Download pdf - PUBLIC RECORD - MPTS · Primary medical qualification: MB BCh 2002 Ain Shams University Type of case Outcome on impairment New - Misconduct Impaired Summary of outcome Suspension,

Record of Determinations –

Medical Practitioners Tribunal

MPT: Dr SEDA 1

PUBLIC RECORD Dates: 22 – 26 July 2019

21 August 2019 11 – 12 December 2019

Medical Practitioner’s name: Dr Tarek SEDA

GMC reference number: 6124507

Primary medical qualification: MB BCh 2002 Ain Shams University

Type of case Outcome on impairment New - Misconduct Impaired

Summary of outcome

Suspension, 12 months. Review hearing directed Immediate order imposed

Tribunal:

Legally Qualified Chair Ms Alice Moller

Lay Tribunal Member: Mr John Ennis

Medical Tribunal Member: Mr John Hayward

Tribunal Clerks: Mr Michael Murphy (Days 1 – 5, 7 - 8) Mr Sewa Singh (Day 6)

Attendance and Representation:

Medical Practitioner: Present and represented

Medical Practitioner representative: Mr Alan Jenkins, Counsel

GMC Representative: Ms Elizabeth Dudley-Jones, Counsel, instructed by GMC Legal

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.



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Overarching Objective Throughout the decision making process the tribunal has borne in mind the statutory overarching objective as set out in s1 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/Impairment - 21/08/2019 Background

1. Dr Seda qualified in Egypt in 2002 and prior to the events which are the subject of the hearing he was practising as a private GP for Doctorcall in Harley Street London. At the time of the events Dr Seda was still practising for Doctorcall but was also practising as a Specialty Doctor in Emergency Medicine - Certificate of Eligibility of Specialist Registration (CESR) Rotations at King’s Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust (‘SFHFT’).

2. The Allegation against Dr Seda included claims that he failed to adhere to his allocated break times at King’s Mill Hospital, that he fell asleep whilst on duty and did not tell anyone he was going on a break. There were also concerns related to Dr Seda’s treatment of Patients A, C and D; it is alleged that he failed to carry out a number of actions required for the assessment and treatment of patients. It is further alleged that Dr Seda did not inform Silverstone Medical locum agency of his IOT conditions, as he was required to do, and offered to take up one day’s employment in breach of conditions, which was dishonest. The GMC also allege that Dr Seda created a false certificate of employment purporting to be from Doctorcall Medical Services and submitted this to the Dataflow Group, which was also dishonest.

3. Initial concerns were raised with the GMC on 20 July 2017 by the Trust after an internal investigation, arising from concerns about record keeping, clinical management and conduct.

The Outcome of Applications Made during the Facts Stage

4. The Tribunal considered the GMC’s application, made pursuant to Rules 17(2) C and 17(6) of the General Medical Council (Fitness to Practise Rules) 2004 as amended (‘the Rules’), to amend the Allegation. Ms Dudley-Jones, on behalf of the GMC applied to withdraw paragraph 2(d) of the Allegation; that Dr Seda spoke inappropriately to Patient A and/or Ms B. There was no reliable evidence that Dr Seda was the doctor involved. Mr Jenkins, Counsel for Dr Seda, raised no objection to the application. The Tribunal granted the application to withdraw paragraph 2(d) of the Allegation.



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The Admitted Facts including withdrawals

5. The Allegation made against Dr Seda is as follows:

That being registered under the Medical Act 1983 (as amended):

Nightshift on 27-28 June 2017

1. You were working a nightshift in the emergency department of the King’s Mill Hospital on 27-28 June 2017 and you:

a. failed to inform anyone that you were going on a break; Admitted and found proved

b. fell asleep whilst on duty; Admitted and found proved

c. failed to adhere to your allocated break time. Admitted and found proved

Patient A

2. On 27 June 2017 you failed to provide good clinical care to Patient A in that you:

a. did not:

i. appropriately consider the importance of Patient A’s low blood pressure upon your examination of her; Admitted and found proved

ii. correct any obvious infection or heart failure before considering intervening with medication; Admitted and found proved

iii. consider Patient A for a DC cardio version before using IV medication; Admitted and found proved

iv. seek senior help or advice from a cardiologist; Admitted and found proved

v. take an adequate history, in that you did not properly enquire with Patient A and/or Patient A’s daughter, Ms B:

i. whether Patient A had an exacerbation of any of her pre-existing problems; Admitted and found proved



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ii. if there were any signs of infection/chest pain and/or heart failure; Admitted and found proved

iii. about Patient A’s medication list; Admitted and found proved

iv. whether Patient A’s chest infection had become worse; Admitted and found proved

v. whether Patient A was already on any treatment for atrial fibrillation; Admitted and found proved

vi. obtain informed consent from Patient A in relation to the use of IV metoprolol; Admitted and found proved

b. inappropriately;

i. prescribed IV metoprolol to Patient A; Admitted and found proved

ii. administered IV metoprolol to Patient A; Admitted and found proved

c. failed to:

i. explain to Ms B what the implications of prescribing IV metoprolol to Patient A were; Admitted and found proved

ii. demonstrate appreciation of Patient A’s clinical observations; Admitted and found proved

iii. correct/attempt to correct the underlying cause of Patient A’s clinical observations; Admitted and found proved

iv. correct/attempt to correct the underlying causes of Patient A’s atrial fibrillation; Admitted and found proved

d. spoke inappropriately to Patient A and/or Ms B. Withdrawn by GMC



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3. You failed to maintain an adequate clinical record, in that you did not record:

a. whether Patient A had had an exacerbation of any of her pre-existing problems, particularly if there had been any signs of infection, chest pain or heart failure; Admitted and found proved

b. sufficient detail for other clinicians taking over the care of Patient A. Admitted and found proved

Patient C

4. On 28 June 2017 you failed to provide good clinical care to Patient C in that you:

a. did not:

i. take an adequate history, in that you did not ask Patient B about possible symptoms of infection; Admitted and found proved

ii. adequately examine Patient C to establish a possible source of infection; Admitted and found proved

iii. provide any safety netting advice; Admitted and found proved

b. inappropriately advised Patient C to take paracetamol; Admitted and found proved

c. did not admit Patient C for further tests and observation. Admitted and found proved

5. You failed to maintain an adequate clinical record, in that you did not record:

i. any examination you performed; Admitted and found proved

ii. Patient C’s presenting complaint; Admitted and found proved

iii. your clinical assessment; Admitted and found proved



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iv. your management plan; Admitted and found proved

v. any conversation(s) you had with Patient C’s oncologist; Admitted and found proved

vi. any safety netting advice. Admitted and found proved

Nightshift on 28-29 June 2017

6. You were working a nightshift in the emergency department of the King’s Mill Hospital on 28-29 June 2017 and you:

a. fell asleep whilst on duty; Admitted and found proved

b. failed to inform anyone you were going on a break; Admitted and found proved

c. failed to adhere to your allocated break time. Admitted and found proved

Patient D

7. On 29 June 2017 you failed to provide good clinical care to Patient D in that you:

a. inappropriately attempted to intubate Patient D when:

i. you did not have the experience or expertise to do so; Admitted and found proved

ii. Patient D had not been anaesthetised; Admitted and found proved

b. did not record in the medical records that you had attempted to intubate Patient D. Admitted and found proved

Interim Order

8. You failed to inform Silverstone Medical locum agency of your Interim Orders Tribunal (‘IOT’) conditions imposed on 11 August 2017. Admitted and found proved



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9. You knew you were required to disclose your IOT conditions to locum agencies. Admitted and found proved

10. Your actions at paragraph 8 were dishonest by reason of paragraph 9. Admitted and found proved

11. On 19 October 2017 you breached your IOT conditions as you sent an email to Silverstone Medical confirming:

a. you were able to take up one day’s employment with them; and Admitted and found proved

b. failed to tell them at the point of application about your IOT conditions. Admitted and found proved

12. You knew:

a. your IOT conditions prevented you taking up one day’s employment; Admitted and found proved

b. you were required to inform locum agencies of your IOT conditions at the point of application. Admitted and found proved

13. Your actions at paragraph 11 were dishonest by reason of paragraph 12. Admitted and found proved

Certificate of Employment

14. On or around the 28 February 2018 you created a false certificate of employment (‘the Certificate’) purporting to be from Doctercall Medical Services. Admitted and found proved

15. You submitted the Certificate to Dataflow Group. Admitted and found proved

16. You knew the Certificate was false. Admitted and found proved

17. Your actions at paragraphs 14 and 15 were dishonest by reason of paragraph 16. Admitted and found proved



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And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct.

6. At the outset of these proceedings, Mr Jenkins made full admissions on behalf of Dr Seda, to the Allegation, as set out above, in accordance with Rule 17(2)(d) of Rules. In accordance with Rule 17(2)(e) of the Rules, the Tribunal announced that these paragraphs and sub-paragraphs of the Allegation had been admitted and found proved.

Impairment

7. The Tribunal now has to decide in accordance with Rule 17(2)(l) of the Rules whether, on the basis of the facts which were admitted and found proved as set out above, Dr Seda’s fitness to practise is impaired by reason of misconduct. The Outcome of Applications Made during the Impairment Stage 8. The Tribunal granted the GMC’s application, made pursuant to Rule 34(13) of the General Medical Council (Fitness to Practise Rules) 2004 as amended (‘the Rules’), to allow Mr E to give expert witness evidence on behalf of the GMC, via video link. Mr Jenkins had no objection to this. The Tribunal granted the application. Factual Witness Evidence

9. The Tribunal received evidence on behalf of the GMC in the form of witness statements from the following witnesses who were not called to give oral evidence:

• Dr F, Consultant in Emergency Medicine, at Sherwood Forest Hospitals NHS Foundation Trust (SFHFT);

• Dr G, CT1 ACCS Acute Medicine trainee, at King’s Mill Hospital (part of SFHFT);

• Mr H, Medical Services Team leader, at Silverstone Race Circuit; • Ms I, Deputy Sister in the Emergency Department of SFHFT; • Ms J, Clinical Practitioner and Governance lead for the emergency department

of SFHFT; • Ms K, Rota Coordinator for Emergency Care and Medicine at SFHFT; • Dr L, Consultant in Emergency Medicine at SFHFT;

• Ms M, Registered Nurse at SFHFT; • Ms N, Group Operations Manager for Doctorcall; • Daughter of Patient A and her sole carer; • Patient C.

10. Dr Seda provided his own witness statement dated 19 June 2019.



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Expert Witness Evidence

11. The Tribunal also received evidence from Mr E, Consultant in Emergency Medicine and Clinical Team Leader at a large teaching hospital Trust, unconnected with Dr Seda. He provided the Tribunal with an expert witness report and gave oral evidence via video link.

Documentary Evidence

12. The Tribunal considered all documentary evidence provided by both parties. This evidence included, but was not limited to, patient medical records, SHFHT Disciplinary Investigation Report and Dr Seda’s written submissions. The Tribunal also received evidence from Dr Seda including certificates of continuing professional development (CPD), reflective statements, references and his Personal Development Plan (PDP).

Submissions

13. On behalf of the GMC, Ms Dudley-Jones submitted that Dr Seda failed to provide good clinical care to Patients A, C and D in a number of ways which risked their safety and could have proved fatal in all three cases. She argued that Dr Seda’s actions resulted in numerous breaches of Good Medical Practice (GMP) (2013 version) and were not limited to his clinical conduct but also raised concerns as to his probity whilst working in the Emergency Department (ED). The GMC expert Mr E said that Dr Seda had a contractual obligation with the Trust to work, unless cover was arranged. His report concludes that the overall standard of care fell seriously below that expected of a reasonably competent Emergency Department middle grade doctor.

14. Ms Dudley-Jones said that documents provided by Dr Seda show partial insight, but he does not appear directly to acknowledge that his errors were the result of his lack of clinical knowledge or poor judgment. Dr Seda seemed to believe that concerns about his clinical errors had been exaggerated ‘yes, why has this been treated formally rather than informally? …. No patient died and it wasn’t medication related’ (statement of Dr Seda to the SFHFT Investigation Meeting). Ms Dudley-Jones asserted that he is unlikely to be able to remediate simply by completing online courses, but would instead require focused re-training, guidance and support.

15. Ms Dudley-Jones argued, that in all the circumstances, and given the seriousness of the matters found proved, Dr Seda’s fitness to practise is impaired by reason of misconduct.

16. Mr Jenkins did not contest current impairment of fitness to practise, but said that this is a matter for the Tribunal. Dr Seda conceded that his fitness to practise is impaired by reason of dishonesty in connection with paragraphs 8 to 17 of the Allegation, but not in relation to paragraphs 1 to 7, the clinical allegations.



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17. Mr Jenkins suggested that the Allegation relating to King’s Mill Hospital does amount to misconduct, but not serious misconduct. He reminded the Tribunal of Dr O’s statement that, during Dr Seda’s first four weeks, there were no clinical concerns so he progressed to night duties; this was when a few concerns were raised. Mr Jenkins said that Dr Seda was unhappy with how the job was going and tried to resign after two weeks, as he felt he had no clinical support. It was legitimate for the Tribunal to take into account Dr Seda’s state of exhaustion at the relevant time.

18. Mr Jenkins submitted that Dr Seda has reflected on his dishonesty, displayed insight, made full admissions to the Allegation and taken positive steps towards remediation.

The Legally Qualified Chair’s Advice

19. The Legally Qualified Chair gave advice on principles relevant at the Impairment stage. The Tribunal must follow a staged process in regulatory proceedings. It has made findings of fact following admissions. The Tribunal must consider whether or not facts admitted and found proved amount to misconduct. If so, is current fitness to practise impaired by reason of misconduct?

Cohen v GMC [2008] EWHC 581 confirms that not every case of misconduct results in a finding of impairment.

Misconduct was described as a wrongful or inadequate mode of performance of professional duty to be judged by the Tribunal in Mallon v GMC [2007] CSIH 17.

The word misconduct in the Medical Act 1983 section 35C(2)(a) connotes a serious breach indicating that a doctor’s fitness to practise was impaired. It is important to set the matters complained of in the context of the doctor’s whole practice.

GMC v Nwachuku [2017] EWHC 2085 provides that:

• It will be an unusual case where dishonesty is not found to impair fitness to practise, at [20].

• When considering any admissions, including of dishonesty, a Tribunal must take account of when those admissions were made.

GMC v Nooh [2017] EWHC 2948 provides that “dishonesty is always serious, but these are the questions of fact and degree for the Tribunal to assess”, at [55]. There is a scale of seriousness of dishonesty, taking account of context, such as whether or not it occurred in a clinical context.



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In Calhaem v GMC [2007] EWHC 2606 Admin Jackson J considered the interface between misconduct and deficient professional performance, having conducted a review of key authorities. He set out five relevant principles, the first two being relevant to misconduct:

1. Mere negligence is not misconduct unless it is ‘particularly serious’;

2. Multiple acts/omissions are more likely to be misconduct; a single particularly grave act could be misconduct.

Remedy UK v GMC [2010] EWHC 1245 provided that misconduct is of two principal kinds:

1. Misconduct going to fitness to practise in the exercise of professional practice;

2. Morally culpable or otherwise disgraceful conduct outside or within professional practice.

Conduct falls into the second category if it is dishonourable or attracts some kind of opprobrium – that fact may be sufficient to bring the profession of medicine into disrepute and it does not matter whether or not it is directly related to the exercise of professional skills, at [37(6)].

Action taken in good faith and for legitimate reasons, however inefficient or ill judged, is not capable of constituting misconduct within the meaning of section 35 merely because it might damage the reputation of the profession, at [37(10)].

There is no burden or standard of proof at the impairment stage. It is a question of judgment for the Tribunal: Biswas [2006] EWHC 464.

Impairment may be based on historical matters or a continuing state of affairs, but it is to be assessed at the time of the hearing. To do this the Tribunal must look forward, taking account of any reparation changes in practice, conduct or attitude since the matters found proved occurred. Personal mitigation has less relevance, but an effort to accept and correct remediable errors should be taken into account.

As a general principle it is accepted that everyone sometimes makes a mistake. One off incidents will need to be investigated and any harm put right but, unless very serious or with very serious consequences, they are unlikely in themselves to indicate a fitness to practice problem. Serious or persistent failure to follow Good Medical Practice will put a doctor’s registration at risk.



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CHRE v NMC and Grant [2011] EWHC 927 citing the Fifth Shipman report provides that the Tribunal must consider the following questions in determining impairment:

“Do our findings of fact in respect of the doctor’s misconduct, deficient professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he:

a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or

b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or

c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or

d. has in the past acted dishonestly and/or is liable to act dishonestly in the future.”

Yeong v GMC [2009] EWHC 1923 provides that:

The need to maintain public confidence in the medical profession and declare/uphold standards of behaviour may mean that a doctor’s fitness to practise is impaired by reason of certain acts of misconduct of themselves. This is because the public simply would not have confidence in him, or in the profession’s standards, if the Tribunal regarded that sort of conduct as leaving fitness unimpaired. A finding can be necessary to reaffirm to the public and doctors the standard of conduct expected of them.

Chaudhury [2017] EWHC 2561 reminds us of the importance of the overarching objective, the tripartite public interest and the need for Tribunals to conduct a proper balancing exercise of all three elements of the public interest test, rather than to focus on just one aspect of the test.

20. The Legally Qualified Chair asked both counsel if there were any comments on this advice; there were none.

The Tribunal’s Approach

21. At this stage of the proceedings, there is no burden or standard of proof and the decision as to impairment is a matter for the Tribunal’s judgement alone.

22. 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 which was



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serious and then whether the finding of that misconduct could lead to a finding of impairment.

23. The Tribunal must determine whether Dr Seda’s fitness to practise is impaired today, taking into account his 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.

Analysis

24. The Tribunal assessed the expert witness written evidence supplied by Mr E. It had concerns about the care with which the report had been written. His report contained, by his own admission, two “rogue” paragraphs concerning his experience in treating cellulitis which were irrelevant to this case. In addition there was an unfortunate error in the spelling of Dr Seda’s name which the Tribunal thought would have been noticed in even a cursory check either by himself or the legal team to whom he submitted the report.

25. The Tribunal did not find the term “middle grade doctor working in ED” a particularly helpful standard against which to judge Dr Seda as it seemed to encompass a range of seniority as evidenced by the Disciplinary Investigation Team’s background findings. Mr E said that he would put Dr Seda somewhere between Tier 3 and Tier 4. This ambiguity extended to the apparent conflation of “middle grade” with “EM Registrar” as the comparative standard.

26. The Tribunal also considered that Mr E did not differentiate between a medicolegal report on causation and a GMC report assessing a Doctor’s actions against the standards of GMP. An action or inaction that has the potential to cause harm can be serious whether or not the patient actually suffers harm.

27. The Tribunal thought that Mr E had used the norms of his own department as a standard, rather than what might have been available to Dr Seda working in a less well organised emergency department. Dr Seda’s ability to contact a cardiology registrar at 7.30am was doubtful. The evidence suggested that Dr Seda’s one hour induction was far less thorough than Mr E would expect.

28. According to Mr E’s written and oral evidence, the GMC did not originally provide him with those sections of the Trust’s report revealing inadequacies in the emergency department. The Tribunal was concerned at this omission because systemic and other issues in the emergency department would adversely affect any doctor’s ability to perform and were clearly relevant to the findings that Mr E would make in his report.

29. In answer to questions, Mr E said that he had been ‘advised’ by the GMC not to include in his report his views on the failings of the ED department, including the inappropriateness of the level at which Dr Seda had been expected to work. If this



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was indeed the case, the Tribunal would be concerned about any breach of CPR Section 35.

30. The Tribunal approached some of the findings in the written report with circumspection, for the reasons given above. However, it found much of Mr E’s written report to be well supported in his oral evidence, during which he was willing to make concessions where appropriate.

The Tribunal’s Determination on Impairment

Misconduct

31. The Tribunal considered Dr Seda’s actions, in the light of all written documentary evidence, as well as the facts admitted and found proved to determine whether or not his actions amounted to misconduct.

32. As they all related to break and sleep issues, paragraphs 1(a), (b), (c) and 6(a), (b) and (c) of the Allegations were considered together. The Tribunal did not consider that allegations 1(b) and 6(a), as drafted, amounted to misconduct. Many doctors will have fallen asleep on night shifts, working against their body clock. Mr E stated that ‘power naps’ are acceptable, and could be beneficial, during authorised breaks in night shifts. The Tribunal did consider that the allegations at paragraphs 1(a) and 1(c) amounted to misconduct, as it had the potential to deprive others of their allocated breaks and put patients at risk.

33. However, it found the allegation at paragraphs 6(b) and 6(c) to be more serious as Dr Seda and colleagues had, at the beginning of this night shift, been given a specific instruction with regard to how breaks were to be undertaken. The Tribunal found that his actions on this occasion had an element of willfulness and therefore amounted to serious misconduct.

34. The Tribunal next considered the clinical allegations at paragraphs 2 - 5 and 7 regarding Patients A, C and D. It was aware that Sections 35A and B of the Medical Act should not be regarded as interchangeable. In Remedy UK (cited above) Elias LJ held [at 37(7)] that:

Deficient performance or incompetence, may, in principle, arise from the inadequate performance of any function which is part of medical calling. Which charge is appropriate depends on the gravity of the alleged incompetence. Incompetence falling short of gross negligence but which is still seriously deficient will fall under section 35C(2)(b) rather than (a). Poor judgment could not of itself constitute gross negligence or negligence of a high degree but it may in an appropriate case, and particularly if exercised over a long period of time, constitute seriously deficient performance.



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35. The Tribunal also took account of definitions used by Jackson J in Calhaem, [at para 39] and [43-63]. He emphasises that an act or omission “did not, in isolation, constitute misconduct, but formed part of a wider picture relevant to misconduct.”

36. The Tribunal considered the allegations surrounding the management of each of the Patient’s A, C and D in turn.

Patient A

37. The Tribunal considered the allegations under the following headings: Allegation 2(a)(v) (i - v) and 3(a) and 3(b) History taking; Examination and Record Keeping; 2(a) (i – iv) and 2(c) (ii – iv) Management of Atrial Fibrillation; 2(a) (vi) and 2 c (i); 2(b) (i – ii) treatment with metoprolol and consent.

History Taking, Examination and Record Keeping

38. With regard to history taking, examination and record keeping, Dr Seda’s medical record is in stark contrast to those undertaken by other ED doctors at the relevant time. In particular, Dr Seda made no attempt to elicit a list of medication prescribed to the patient, in particular those taken by her for AF. A doctor requires this essential information for safe management of AF. Dr Seda did note that the patient had chest pain, shortness of breath, fast AF, wheezes and ‘creps’ (crepitations) on chest examination. In view of this, the opinion of the expert was that, in this regard, Dr Seda’s actions fell below, but not seriously below, the standard expected. The Tribunal’s opinion was that, although it showed a lack of focus (or concern) it did not, in isolation, constitute misconduct, but could form part of a wider picture relevant to misconduct.

Management of Atrial Fibrillation

39. The Tribunal was aware that AF is a common condition, the management of which would be on medical school curricula as well as in GP training, which Dr Seda had previously studied. A guideline for the management of AF was available in the department but documentary evidence suggested that it was not readily accessible. But, Dr Seda did not ask nursing staff if one was available or ask anyone for advice. Had he done so he would have been made aware of the fact that the co-morbidities should have been treated prior to pharmacologically treating the AF. Although the Tribunal did not accept the expert’s claim that he could obtain advice from a cardiology registrar in time, given his lack of knowledge Dr Seda should have discussed this patient with the medical registrar on call, but did not do so. The Tribunal was concerned that instead Dr Seda had used the British National Formulary (BNF) in a manner for which it was not intended. The expert opined that Dr Seda’s care in this regard fell seriously below the standard expected. The Tribunal’s opinion was that although it showed a pattern of poor performance, it did



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not, in isolation, constitute misconduct, but could form part of a wider picture relevant to misconduct.

Treatment with Metoprolol

40. The expert’s opinion was that Dr Seda’s treatment with metoprolol was seriously below the standard expected. The Tribunal considered the expert’s opinion and thought that there were two obvious reasons not to give this patient an intravenous beta blocker. The first was that Dr Seda had elicited a history of asthma/COPD which is a contraindication to treatment with Beta blockers, again a basic pharmacological interaction taught at medical school. The second was that the patient was hypotensive and the administration of this drug led to a further fall in blood pressure requiring treatment with IV fluids. The third reason, not apparent to Dr Seda as he had not taken a drug history, was that the patient was already taking Beta blockers. Furthermore, there is no evidence that Dr Seda discussed with either the patient or her relatives the proposed treatment with metoprolol and its possible side effects. The expert said that Patient A, even if she had mild cognitive impairment, had the capacity to make decisions. He regarded this omission as being below a reasonable standard of care. The Tribunal concluded that given the possible severe side effects, including death, of IV metoprolol treatment, the lack of senior advice and the failure to discuss the treatment with the patient or her relatives contributed to an overall picture of serious misconduct at the time in question.

Patient C

41. The Tribunal considered the allegations under the following headings 4(a)(i) history taking; 4(a)(ii) examination; 4(b) advice to take paracetamol; 4(c) failure to admit; 4(a)(iii), failure to safety net; and 5 (i – vi) failure to make any clinical record.

History Taking

42. The Tribunal noted the completed nursing check list in use at the Trust. This pointed towards sepsis not being present. The box beside the words ‘does the patient have any high risk factors’ has not been ticked and it would not have been unreasonable for Dr Seda to have assumed that this question had been asked (it is a design fault in the form that the person completing it is not required to mark a ‘no’ box). Mr E says in his report that ‘from the evidence provided it is likely that Dr Seda did ask Patient C about her past medical history and knew that she had been complaining of a fever.” Although the Tribunal considered Dr Seda’s history taking may have fallen below the standard expected, the Tribunal attached less importance to this than other deficits in his approach at the relevant time.



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Examination

43. Mr Jenkins submitted:“Whilst he said in the Trust interview of 30th June 2017 that he had examined her … he has accepted that this was not an adequate examination. His recollection is that this was more of an ‘examination from the foot of the bed’ and which he accepts was not appropriate”. This would account for Patient C’s testimony of not having been examined, an omission the expert regarded as being seriously below the standard expected. The Tribunal concluded that this was strong evidence in forming part of a wider picture of misconduct in relation to examinations.

Advice to take paracetamol

44. In his evidence to the disciplinary inquiry Dr Seda stated that Weston Park Hospital had informed him that Patient C should not take paracetamol. The evidence from Patient C’s statement is that Dr Seda told her to keep on taking Ibuprofen (not paracetamol). Therefore, the Tribunal did not take this allegation into account.

Record Keeping

45. The expert’s view was that it was completely unacceptable for Dr Seda not to make any contemporaneous records of Patient C’s presenting complaint, clinical assessment, management plan and safety netting and that this fell seriously below the standard expected. The Tribunal concluded that, notwithstanding any issues of competence, this indicated a lack of attention or focus contributing to the impression of carelessness and thus misconduct.

Failure to admit

46. The Tribunal recognised that the screening checklist provided by the Trust was confusing (and this was acknowledged by Mr E in his oral evidence) and the guidelines equally so. A consultant whose opinion had been sought did not mention the need to admit. The Tribunal concluded that Dr Seda’s actions, in this instance, were incorrect but that these factors might have led him into error in making this decision.

Failure to safety net

47. Dr Seda told the disciplinary inquiry that Weston Park Hospital had told him that if the patient developed a temperature they were to phone Weston Park. Patient C’s statement indicates that Dr Seda did not pass this or any other information on to the patient as a safety netting procedure. The expert’s opinion was that although below the standard expected, it was not seriously below as the patient did return the following day. For the reasons explained in paragraph 26 above, the Tribunal found the reasoning employed by Mr E to be flawed. The Tribunal found the failure to safety net to be strong evidence in forming part of a wider picture of misconduct.



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Patient D

48. The Tribunal noted the account of Dr G which it found to be straightforward and unbiased. It considered that Dr Seda’s attempt to intubate Patient D followed a request or an ambiguous statement from Ms I (Deputy Sister) that intubation was required. It is obvious from Dr G’ testimony that at one stage the patient seemed to be deteriorating rapidly and there was confusion as to who might be available to assist. The Tribunal also considered that this was the sort of case where Dr Seda was not experienced enough to act as the senior clinician and should not have been put in this position. The Tribunal accepts that his management was wrong but also that he believed he had been asked to take action in a critical situation. The Tribunal considered that Mr E’s critical comments reflected more the situation of an ED middle grade who has been the subject of appropriate induction and training, both of which seemed to be lacking in this department at the time. There was also written evidence to the effect that there were no formal written guidelines in the department concerning airway management. Mr E is critical of an examination of the tonsils in this sort of case but another ED doctor acted similarly, suggesting that this contraindication was not widely known by junior doctors in this ED. With regard to allegation 7b, another doctor, as part of the team looking after Patient D, has made a full retrospective note of the events and the Tribunal considered that Dr Seda might well have thought that it was not necessary for him to add to this.

Overall conclusion regarding the clinical cases

49. For the reasons above, the Tribunal did not think that allegation 7 (Patient D’s management) formed part of a wider picture of misconduct. It therefore had to consider whether paragraphs 2, 3, 4 and 5 of the Allegation could amount to more than a pattern of poor performance and indicate serious misconduct. It determined that it had found enough instances of individual actions or omissions which could be said to form part of a wider picture of misconduct. Some were particularly serious such as the giving of a dangerous drug to an already compromised patient without senior advice, the failure to examine Patient C, the failure to produce any sort of clinical record for patient C and the failure, despite advice to do so, to safety net. It therefore determined that these allegations, taken as a whole, amounted to serious misconduct.

Overall conclusion regarding dishonesty

50. The Tribunal considered paragraphs 8, 9 and 10 of the Allegation together as they related to Dr Seda’s omission to disclose information relating to his IOT conditions. This behaviour had the potential to undermine the whole regulatory system, as conditions can be of no practical effect unless disclosed to any potential employer. Therefore the Tribunal concluded that these omissions amounted to serious misconduct.



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51. The Tribunal then considered paragraphs 11, 12 and 13 of the Allegation together as they all involved provision of false information in a clinical context. Any forgery of documents or misleading statements pose a risk to the safety of patients. Employers have systems in place to ensure that they hire doctors who are safe to practise. Dr Seda’s actions showed no awareness of the importance of the regulatory provisions or other safeguards.

52. Finally, the Tribunal considered paragraphs 14, 15, 16 and 17 of the Allegation. It bore in mind that Dr Seda sought to gain a financial advantage from providing a false certificate of employment; this dishonesty amounted to serious misconduct.

53. The Tribunal considered that Dr Seda breached paragraphs 7, 14, 15a, b and c, 16a and d, 17, 19, 21a – e, 31, 35, 36, 37, 65, 66 and 71 of GMP.

54. In conclusion, the Tribunal has found that Dr Seda’s conduct fell so far short of the standards of conduct reasonably to be expected of a doctor as to amount to serious misconduct, for those elements of the Allegation identified above.

Impairment

55. Having found that some of the facts found proved amounted to serious misconduct, the Tribunal went on to consider whether, as a result of this, Dr Seda’s fitness to practise is currently impaired.

56. On behalf of Dr Seda, Mr Jenkins conceded that his fitness to practise was impaired by reason of dishonesty. His behaviour posed a risk of harm to patients as Dr Seda presented himself to Silverstone as unrestricted and this was untrue. Dr Seda’s dishonesty in this context could undermine public trust in the medical profession. A finding of impairment is thus necessary to declare and uphold professional standards.

57. The Tribunal had regard to the case of Cohen in which Silber J held: ‘It must be highly relevant in determining if a doctor’s fitness to practise is impaired that his or her conduct which led to the charge; is easily remediable, has been remedied, and is highly unlikely to be repeated.’

58. The Tribunal found many instances where Dr Seda’s care fell below, and in some areas seriously below, the standards expected of someone in his position. These included matters which were at a very basic level of medical training and knowledge. The Tribunal did not believe that these failings were easily remediable, nor that Dr Seda had sufficient insight as to how to remedy them. The Tribunal considered that any doctor working in an Emergency Department at any level should be aware of the need to take an adequate history from patients, examine patients and to maintain an accurate patient record. It should have been obvious to Dr Seda that beta blockers were contraindicated for Patient A, or any other patient with COPD/asthma, particularly in the presence of hypotension, without senior advice.



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59. In regard to Patient D, Dr Seda’s reflection omitted to mention his failure to keep his ALS qualification in date. This would have been more relevant than simply confirming attendance at an ALS course. There was nothing in Dr Seda’s reflections to address his inadequacies in basic techniques, such as record keeping, history taking, patient examination and obtaining informed consent.

60. The Tribunal considered that Dr Seda had not shown much insight into his errors and omissions, despite attending courses. His failure to learn from previous mistakes is shown by the fact that he has had to appear before his regulator again in 2019, despite having been given formal warnings by both a previous employer and the GMC.

61. A letter addressed to Professor P of Health Education England, dated 23 November 2017, from Dr Q (GP Dean), states that Dr Seda downloaded ‘an unauthorised programme onto 8 computers within the practice to allow him to access their clinical notes system on his home computer and mobile phone’ ; and also that ‘an issue arose following a complaint by a patient which resulted in Dr Seda’s employing practice issuing him with a Formal Written Warning’.

62. Dr Seda’s revalidation information reveals that he received a Warning in 2015 from the GMC because ‘On 26 June 2014 Dr Seda saw a very vulnerable patient in A&E. He offered religious documentation, which he suggested might help the patient and gave her his telephone number.’

63. The Tribunal did not accept as accurate Dr Seda’s assertion that he was ‘always honest’, despite ‘examples’ such as repaying money. He told the Disciplinary Investigation Team that he had examined Patient C; he now admits that this is untrue. He also told the Team that he had completed his GP training except for a pass in the CSA whereas the letter from Dr Q indicates that this was not the case. Dr Seda has been criticised for plagiarism and downloading an unauthorised programme to access patient records outside work. All this undermines his assertion that his behaviour is generally honest.

64. Despite the fact that Dr Seda was clearly under pressure from one of his employers to work consecutive night shifts, with a day clinic in between, the serious clinical errors and omissions reflected in the Allegation were so fundamental that any exhaustion or lack of experience does not excuse them. The Tribunal considered that the undoubted shortcomings in the clinical management of the emergency department did not excuse Dr Seda’s failings.

65. In all the circumstances, the Tribunal concluded that a finding of impaired fitness to practise was required for the protection of members of the public, in order to maintain public confidence in the profession, and to promote and maintain proper professional standards and conduct for members of the profession. The Tribunal has therefore determined that Dr Seda’s fitness to practise is impaired by reason of misconduct.



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Determination on Sanction - 12/12/2019 1. Having determined that Dr Seda’s fitness to practise is impaired by reason of misconduct, the Tribunal now has to decide in accordance with Rule 17(2)(n) of the Rules on the appropriate sanction, if any, to impose.

The Evidence

2. The Tribunal has taken into account evidence received during the earlier stages of the hearing where relevant to reaching a decision on sanction.

3. Dr Seda gave oral evidence at this stage and submitted further documentary evidence including:

• Certificate of good standing from Oman dated 21 October 2019; • Reflective statement dated 6 November 2019; • Certificate of attendance at a maintaining professionalism course dated 21

November 2019; • Letter of recommendation from Dr R dated 2 August 2019; • MSc Emergency Medicine test results dated 4 December 2019.

Submissions

4. On behalf of the GMC, Ms Dudley-Jones submitted that there are no exceptional circumstances to justify taking no action in this case and that it would be wholly inappropriate to impose a sanction of conditions given the probity and patient safety concerns raised in this case. She went on to argue that a period of suspension would also be inappropriate as Dr Seda has demonstrated numerous serious breaches of GMP and shown limited insight, adding that this Tribunal has found that there is a risk of repetition of his misconduct.

5. Ms Dudley-Jones submitted that the appropriate sanction in this case is one of erasure as Dr Seda’s misconduct is fundamentally incompatible with continued medical registration. She stated that Dr Seda showed a deliberate disregard for the guidelines set out in GMP, displayed dishonesty which was persistent and covered up and that he failed to work collaboratively with his colleagues. Ms Dudley-Jones argued that it is necessary to erase Dr Seda’s name from the medical register, including to protect public confidence in the medical profession.

6. On behalf of Dr Seda, Mr Jenkins submitted that a doctor who is very tired may make clinical mistakes or absent himself to try to sleep. He agreed with the GMC’s submissions that it would not be appropriate to take no action or to impose conditions in this case.

7. Mr Jenkins submitted that a sanction of suspension would be appropriate to deal with the risks identified and said that this would assist with Dr Seda’s return to practice



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as he could use the time for further training such as clinical attachments. He reminded the Tribunal that Dr Seda has made full admissions to the Allegation at this hearing and has apologised to patients. Mr Jenkins said that Dr Seda was suffering from tiredness during the events in the Allegation and had not wanted to undertake the Tuesday evening night shift.

8. Mr Jenkins also submitted that should a period of suspension be imposed there should be a review hearing to consider what further steps to take to salvage Dr Seda’s career. He asserted that erasure would be excessive, as Dr Seda’s misconduct was not at the upper end of the seriousness scale, despite being wholly inappropriate.

The Tribunal’s Determination on Sanction

9. The decision as to the appropriate sanction to impose, if any, is a matter for this Tribunal exercising its own judgement. 10. In reaching its decision, the Tribunal has taken account of the Sanctions Guidance (2018) (SG) and GMP. It has borne in mind that the purpose of a sanction is not to be punitive, but to protect patients and the wider public interest, although it may have a punitive effect. 11. Throughout its deliberations, the Tribunal applied the principle of proportionality, balancing Dr Seda’s interests with the public interest. It has already given a detailed determination on impairment and has taken all relevant facts into account during its deliberations on sanction. 12. The Tribunal considered the mitigating factors in this case. It took account of the unfavourable working circumstances of Dr Seda during the time of events giving rise to the Allegation; these included the lack of an adequate induction for his role and a lack of supervision by senior staff. The Tribunal was aware that these factors caused Dr Seda a degree of work related stress due to his relative inexperience. He has provided a number of testimonials, two of which make frank but positive observations about insight. The Tribunal noted that Dr Seda has fully engaged with this Tribunal, demonstrated some insight and made full admissions to the Allegation. He has attended various courses to address his misconduct, including four courses relating to ethics. 13. The Tribunal next considered the aggravating factors in this case. It was of the view that Dr Seda’s insight is not yet complete. He told the Tribunal that he is generally an honest person, but in 2012 he was found to have used large quantities of material copied from published sources without referencing the source. Also around this time he downloaded an unauthorised programme onto eight computers to allow him to access clinical notes on his home computer and mobile phone. The present Allegation arose, in part, from his failure to disclose conditions of practice, as well as creating a false document. His failure to work collaboratively with his



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colleagues included not telling them about unauthorised naps on the night shifts. No Action 14. In reaching its decision as to the appropriate sanction, if any, to impose in this case, the Tribunal first considered whether to conclude by taking no action. 15. The Tribunal determined that there were no exceptional circumstances so it would not meet the public interest to take no action in this case. Conditions 16. The Tribunal next considered whether it would be appropriate to impose conditions on Dr Seda’s registration. It bore in mind that any conditions imposed should be appropriate, proportionate, workable and measureable. 17. The Tribunal was not satisfied that a sanction of conditions would be sufficient to address the dishonesty displayed by Dr Seda as he has fabricated a Certificate and misled Silverstone as to his ability to practice on an unrestricted basis, and also King’s Mill Hospital by claiming to have examined a patient that he had only looked at from ‘the foot of a bed’. Neither Ms Dudley-Jones nor Mr Jenkins argued that conditions were appropriate in this case. 18. The Tribunal determined that conditions would not be appropriate to deal with the probity issues, workable or sufficient to deal with risk or satisfy the public interest. Suspension 19. The Tribunal then went on to consider whether imposing a period of suspension on Dr Seda’s registration would be appropriate and proportionate. In its deliberations, it had regard to the following paragraphs of the SG:

‘24) The tribunal needs to consider and balance any mitigating factors presented by the doctor against the central aim of sanctions (see paragraphs 14–16). The tribunal is less able to take mitigating factors into account when the concern is about patient safety, or is of a more serious nature, than if the concern is about public confidence in the profession… …97) Some or all of the following factors being present (this list is not exhaustive) would indicate suspension may be appropriate.

a) A serious breach of Good medical practice, but where the doctor’s misconduct is not fundamentally incompatible with their continued registration, therefore complete removal from the medical register would not be in the public interest. However, the breach is serious enough that



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any sanction lower than a suspension would not be sufficient to protect the public or maintain confidence in doctors. b) In cases involving deficient performance where there is a risk to patient safety if the doctor’s registration is not suspended and where the doctor demonstrates potential for remediation or retraining… …e) No evidence that demonstrates remediation is unlikely to be successful, eg because of previous unsuccessful attempts or a doctor’s unwillingness to engage. f) No evidence of repetition of similar behaviour since incident. g) The tribunal is satisfied the doctor has insight and does not pose a significant risk of repeating behaviour.’

20. The Tribunal considered that Dr Seda’s misconduct involved serious breaches of GMP, but his acts and omissions were on the low/middle part of the spectrum of seriousness. Dr Seda has not demonstrated sufficient insight into the possible consequences of misleading employers or medical colleagues. He appears to lack confidence and good judgement when under pressure. At times, he seems to be focused on his own needs, as opposed to those of patients. An example of this is that he had not completed the Advanced Life Support course when he applied to work as a doctor at Silverstone. Although he recognised that this race course was a prestigious venue, he had not thought through the consequences of seriously injured racing drivers being dealt with by an inexperienced doctor. 21. The Tribunal concluded that Dr Seda is likely to make other mistakes if he does not develop fuller understanding of risks and insight into his own inadequacies. However, he has shown an intention to learn from his errors and has engaged with this Tribunal. References testify to the ‘uncomfortable conversations’ he has had to have to address insight and that this is developing although not complete. For the past 18 months Dr Seda has been working as a General Practitioner in Oman and has a certificate of good standing relating to this work. There has been no evidence of repetition of similar misconduct since the time of the Allegation. 22. The Tribunal also considered a sanction of erasure. The following paragraphs of the SG were potentially relevant:

‘109) Any of the following factors being present may indicate erasure is appropriate (this list is not exhaustive).

a) A particularly serious departure from the principles set out in Good medical practice where the behaviour is fundamentally incompatible



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with being a doctor. b) A deliberate or reckless disregard for the principles set out in Good medical practice and/or patient safety. c) Doing serious harm to others (patients or otherwise), either deliberately or through incompetence and particularly where there is a continuing risk to patients (see further guidance below at paragraphs 129–132 regarding failure to provide an acceptable level of treatment or care)… …h) Dishonesty, especially where persistent and/or covered up (see guidance below at paragraphs 120–128). i) Putting their own interests before those of their patients (see Good medical practice paragraph 1: – ‘Make the care of [your] patients [your] first concern’ and paragraphs 77–80 regarding conflicts of interest). j) Persistent lack of insight into the seriousness of their actions or the consequences.’

23. With regard to the clinical issues and working with colleagues (paragraphs 109(b)(c) and (i) the Tribunal acknowledge that Dr Seda’s care of Patients A and C was seriously below the standard required. However, these were just two patients out of many that he would have seen and treated during his time at King’s Mill Hospital and both occurred during the night shift when clinical supervision was conspicuously lacking. It took into account the medical expert’s remarks during one of the GMC telephone conferences: ‘this doctor has been catapulted into a senior role he was never fit for and stuck on the night shift. His employer never assessed how competent he was and never gave him a proper induction. The Trust failed here in terms of its recruitment.’ The expert went on to say‘the reality was that Dr Seda should have made it clear that he wasn’t up to this’. The Tribunal acknowledged this but took the view that it was not always easy for doctors in this position to be so forthright. In view of the Trust’s undoubted failings, acknowledged in their own internal report, the Tribunal took the view that it would not be proportionate to erase Dr Seda on the basis of his failings, serious though they were. 24. With regard to paragraph 109(h) of the SG the Tribunal took account of the fact that the falsified document contained no incorrect information and did not represent an attempt to exaggerate Dr Seda’s experience. The IOT conditions breach was dishonest but occurred just once and the dishonesty was admitted at an early stage.



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25. The Tribunal has dealt with insight above and considered that Dr Seda has the potential to develop adequate insight. 26. The Tribunal was mindful that the sanction imposed should be the least restrictive option, where sufficient to address the statutory overarching objective and concluded that Dr Seda’s misconduct is not fundamentally incompatible with continued medical registration. The Tribunal therefore determined that a period of suspension would be an appropriate and proportionate sanction which would protect public confidence in the profession and promote and maintain proper standards of conduct and behaviour. 27. In considering the appropriate period of suspension, the Tribunal was aware that the maximum period of suspension is 12 months. It determined that a period of suspension for 12 months was required to give Dr Seda sufficient time to develop his insight and to provide a review Tribunal with evidence of this. It would also be sufficient to mark the seriousness of his misconduct and maintain public confidence in the medical profession. 28. Shortly before the end of the period of suspension, Dr Seda’s case will be reviewed by a Medical Practitioners Tribunal. A letter will be sent to Dr Seda about the arrangements for the review hearing. At the next hearing, the review Tribunal will be assisted by the following:

• A reflective piece detailing the potential consequences of dishonesty in a clinical context;

• The steps he has undertaken to improve his abilities in basic medical care as outlined by this Tribunal in its determination on impairment;

• Any other relevant evidence he wishes to present to assist the Tribunal, for example, evidence of his continuing professional development.

29. The effect of the foregoing direction is that, Dr Seda exercises his right of appeal, his registration will be suspended 28 days from the date on which written notice of this decision is deemed to have been served upon him. A note explaining his right of appeal will be sent to him. Determination on Immediate Order - 12/12/2019 1. Having determined to suspend Dr Seda’s registration the Tribunal has considered, in accordance with Rule 17(2)(o) of the Rules, whether his registration should be subject to an immediate order.



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Submissions 2. On behalf of the GMC, Ms Dudley-Jones submitted that the Tribunal should impose an immediate order of suspension. 3. On behalf of Dr Seda, Mr Jenkins said that he had no objection to an immediate order of suspension being imposed. The Tribunal’s Determination 4. Given its findings the Tribunal was of the view that an immediate order should be imposed both for patient safety and to maintain public confidence in the profession. 5. The Tribunal determined to impose an immediate order of suspension. 6. This means that Dr Seda’s registration will be suspended from today. The substantive direction, as already announced, will take effect 28 days from when written notice of this determination has been served upon Dr Seda, unless an appeal is made in the interim. If an appeal is made, the immediate order will remain in force until the appeal has concluded. 7. The interim order currently imposed on Dr Seda’s registration will be revoked when the immediate order takes effect. 8. That concludes the case. Confirmed Date 12 December 2019 Ms Alice Moller, Legally qualified Chair