When asked 3

4 whether the patient would be admitted or treated as a day case, Dr Aftab allegedly said no but that the patient would be like an out-patient. Following further questions as to the quantity, Ms F advised Dr Aftab that the Hospital could probably get some Dysport the following day and that if he was to send a prescription for the patient with a G number (a hospital number), it would be ordered. At this point, Ms F was not aware of the conversation Dr Aftab had had with Ms I concerning prescribing for NHS patients without a hospital number. Nor was she aware that Ms I had advised Dr Aftab that if the Botox was for himself, then another consultant would need to prescribe it. On the same day, a hospital prescription was received by the dispensary reception, signed by a Dr H, in the Emergency Department. The prescription bore the name of Patient D and a G number. It was alleged that Dr Aftab asked the Hospital receptionist to open a patient record and that he asked Dr H to write the prescription for Patient D. Upon cross checking, Ms F established that Patient D had only been registered that day. Following further inquiries, and having retrieved the CAS card (the patient record that is created on a card when a patient presents at the Emergency Department), Ms F established that Dr Aftab had asked for Patient D to be registered. The CAS card showed that Patient D arrived at 12:52 and departed at 13:00. The CAS card also showed that Patient D was a XXX family member of Dr Aftab. Further, Ms F also established that Patient D resided in XXX, which is not local to the Hospital. Due to her various concerns, Ms F then referred the matter to Dr G, Medical Director for Quality and Transformation at the Hospital. It is further alleged that on one or more occasions between 2010 and 2015 Dr Aftab prescribed and/or administered medication for Patient D, a family member and treated Patient D with Botox. At meetings on 21 July 2015, Dr Aftab made apparent admissions to Dr G that he had been prescribing and treating Patient D with Botox for several years. Further, it is alleged that Dr Aftab sought to obtain a prescription for Patient D free of charge when he knew that Patient D had not attended the Emergency Department of the Hospital. In addition, it is alleged that Dr Aftab made dishonest statements at the Health Board meeting with Dr G regarding his actions. 3. The initial concerns were raised with the GMC on 27 July 2015 by Dr G, Medical Director for Quality and Transformation for the Health Board. The referral to the GMC followed a local investigation. The Outcome of Applications Made during the Facts Stage 4. The Tribunal granted the GMC s application to hear from a witness by telephone. The Tribunal s full decision on the application is included at Annex A. The Tribunal refused the application made by Dr Aftab s Counsel, Mr Len Furlong, of no case to answer, pursuant to Rule 17(2)(g) of the General Medical Council (Fitness to 4

5 Practise Rules) 2004 as amended ( the Rules ). The Tribunal s full decision on the application is included at Annex B. The Allegation and the Doctor s Response 5. The Allegation made against Dr Aftab is as follows: Patient A Patient D That being registered under the Medical Act 1983 (as amended): 1. On 19 February 2015, when Dr B asked you why only Patient A s head and neck had been scanned you told Dr B that: a. you had requested a CT scan of Patient A s head, chest, abdomen and pelvis, or words to that effect; Admitted and Found Proved b. Dr C had refused your request for a CT scan of Patient A s chest, abdomen and pelvis, or words to that effect. Admitted and Found Proved 2. You knew that your statements as set out at paragraphs 1a to 1b were untrue because you had only requested a CT scan of Patient A s head and neck. To be determined 3. Your actions as described in paragraphs 1 to 2 were dishonest. To be determined 4. On one or more occasions between 2010 and 2015 you: a. prescribed and/or administered the medication set out in Schedule 1 for a member of your family ( Patient D ); Admitted and Found Proved only in relation to prescribing in July To be determined b. treated Patient D for the condition set out in Schedule 2. To be determined 5. On 29 June 2015 you: a. instructed Ms G to open a patient record for Patient D at Glan Clwyd Hospital ( the Hospital ); Admitted and Found Proved 5

6 b. asked Dr H to: i. complete the patient record to indicate that Dr H had seen Patient D; Admitted and Found Proved ii. issue a prescription for the medication set out in Schedule 3 for Patient D. Admitted and Found Proved 6. Through your actions at paragraphs 5a to 5b above you sought to obtain a prescription for Patient D for the medications set out in Schedule 3: a. free of charge; To be determined b. when you knew that Patient D: i. was a member of your family; Admitted and Found Proved ii. did not attend the Emergency Department of the Hospital between 12:52 and 13:00 as indicated in the patient record. Admitted and Found Proved 7. On or around 3 July 2015 you issued a private prescription for Patient D for the medications set out in Schedule 4. Admitted and Found Proved 8. During the meetings with the Betsi Cadwaladr Local Health Board, you stated that when you spoke to the Hospital pharmacy: a. you told them that the prescription you intended to obtain was for a member of your family, or words to that effect; Admitted and Found Proved b. they told you: i. that you could issue a prescription to Patient D, or words to that effect; Admitted and Found Proved ii. to book Patient D into the Hospital, or words to that effect. Admitted and Found Proved 9. You knew that your statements as set out at paragraphs 8a to 8b were untrue. To be determined 10. Your actions as described in paragraphs 5 to 6 and 8 to 9 were dishonest. 6

7 To be determined And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct. The Admitted Facts 6. At the outset of these proceedings, through his counsel, Mr Furlong, Dr Aftab made admissions to some paragraphs and sub-paragraphs of the Allegation, as set out above, in accordance with Rule 17(2)(d) of the General Medical Council (GMC) (Fitness to Practise) Rules 2004, as amended ( the Rules ). In accordance with Rule 17(2)(e) of the Rules, the Tribunal announced these paragraphs and sub-paragraphs of the Allegation as admitted and found proved. The Facts to be Determined 7. In light of Dr Aftab s response to the Allegation made against him, the Tribunal is required to determine whether the statements Dr Aftab made to Dr B regarding the request for a CT scan were untrue and whether his actions in this regard were dishonest. It is also required to determine whether, on one or more occasions between 2010 and 2015, Dr Aftab prescribed and/or administered medication to Patient D, a family member, or treated Patient D. Furthermore, whether on 29 June 2015 Dr Aftab s actions in instructing the Hospital receptionist to open a patient record and asking Dr H to complete the patient record to indicate that he had seen Patient D and then issuing a prescription for medication was an attempt by Dr Aftab to obtain a prescription free of charge, when he knew Patient D was a family member and had not in fact attended the Hospital. The Tribunal considered whether his actions in this regard were dishonest. The Tribunal also determined whether Dr Aftab made untrue statements during meetings with the Health Board and whether his actions in this regard were dishonest. Factual Witness Evidence 8. The Tribunal received evidence on behalf of the GMC in the form of witness statements from the following witnesses who were also called to give oral evidence in person and via telephone: Dr G, dated 19 June 2017; and Ms E, Medical Workflow Manager, at the Hospital, dated 2 June The Tribunal received evidence on behalf of the GMC in the form of a witness statement, dated 23 May 2017, from Ms F and oral evidence. 7

8 10. The Tribunal received evidence on behalf of the GMC in the form of witness statements from the following witnesses who were also called to give evidence via telephone: Dr H, dated 14 September 2017; Dr B, dated 13 June 2017; Dr C, dated 26 May 2017; and Ms I, Assistant at the Hospital pharmacy at the time of the events, dated 25 January The Tribunal received evidence on behalf of the GMC in the form of a witness statement from Ms J, 26 May Dr Aftab provided his own witness statement, dated 31 March 2018, and also gave oral evidence at the hearing. In addition, the Tribunal received a witness statement from Patient D, dated 4 May 2018, and oral evidence. The Tribunal also received witness statements from: Dr K, dated 10 September 2018; Mr M, dated 14 June 2018; Mr L, dated 7 September Documentary Evidence 13. The Tribunal had regard to the documentary evidence provided by the parties. This evidence included, but was not limited to: Patient A: statements made by the GMC s witnesses; Patient A s medical records; the CT scan request. Patient D: statements made by the GMC s witnesses; the CAS card; private prescription form dated 3 July 2015 (after the date of the allegation); NHS prescription form for Patient D; correspondence between Ms F and Counter Fraud; handwritten and typed notes of Heath Board Meetings with Dr Aftab; the written referral to the GMC; Dr Aftab s witness statement regarding Ms F before the General Pharmaceutical Council; Dr Aftab s certificate of satisfactory appraisal; 8

9 Testimonials. The Tribunal s Approach 14. In reaching its decision on facts, the Tribunal has borne in mind that the burden of proof rests on the GMC and it is for the GMC to prove the Allegation. Dr Aftab does not need to prove anything. The standard of proof is that applicable to civil proceedings, namely the balance of probabilities, i.e. whether it is more likely than not that the events occurred. 15. The legally qualified Chair referred the Tribunal to the recent Supreme Court judgment in the case of Ivey v Genting Casinos (UK) Limited [2017] UKSC 67, in which Lord Hughes set out the correct test for dishonesty, which is as follows: When dishonesty is in question the fact-finding tribunal must first ascertain (subjectively) the actual state of the individual s knowledge or belief as to the facts. The reasonableness or otherwise of his belief is a matter of evidence (often in practice determinative) going to whether he held the belief, but it is not an additional requirement that his belief must be reasonable; the question is whether it is genuinely held. When once his actual state of mind as to knowledge or belief as to facts is established, the question whether his conduct was honest or dishonest is to be determined by the fact-finder by applying the (objective) standards of ordinary decent people. There is no requirement that the defendant must appreciate that what he has done is, by those standards, dishonest. The Tribunal s Analysis of the Evidence and Findings 16. The Tribunal has considered each paragraph of the Allegation and has evaluated the evidence in order to make its findings on the facts. Patient A 1. On 19 February 2015, when Dr B asked you why only Patient A s head and neck had been scanned you told Dr B that: a. you had requested a CT scan of Patient A s head, chest, abdomen and pelvis, or words to that effect; Admitted and Found Proved b. Dr C had refused your request for a CT scan of Patient A s chest, abdomen and pelvis, or words to that effect. Admitted and Found Proved 2. You knew that your statements as set out at paragraphs 1a to 1b were untrue because you had only requested a CT scan of Patient A s head and neck. 9

10 17. The Tribunal noted, and Dr Aftab confirmed in his evidence, that the Trauma Team had made a joint decision that Patient A should undergo a full CT scan. This decision was recorded in the medical notes made by others within the trauma team as Plan CT Head to Pelvis. The Tribunal also had regard to the clinical notes made by Dr Aftab in Patient A s medical records. It noted that Dr Aftab subsequently recorded his decision to request only a head and neck scan PLAN CTB; CT spine CXR/ABX The Tribunal also noted a further entry made by Dr N, Trainee doctor, which recorded the change of plan by Dr Aftab as Trauma Team Leader CT Head/neck/chest/abdo/Pelvis declined by ED TTL. 18. In his oral evidence, Dr Aftab told the Tribunal that when he went to see the radiologist, Dr C, Dr C advised him to re-evaluate Patient A as a full CT scan might not be necessary. Dr Aftab said that he therefore decided to only request a scan of Patient A s head and neck. He told the Tribunal this was a joint decision with Dr C after discussion. 19. The Tribunal had regard to Dr C s witness statement dated 26 May 2017 in which he stated in paragraph 3:. From my recollections, Dr Aftab had requested a scan and I may have told him to re-evaluate the patient and then come back. However, given the passage of time since the event I cannot be sure of this. 20. In his oral evidence to the Tribunal, Dr C was clear that he would not have declined a request for a full CT scan if Dr Aftab had maintained his request for a full CT scan. This is consistent with paragraph 5 of his witness statement, in which Dr C stated we would never change the detail of a request for a scan from the Emergency Department without the agreement of the consultant. 21. The Tribunal heard evidence from Dr B. Dr B was informed by his trainee, Dr N, that only a head and neck scan had been done. Dr B was consternated that a trauma patient had not received the full scan. He said that he was unhappy and that he was on the warpath. He therefore challenged Dr Aftab as to why the full scan had not been done. Dr Aftab told him that he had indeed requested the full scan but that Dr C had turned him down. Dr B went to see Dr C who told him that Dr Aftab had requested only a head and neck scan. 22. Dr Aftab has already admitted paragraph 1 of the Allegation. The Tribunal is mindful that Dr Aftab was the Trauma Team Lead at the time of Patient A s admission and, therefore, he would have the authority to change the care plan for Patient A. 23. The Tribunal noted Dr Aftab s Rule 7 response, dated 14 November At paragraph 23, Dr Aftab s position was that he requested a full CT scan but this was 10

11 refused by the Radiologist. In paragraph 24, Dr Aftab said that the decision for a full CT scan had been over-ruled by the Radiologist. The Tribunal noted the inconsistency in Dr Aftab s account of events between his case in the Rule 7 letter and his evidence at this Tribunal that he had re-evaluated the position after speaking to Dr C. 24. Whilst acknowledging the written statements of Dr K, Mr M and Mr L, and the other evidence before Tribunal that radiologists undertook a gatekeeper role, having considered the inconsistencies in Dr Aftab s evidence, the Tribunal preferred Dr B s evidence that Dr Aftab told him that Dr C had over-ruled him when this was not in fact the case. The Tribunal therefore concluded that Dr Aftab deliberately misrepresented what Dr C had said. 25. It therefore found paragraph 2 of the Allegation proved on the balance of probabilities. 3. Your actions as described in paragraphs 1 to 2 were dishonest. 26. The Tribunal had regard to paragraphs 8 and 9 of Dr B s statement dated 13 June It took into account the inconsistency in Dr Aftab s evidence in his Rule 7 response and his oral evidence to the Tribunal. 27. Taking all of the evidence into account, and in view of its findings in respect of paragraph 2 of the Allegation, the Tribunal determined that Dr Aftab s actions in misrepresenting what Dr C had said were dishonest. When challenged by Dr B, Dr Aftab had blamed Dr C rather than taking responsibility for his own decision. The Tribunal concluded that any objective observer would regard such a misrepresentation as dishonest. Patient D 4. On one or more occasions between 2010 and 2015 you: a. prescribed and/or administered the medication set out in Schedule 1 for a member of your family ( Patient D ); 28. In his statement dated 31 March 2018, Dr Aftab stated I have never prescribed nor administered the medication to Patient D. Dr Aftab s evidence to the Tribunal was that he had taken a training course for the administration of Botox some years previously, but that he had never prescribed the medication or treated anyone with it. By contrast, in his interview with Dr G, he made admissions that he had treated Patient D for the past five years. 29. The Tribunal was provided with typed notes of two meetings Dr Aftab had with Dr G and Ms E on 21 July In addition, a copy of Ms E s contemporaneous 11

12 handwritten notes were also provided which supported the subsequently prepared typed notes. Tribunal was mindful that the notes are not intended to be a verbatim record. In her notes, Ms E recorded that Dr Aftab said words to the effect: Yes I had to resort to pay 240 for [Patient D] as she has a medical condition. I administer the treatment to [Patient D] every year, you can verify this with the pharmacy I use, I spoke to pharmacy [Patient D] has hyperhydrosis for which she received treatment every summer. I have received training, skin course to administer Botox some time ago so instead of paying some other provider to do this for [Patient D]. I was also doing this for extra income but no lately...they wanted a prescription for a patient in pharmacy. I could not find GP or other GP to prescribe. I previously had a book of prescriptions for cosmetic procedures for friends etc. I did not have any left. I can provide you with evidence that I have been treating [Patient D] with this for years. I normally pay for this. I have prescribed privately for [Patient D] or treated her with left over drug when I was doing it for extra income, 30. Further, when Dr G gave Dr Aftab the opportunity to confirm that he had been prescribing and administering the Botox to Patient D every summer for years, Dr Aftab replied Yes, I cannot afford to go to private clinic as it is too expensive. 31. The Tribunal also had regard to Ms E s handwritten notes of the meetings. The Tribunal was satisfied that the typed notes were an accurate and fair reflection of the handwritten notes and of Ms E s recollection of the responses provided by Dr Aftab. It accepted Ms E s evidence that she had typed up the notes within 24 hours of the meetings. 32. During his oral evidence, Dr G confirmed that the typed notes accurately reflected what was said at the meetings. 33. Dr Aftab asserted at one stage during his oral evidence that both Dr G and Ms E had engineered the record of what was said at the meetings. In his evidence to this Tribunal, Dr Aftab said that he had only once prescribed for Patient D and that he had never administered the medication. This evidence was at odds with his account during the meeting with Dr G and Ms E, where he is recorded as saying that he administered the medication every year to [Patient D], and that he had attended training to administer it. 12

13 34. The Tribunal noted the evidence given by Patient D to this Tribunal that she had not been treated by Dr Aftab. However, given the extent of the detailed admissions by Dr Aftab during the meetings with Dr G and Ms E, the Tribunal concluded that Dr Aftab had prescribed and/or administered the medication set out in Schedule 1 for a member of his family ( Patient D ). It therefore found paragraph 4a of the Allegation proved, on the balance of probabilities. b. treated Patient D for the condition set out in Schedule By virtue of its findings in relation to paragraph 4a above, namely that Dr Aftab gave a detailed account during the Health Board meetings of administering the medication to Patient D, the Tribunal was satisfied that Dr Aftab did treat Patient D for the condition set out in Schedule 2 and therefore found paragraph 4b proved on the balance of probabilities. 5. On 29 June 2015 you: a. instructed Ms G to open a patient record for Patient D at Glan Clwyd Hospital ( the Hospital ); Admitted and Found Proved b. asked Dr H to: ii. complete the patient record to indicate that Dr H had seen Patient D; Admitted and Found Proved ii. issue a prescription for the medication set out in Schedule 3 for Patient D. Admitted and Found Proved 6. Through your actions at paragraphs 5a to 5b above you sought to obtain a prescription for Patient D for the medications set out in Schedule 3: a. free of charge; 36. Dr H gave evidence that Dr Aftab had asked him to write the prescription for Patient D and that he was aware Patient D was a XXX family member. Dr H said that he had therefore questioned whether the prescription was in order more than once, but that Dr Aftab assured him that it had been cleared with the pharmacy. Dr H said that he felt under duress. Dr Aftab admitted asking Dr H to write the prescription but said that it was Dr H who took the initiative in volunteering to do it for him and that he had little control over it. 37. Dr H has a conviction in 2003 for forging prescriptions. He was crossexamined fairly and vigorously on this matter with a view to undermining his credibility as witness. Furthermore, during the Tribunal s deliberations on the facts, both parties asked that the Tribunal consider a further disclosure that Dr H had 13

14 appeared before Llandudno Magistrates Court on 23 July 2018, after he had given evidence to this Tribunal, and pleaded guilty to stealing sleeping pills once and painkillers on ten occasions. There was significant personal mitigation. He was sentenced to 26 weeks imprisonment, suspended for 12 months and ordered to pay 200 costs. Mr Furlong submitted that the recent conviction reinforced his submission that the Tribunal should apply extreme caution before accepting Dr H s evidence. The Tribunal accepts that submission and does not accept Dr H s evidence that Dr Aftab placed him under duress. However, it is clear from Dr Aftab s admissions to Paragraph 5 and his own oral evidence under crossexamination that he asked Ms G, the hospital receptionist, to open the patient record for Patient D, who was not in fact a patient at the hospital, and that he asked or agreed that Dr H should complete the patient record and write the prescription for Patient D. 38. The Tribunal was provided with a copy of the prescription, written by Dr H, for the following: Dysport Injection 300 units intrathecal One vial Lodoxamide Alomide eye drops topical Two bottles for 7/7 Coamoxyclav 625 mg TDS oral 7/7 Metronidazole 400mg TDS oral 7/7 39. In paragraph 15 of his statement dated 31 March 2018, Dr Aftab stated I did not seek to obtain the prescription free of charge and provided my credit card details on the order and would have paid for the medication at the point of collecting the medication. Dr Aftab maintained this position in his oral evidence. 40. However, the Tribunal has regard to the overall sequence of events. It took into account that Dr Aftab inquired with the pharmacy how he could obtain the medication; that he had instructed or asked Ms G to open a patient record for Patient D at Glan Clwyd Hospital to make it look like Patient D had presented at the Emergency Department; that he had asked Dr H to complete the patient record to indicate that Dr H had seen Patient D; and asked Dr H to issue a prescription for the medication set out in Schedule 3 for Patient D. 41. The Tribunal concluded that Dr Aftab would have been aware that registering as an NHS patient would have entitled Patient D to free medication at an NHS hospital in Wales. Even if prescription charges had applied, he would have been aware that they represented a much lower price than the actual cost of the drug. 42. The Tribunal determined therefore that, on the balance of probabilities, Dr Aftab sought to obtain a prescription for Patient D for the medications set out in Schedule 3 free of charge. It therefore found paragraph 6a of the Allegation proved on the balance of probabilities. In making this finding, the Tribunal accepts that it may not have been Dr Aftab s initial intention to obtain a prescription free of charge. 14

15 However, it became his intention when he failed to obtain the medication privately. There was no evidence before the Tribunal that Dr Aftab had misused NHS prescriptions previously. b. when you knew that Patient D: ii. was a member of your family; Admitted and Found Proved ii. did not attend the Emergency Department of the Hospital between 12:52 and 13:00 as indicated in the patient record. Admitted and Found Proved 7. On or around 3 July 2015 you issued a private prescription for Patient D for the medications set out in Schedule 4. Admitted and Found Proved 8. During the meetings with the Betsi Cadwaladr Local Health Board, you stated that when you spoke to the Hospital pharmacy: a. you told them that the prescription you intended to obtain was for a member of your family, or words to that effect; Admitted and Found Proved b. they told you: i. that you could issue a prescription to Patient D, or words to that effect; Admitted and Found Proved ii. to book Patient D into the Hospital, or words to that effect. Admitted and Found Proved 9. You knew that your statements as set out at paragraphs 8a to 8b were untrue. 43. In his statement dated 21 March 2018, Dr Aftab stated: I had previously spoken to the with the pharmacist could not dispense the drug without a prescription. She advised me to obtain a prescription and book the patient in under a "G" number. We had conversation that the medication was for [Patient D]. [sic] 44. Further, Dr Aftab stated I was open and honest about who the prescription was for and my relationship to the patient with both Dr H and the pharmacist. Dr H was well aware that he was documenting for a "ghost" patient. 15

16 45. In his evidence to the Tribunal, Dr Aftab maintained that he had expressly told both Ms I and Ms F that the Botox prescription was for Patient D and that he had been transparent about this fact at all times. 46. The Tribunal had regard to the undated typed record prepared by Ms I in relation to her dealings with Dr Aftab. Ms I stated: I received a phone call in Medicines Information from an ENT consultant wanting to prescribe Botox. The initial request was asking whether Botox could be prescribed and dispensed in our pharmacy, to which I advised that we do not stock Botox but we do keep the Dysport brand. I was then asked whether we would require a hospital number for the patient on the prescription as he didn't have one, or whether he could write the prescription in his own name. This rang alarm bells so I enquired as to the indication of treatment which I was told was for cosmetic purposes. He explained to me that he was trained and accredited to perform these procedures. I asked if there was a specific patient involved and advised that it is possible for us to dispense for a patient without a G number, however, if the patient is an NHS patient they should have one. If the prescription was for him then he would require another consultant to prescribe it for him. I was given the impression that this was for a private patient, although this was not stated during the conversation. He asked how he could send the prescription to pharmacy and we discussed sending it via POD In her evidence to the Tribunal, Ms I said she had no recollection of Dr Aftab saying that the medication was for Patient D, a XXX family member. Her impression was that Dr Aftab was seeking medication via the NHS for a private patient. 48. At paragraph 8 of her statement dated 26 May 2017, Ms F stated: She [Ms I] came to me saying that an ENT consultant was asking about how to get a supply of Botox for cosmetic purposes and that she had become suspicious that it might be for a private patient Paragraph 9 states I asked him [Dr Aftab] if his request was associated with treating private patients to which he replied that it was not and that it was for NHS patients. I asked whether he was going to admit the patient or treat the patient as a day case. He replied in the negative for both but the patient would be 'like an outpatient'. I did ask him directly why he had sought to obtain the medicine from Medics Direct. I cannot remember what he said in reply. 16

17 50. In paragraph 10 Ms F stated. I asked what the indication was and he said cosmetic. I probed further and he said hyperhidrosis to which I said that patients with this condition are treated fairly regularly at the Hospital. I said we could probably get some the following day and that if he was to send a prescription for the patient with a G number (a hospital number) to us it would be ordered. 51. In her oral evidence to the Tribunal, Ms F maintained that Dr Aftab did not disclose at any stage that he was seeking medication for Patient D. She had suspicions and she gave him every opportunity to disclose that the patient was a XXX relative but he did not do so. 52. The Tribunal found that both Ms I and Ms F were credible witnesses. Their credibility is reinforced by the fact that Ms I reported her concerns to Ms F immediately, thereby putting Ms F on notice of the possible issues prior to Ms F s conversation with Dr Aftab. Furthermore, following her dealings with Dr Aftab, Ms F was sufficiently concerned to refer the matter promptly to Dr G. The Tribunal therefore concluded that Dr Aftab did not inform either Ms I or Ms F that the intended patient was a XXX family member. He had ample opportunities to do so but he deliberately withheld this important information. The Tribunal therefore found that his statement at 8a was untrue. In relation to 8b, Dr Aftab s account to the Health Board meetings that the pharmacy told him he could issue a prescription and book the patient into a hospital, were based on conversations in which he had withheld essential information from the pharmacy, namely that the prescription was for Patient D. He was not therefore telling the whole truth and in that context his account was untrue. 53. The Tribunal therefore found paragraph 9 of the Allegation in relation to paragraphs 8a and 8b proved on the balance of probabilities. 10. Your actions as described in paragraphs 5 to 6 and 8 to 9 were dishonest. 54. The tribunal did not find Dr Aftab to be a credible witness. During his oral evidence he varied his account of events and made serious allegations of impropriety and collusion against a number of GMC witnesses and stated that they were being told what to say by the Hospital legal team. The Tribunal did not consider that these allegations had any merit and, for the reasons previously stated, found the oral evidence of Ms F, Ms I, Dr G, Ms E, Dr B and Dr C to be credible. The Tribunal preferred the evidence of those witnesses to that of Dr Aftab. In relation to paragraph The Tribunal has already determined that Dr Aftab knew that Patient D was not in reality a patient in the Hospital when he asked Ms G to open a patient record and when he asked Dr H to issue a prescription. Dr Aftab also knew that he had 17

18 provided incomplete information to the pharmacy when he asked Dr H to complete the prescription. For these reasons, the Tribunal found that Dr Aftab s actions were dishonest. It therefore found paragraph 10 in relation to paragraph 5a and 5b of the Allegation proved. In relation to paragraph Dr Aftab has already made admissions in respect of paragraph 6b. 57. The Tribunal has already determined that Dr Aftab sought to obtain a prescription, free of charge, for Patient D for the medications set out in Schedule The Tribunal has also determined that Dr Aftab gave incomplete information to the pharmacy and withheld crucial information that the prescription was for a XXX family member who was not going to attend the Hospital for out-patient treatment. The Tribunal has therefore concluded that Dr Aftab acted dishonestly in his dealings with the Hospital pharmacy. 59. The Tribunal found paragraph 10 in relation to paragraph 6a and 6b of the Allegation proved. In relation to paragraphs 8 and Dr Aftab has already made admissions in respect of paragraphs 8a and 8b. 61. The Tribunal has already determined, in relation to paragraph 9 of the Allegation, that Dr Aftab knew his statements to Dr G at the Health Board interview were untrue. The Tribunal therefore concluded that Dr Aftab was dishonest in the account of events he gave to the Health Board. 62. In making its findings of dishonesty, in relation to paragraphs 5, 6, 8 and 9, the Tribunal has no doubt that a reasonable and objective observer would regard Dr Aftab s actions to be dishonest. The Tribunal s overall findings on the facts Patient A 1. On 19 February 2015, when Dr B asked you why only Patient A s head and neck had been scanned you told Dr B that: a. you had requested a CT scan of Patient A s head, chest, abdomen and pelvis, or words to that effect; Admitted and Found Proved 18

19 Patient D b. Dr C had refused your request for a CT scan of Patient A s chest, abdomen and pelvis, or words to that effect. Admitted and Found Proved 2. You knew that your statements as set out at paragraphs 1a to 1b were untrue because you had only requested a CT scan of Patient A s head and neck. Found Proved 3. Your actions as described in paragraphs 1 to 2 were dishonest. Found Proved 4. On one or more occasions between 2010 and 2015 you: a. prescribed and/or administered the medication set out in Schedule 1 for a member of your family ( Patient D ); Admitted and Found Proved only in relation to prescribing in July Found Proved b. treated Patient D for the condition set out in Schedule 2. Found Proved 5. On 29 June 2015 you: a. instructed Ms G to open a patient record for Patient D at Glan Clwyd Hospital ( the Hospital ); Admitted and Found Proved b. asked Dr H to: iii. complete the patient record to indicate that Dr H had seen Patient D; Admitted and Found Proved ii. issue a prescription for the medication set out in Schedule 3 for Patient D. Admitted and Found Proved 6. Through your actions at paragraphs 5a to 5b above you sought to obtain a prescription for Patient D for the medications set out in Schedule 3: a. free of charge; Found Proved b. when you knew that Patient D: iii. was a member of your family; Admitted and Found Proved 19

20 ii. did not attend the Emergency Department of the Hospital between 12:52 and 13:00 as indicated in the patient record. Admitted and Found Proved 7. On or around 3 July 2015 you issued a private prescription for Patient D for the medications set out in Schedule 4. Admitted and Found Proved 8. During the meetings with the Betsi Cadwaladr Local Health Board, you stated that when you spoke to the Hospital pharmacy: a. you told them that the prescription you intended to obtain was for a member of your family, or words to that effect; Admitted and Found Proved b. they told you: i. that you could issue a prescription to Patient D, or words to that effect; Admitted and Found Proved ii. to book Patient D into the Hospital, or words to that effect. Admitted and Found Proved 9. You knew that your statements as set out at paragraphs 8a to 8b were untrue. Found Proved 10. Your actions as described in paragraphs 5 to 6 and 8 to 9 were dishonest. Found Proved Determination on Impairment - 28/09/ The Tribunal now has to decide in accordance with Rule 17(2)(l) of the Rules whether, on the basis of the facts which it has found proved as set out before, Dr Aftab s fitness to practise is impaired by reason of misconduct. 2. Shortly before handing down the decision on impairment the Tribunal was informed that Dr Aftab had dispensed with the services of his legal representative Mr Len Furlong - and that he wished to be represented by his father, Dr Syed Ahmed. The Tribunal exercised its discretion under Rule 33(1)(c) of the Rules to permit Dr Aftab s father to represent him, having established that he was a fit and proper person to do so. It noted that the GMC did not oppose the application. 20

21 3. Prior to handing down its decision on impairment, the Tribunal agreed to hear Dr Ahmed s application to re-open submissions on the issue of impairment on the following grounds: the evidence was one sided there were inconsistencies and omissions in the Tribunal s determination on the facts there had been an inconsistent approach by the hospital at which he was employed the record of his interview with Dr G was unreliable there were flaws in the Pharmacist s evidence there was no diversity in the composition in the Tribunal he had received poor legal advice in relation to his Rule 7 response 4. Mr Williams for the GMC submitted that these grounds do not justify reopening the issue of impairment. He pointed out that the fact finding stage cannot be reopened as the decision of the Tribunal had already been announced. Mr Williams accepted the Tribunal had discretion to consider matters at the impairment stage if those matters are relevant, but submitted they were not. 5. The Tribunal considered that the issues in relation to the allegedly one sided nature of the case, the allegedly inconsistent approach by the Hospital, the alleged unreliability of the records in relation to the interview with Dr G, and any alleged flaws in the Pharmacist s evidence, have all been fully and exhaustively ventilated in these proceedings to date. 6. In relation to the criticisms of the alleged inconsistencies and omissions in the Tribunal s determination on the facts, the Tribunal notes that no criticisms of this nature were made prior to submissions on impairment. Having announced its decision on the facts, the Tribunal does not propose to revisit that decision. 7. In relation to the alleged lack of diversity in the composition of the Tribunal, the Tribunal notes that Dr Aftab raised no objection to this previously. Further, this is a properly constituted Tribunal. 8. In relation to the poor legal advice in respect of his Rule 7 response, the Tribunal noted Dr Aftab s concerns but concluded that this was not a matter for this Tribunal but a matter between Dr Aftab and his legal representative. 9. Finally, the Tribunal has carefully considered whether any of these matters justified reopening the issue of impairment. It concluded that all relevant matters had been comprehensively ventilated during the course of the hearing. The Tribunal therefore determined to refuse Dr Aftab s application. 21

22 Determination on Impairment The Evidence 10. The Tribunal has taken into account all the evidence received during the facts stage of the hearing, both oral and documentary. Submissions Submissions on behalf of the GMC: 11. On behalf of the GMC, Mr Williams submitted that Dr Aftab s actions amount to misconduct. Mr Williams stated that Dr Aftab s conduct with respect to Patient A was manipulative. He did not communicate his clinical decision truthfully and honestly. His defence was to blame others and this was deplorable conduct. With respect to Patient D s prescription, Mr Williams submitted that Dr Aftab deliberately told lies and untruths to obtain what he wanted, undermining the standards of probity and integrity that are expected of a doctor in his position. Mr Williams further submitted that Dr Aftab s dishonesty was deliberate, persistent, and over a protracted period of time, being characterised by Dr Aftab s desire to obtain what he wanted, or to cover up courses of action he had taken. He stated that Dr Aftab s conduct would be regarded as deplorable by fellow members of the medical profession and as shocking to the public. 12. Mr Williams stated that dishonesty is very difficult to remediate, and that to do so, one would have to have a high degree of insight into their actions. Mr Williams submitted that Dr Aftab does not have any insight at present, having maintained the denials of his behaviour. He further stated that as Dr Aftab had no present rehabilitation or insight, it follows that there is a significant risk of repetition. Mr Williams submitted that Dr Aftab s actions have the effect of undermining public confidence in the medical profession, had put patient safety at risk, and that a reasonably informed member of the public would expect a finding of impairment to be made. He stated it was therefore necessary, based on the preceding factors, for there to be a finding of impairment. Submissions of behalf of Dr Aftab: 13. On behalf of Dr Aftab, Mr Furlong submitted that while Dr Aftab accepted that the Allegations found proved against him are serious in all the circumstances, that he had put patient safety at risk, and had undermined public confidence in the medical profession, his behaviour was not the most serious type of dishonesty. Mr Furlong stated that Dr Aftab s actions were ill-advised errors and momentary lapses of judgment, during a time of stress in both his professional and personal life in Mr Furlong further submitted that Dr Aftab had no previous record of similar behaviour, nor had he repeated his behaviour since these incidents. He stated that although Dr Aftab may have been impaired at the time of the incidents in 2015, he had 22

23 since overcome the professional and personal difficulties he was facing and has since learned to be more open and honest with colleagues and that he was adamant the conduct would not be repeated. Mr Furlong submitted that Dr Aftab s actions in 2015 do not currently impact his current capability to continue to practise medicine. He stated that for these reasons Dr Aftab s fitness to practise is not currently impaired. The Relevant Legal Principles 15. The Tribunal reminded itself that at this stage of proceedings, there is no burden or standard of proof and the decision of impairment is a matter for the Tribunal s judgement alone. Throughout its deliberations, the Tribunal has borne in mind its overarching objective, which is to: protect and promote the health, safety and wellbeing of the public promote and maintain public confidence in the medical profession promote and maintain proper professional standards and conduct for the members of the profession. 16. In approaching the decision, the Tribunal was mindful of the two stage process to be adopted: first whether the facts as found proved amounted to misconduct, and that the misconduct was serious, and then whether the finding of that misconduct which was serious could lead to a finding of impairment. 17. The Tribunal had regard to the case of Lawrance v General Medical Council [2017] EWHC 586 ( Lawrance ) in which it was stated that dishonesty by doctors will usually be misconduct even if it has nothing to do with professional competence. 18. The Tribunal must determine whether Dr Aftab s fitness to practise is impaired today, taking into account Dr Aftab s conduct at the time of the events and any relevant factors since then such as whether the matters are remediable, have been remedied and any likelihood of repetition. 19. The Tribunal reminded itself of the case of General Medical Council v The Queen (on the application of Dr Iheanyi Nwachuku) [2017] EWHC 2085 (Admin) ( Nwachuku ) in which it was stated that a finding of dishonesty does not automatically result in a finding of impairment, however it noted that it must be an unusual case if there is to be no subsequent finding of impairment. It also had regard to the case of Chaudhary v General Medical Council [2017] EWHC 2561 (Admin) in which it was stated dishonesty is not an all pervading trait, a person can be dishonest just once. It also referred itself to the statutory overarching objective, as well as the guidance set down by the case of Grant [2011] EWHC 927 (Admin) both of which recognise that as part of the process of determining whether a doctor is fit to practise today it must take account of past actions or failures to act, in particular, whether he has in the past acted dishonestly and/or is liable to act dishonestly in the future. 23