THE CHAIRMAN:    Before I open the case formally, Mr Jenkins, presumably I should have confirmation of what I think is obvious that this hearing is to be in public.

MR GLASGOW:  I fear so.

THE CHAIRMAN:  I formally open the case which is a review case of Dr Skinner who is present and is represented by counsel, Mr Jenkins, instructed by RadcliffesLeBrasseur.  Mr Glasgow is counsel instructed by the General Medical Council.  Can you confirm your full name and GMC registration number.

DR SKINNER:  Gordon Robert Bruce Skinner, 0726922. 

THE CHAIRMAN:  Before proceeding can I ask everyone to check that their mobile phones are switched off so we have no interruptions during the course of the hearing.  This is a review hearing and you have attended previously so I think you are familiar with the geography of the room and the procedure that we follow.  At this stage I will ask Mr Glasgow if he will be good enough to open the proceedings.

MR GLASGOW:  I am obliged.  In light of the fact that there are members of the public present, can I begin by outlining the test the Panel needs to apply its mind to today.  I am dealing with the case of Mr Skinner.  The Panel are familiar with it but the test is as follows.  If the Panel are satisfied in all the circumstances that there may be impairment of the practitioner’s fitness to practise which poses a real risk to members of the public, or may adversely affect the public interest or the interests of the practitioner, and after balancing the interests of the practitioner and public, that an interim order is necessary to guard against such a risk, the appropriate interim order should be made. 

As the Panel knows already from its reading of the papers in this matter the restrictions presently imposed on Mr Skinner’s registration arises out of his inappropriate prescribing of thyroid hormones and the potential consequences of that and the failure to notify general practitioners about the treatment he had been providing to individual patients. 

Can I start where matters were left last time.  The Panel will have the breakdown of the various conditions imposed on Mr Skinner’s registration set out in the letter sent to him of 24 March at pages 1049 through to 1052.

I appreciate that I am starting where matters were left last time, but in light of the fact that this is now the third review of Dr Skinner’s case, and given the detailed openings that have been given on previous occasions to the Panel, I do not intend to rehearse the voluminous documentation contained in the bundle.  If at any stage Dr Skinner wishes me to turn to something, or the Panel wishes assistance with any particular document referred to, I am in a position to deal with that.  In light of the fact that this is the third review, I do not propose to rehearse the facts in any detail. 

The Panel will no doubt know that a number of restrictions were applied to Dr Skinner’s registration when the Panel met in January last year.  The Panel will see set out at page 1050 the first five of those conditions.  Can I deal with number 1 first.  The Panel will see from the concluding sentence of that condition:

“Dr Skinner must provide the Panel with anonymised copies of the patients’ referral letter in a paginated and indexed bundle.”

Dealing with condition 2:

“Dr Skinner must provide the Panel with anonymised copies of  the letter sent to patients’ general practitioners and, if different, the referring medical practitioner in a paginated and indexed bundle.”

Condition 3 relating to the contemporaneous log book:

“Dr Skinner must provide the Panel with copies of the logbook with the patients’ name anonymised.  The original logbook should also be provided seven days prior to any review.”

Condition 4 relating to clear, contemporaneous and accurate medical records:

“Dr Skinner must provide the Panel with anonymised copies of the patients’ records and the full details as to his reasons for his care plan in a paginated and indexed bundle.”

The requirement to provide the Panel with fresh references was again to be supplied in a paginated and indexed bundle.  The last two do not relate to any condition of the bundle:

“He shall notify all employers and contractors and all prospective employers and contractors, whether for paid or voluntary employment, for which registration with the GMC is required of the matters under consideration by the GMC.”

Lastly, the requirement to inform in writing the secretariat of the GMC before undertaking any position for which registration is required.

I hope the Panel has received a number of addendums which set out in the first instance, addendum 1, the anonymised copy of the patient logbook.  The original logbook has also been supplied and is a hard log book provided seven days before today’s hearing.

THE CHAIRMAN:  To check that Panel members and everyone has the documentation, we have six addenda and we also have a small bundle of pages which were not paginated in the original bundle and have now been paginated for ease of reference.

MR GLASGOW:  Can I invite the Panel to put the freshly paginated papers to one side.  I do not intend to refer to them in my opening, but if Dr Skinner wishes to make reference to them, he can refer to them in due course.   For the purposes of my opening, can I invite the Panel’s attention to addendum 1.

THE CHAIRMAN:  I think everyone has that.

MR GLASGOW:  As the Panel members will see, each individual page is obviously numbered at the top and is dated on the left‑hand side.  Each patient on each page has been given a patient number.  Provided are the details of the doctor, the contact details and a breakdown of the care plan has been contained within it.  That is an anonymised photocopy of the original log book detailing the patients that have been provided by Dr Skinner.  It is right to say, from recollection of the original log book, that each patient has signed the appropriate entry in respect of them on each and every page.

Thereafter Dr Skinner has provided one lever arch file which contains within it a number of separately tabbed sections which bear, as I now understand it, a correlation to the page numbers and the patient numbers contained within the logbook.  To explain how that now works, can I invite the Panel’s attention to addendum 3, page 3.  The Panel will see that the contents of the original logbook as photocopied in addendum 1 have been provided by way of a breakdown.  One has the individual  page numbers running 1 through to 23 and the corresponding patient numbers that appear.

THE CHAIRMAN:  Is that addendum 3 you are referring to?

MR GLASGOW:  I am sorry, it is addendum 2.

MR GLASGOW:  I will start again  – addendum 2, page 3.  Two columns on page 3,  the first on the left‑hand side providing the relevant page number from the logbook which has been copied and on the right-hand side the corresponding patient numbers which appear on the corresponding pages within the log book.  If one turns the page on to page 4, the next breakdown sets out as follows.  Within each of the separately bound, grey, tabbed parts of the file – and if I am describing this wrong, I will be corrected but I do it from memory – within each separately bound, grey, tabbed section, the numbers have been given both patient numbers and Roman numerals.  They are individually marked accordingly, so that when one looks at page 4, one can see that on page 1 the section that refers to log book, page 1, which contains within it Patients 1 to 4; for Patients 2 and 3 there are new patient referral letters which appear within the Patient 2 section as the third patient, and within the Patient 3 section at the second page.  I think hope that makes sense as I set it out. 

The system continues again with a further breakdown in relation to increase and decrease in dosage on page 6 of addendum 2.  Taking the first one by way of example.  For patient 9, who appears on page 2 of the original logbook, within Patient 9’s separately paginated section on Roman numeral II, which is denoted with a yellow post‑it note, there is the increase or decrease in the respective dosage given to that particular patient. 

The GMC have done their best to work through the system that has been employed by Dr Skinner to identify the relevant page numbers from the log book, relevant patient numbers and to ensure where possible that that which should be in the supplied documentation is indeed within it.  It would appear from our best efforts that what should be there is there.

The difficulty which the GMC faced in performing that exercise was that due to the numbering system employed by Dr Skinner and due to the breakdown he had done of the documents himself by using post‑it notes and separate tabbing sections using post‑it notes to wrap bundles of pages together, it proved almost impossible to photocopy the bundle for provision to the Panel members because in putting it through the photocopier you effectively removed the system that had been used to demark any separate page and any separate patients. 

Can I make this submission in respect of the conditions which have been imposed thus far.  Given our best efforts, the GMC recognises that Dr Skinner has provided within seven days of today’s hearing a paginated and indexed bundle.  It does contain within it, as required by conditions 1 through to 5, anonymised copies of referral letters, anonymised copies of letters sent to patients’ general practitioners, details appropriately anonymised of the logbook, details of appropriate anonymised accurate  medical records and, furthermore, fresh references where appropriate.  The problem we have had is simply working through each and every entry to make sure that everything for every patient is there.  The way the bundle has been set out has made that task extremely difficult for us and it may be that the Panel experienced the same problem for themselves in trying to wade through the file. 

The upshot of the submissions I am to make in due course will be that the conditions presently imposed are appropriate to be maintained and we would invite that in due course.  The only change that we would invite to that is a requirement to particularise the exact form that any further submitted bundle should have in order to facilitate the comprehension of what is contained within it and to make ease of photocopying for provision to all parties that much greater.

Can I turn to deal briefly with the substantive allegations faced by Dr Skinner.  Perhaps best they are contained on page 30 of the bundle in one of the first letters that came through to the GMC in July 2004.   As I said before I do not intend to go through the individual live cases or the multiplicity of complaints that have been joined to those live cases.  If there are specific questions, I can help upon them. 

The letter at page 30 sets out in general terms the allegations faced by Dr Skinner and the concerns the GMC have.  Accordingly the Panel will know from their reading that it begins as follows:

“I understand you may already have received complaints about the inappropriate prescribing of thyroid hormones by Dr Skinner.  This has been of concern to practising endocrinologists in the United Kingdom for some time.  I am reminded of the failure of the General Medical Council to have taken action in the past by having seen two patients who have been inadequately treated with thyroid hormones in recent months.”

Those two particular individual cases of Miss V and G are then set out.

The letter continues in the penultimate paragraph:

“Dr Skinner frequently prescribes thyroid hormone therapy to patients with no evidence of thyroid disease and adjusts the dose often without any biochemical testing.”

By way of conclusion, in the last sentence of the final paragraph:

“My concern is that Dr Skinner’s treatment is inappropriate, dangerous and based on no formal training in endocrinology whatever.”

There then follows the details of the various complaints and live cases.  In fairness to Dr Skinner thereafter in the bundle there are a great number of testimonials that speak in his favour.  I do not propose to draw the Panel’s attention to any of those particular aspects.  If required to I know my learned friend is in a position to take the Panel through them. 

The Panel know that the case first came before the Interim Orders Panel in 2005.  On that occasion it was determined, having given full consideration to the two live cases and the conjoined complaints faced by Dr Skinner, that it was necessary for the protection of the members of the public and in the public interest to make an order imposing conditions on his registration for a period of 18 months. 

On 2 December 2005 the case was reviewed by the Interim Orders Panel.  The same conditions were imposed on the basis that it was necessary once again for the protection of the public, in the public interest and in the interests of Dr Skinner himself that conditions should continue upon his registration. 

The last appearance before the IOP Review Panel was in March of this year and I have already taken this Panel to the relevant section of the bundle which gave the conditions.  Can I take the Panel back to it to simply look at the basis for the determination.  I know the Panel is already familiar with it and have had an opportunity as have all concerned to read with care the submissions made on that occasion and the reasoning employed by the Panel in imposing conditions.  I should draw this Panel’s attention to the importance raised on the last occasion that the provision of documentation by Dr Skinner was essential and that it should be clear, paginated, indexed and provided in advance of the hearing.

This Panel knows that careful consideration was given, as is always done, by the Interim Orders Panel on the last occasion.  The Panel considered whether or not it was necessary to impose an interim order of suspension.  But the Panel on the last occasion concluded that that was not appropriate given the fact that it would be a disproportionate measure given the allegations faced.  The Panel considered it was appropriate to give Dr Skinner the opportunity of demonstrating compliance with the Panel’s conditions and cooperation with the GMC. 

Notwithstanding what I have said about the concerns we had in grappling with the bundle, we do recognise that what should be in there appears to be in there and I am not in a position to identify any particular failings about the contents of the bundle, save to say it was difficult to work round. 

As this Panel knows, the seven conditions that were imposed on that occasion relate principally to the provision of an indexed and paginated bundle, and thereafter to the treatment that Dr Skinner is entitled to give to any patients under his care and the requirement that any treatment he does dispense should be with the approval of any general practitioner who has governance of a patient’s care.  It is respectfully submitted on behalf of the GMC there has been no change in the circumstances since the last review in March and that accordingly this Panel can be satisfied that those conditions as imposed on the last occasion, should be maintained. 

It is respectfully submitted that, having an eye to section 41A of the Medical Act 1983 (as amended), it is necessary for the protection of the public, in the public interest and indeed in Dr Skinner’s own interests that those conditions should remain on his registration.

The only variation that we would seek is a requirement that the documentation provided by Dr Skinner in support of compliance with conditions 1 through to 5, be contained within a file that is separately tabbed to demark each section and is numbered with a running continuous series of numbers to enable anyone looking through it to readily find a page they want to refer to and to identify the sections within it and what is contained within each section.   Additionally, we would invite the provision of a more detailed index to provide greater accessibility to the material provided. 

Presently there is a requirement that the documentation be provided seven days prior to any hearing but, given the importance of considering the documentation and making sure copies are available, we respectfully submit that should be amended to 14 days to enable the GMC to provide numbers of copies of any documents to the Panel for any hearing.  Save for that amendment, to make sure the bundle is more clearly indexed and more accessible to those who have to read it and save requiring its provision 14 days prior to the hearing, it is respectfully submitted that the conditions as presently imposed are appropriate to be maintained. 

Unless I can assist any further with any particular aspects of  the allegations faced by Dr Skinner, those are my submissions on behalf of the GMC.

THE CHAIRMAN:  Thank you very much.  Mrs Kapila is a lay member of the Panel and wishes to ask a question.

MRS KAPILA:  I just wanted to know if you have any indication of the date of the fitness to practise hearing?

MR GLASGOW:  There is no exact date fixed yet, but I understand, following discussions with my learned friend, that it is likely to take place in January.  I know I will be corrected if I had made a mistake.  I believe January is the presently envisaged date, but no final date has been set as yet.

THE CHAIRMAN:  There being no further questions, can I turn to Mr Jenkins.

MR JENKINS:  Sir, my learned friend has been commendably brief.  There is not much between us and in view of the pressing national emergency elsewhere I can, I hope, be equally brief.  We refute the charges completely and we look forward to the fitness to practise hearing in January, we hope.  In the meantime, the conditions have been renewed now on two occasions and I take no issue with them today.

So far as the suggestion for a more readily intelligible bundle are concerned, I would agree that it would be easier and therefore more practicable if we had a running index and continuous pagination, but I suggest we do not dabble any more with tabs.  I think it is tabs that have caused the problem for photocopying and delineation today.  If we have a detailed index at the front and continuous pagination throughout, that will make photocopying very much easier and save everybody expense and time.  Fourteen days does not present us with any difficulty and I take no objection to that.

I think that deals with my learned friend’s points.

THE CHAIRMAN:  Thank you very much.  I will check if there are any questions from members of the Panel.  In the absence of any further questions, I will check with the legal assessor as to what advice he wants to give us.

THE LEGAL ASSESSOR:  The test, as has been indicated, perhaps I ought to repeat so there is no difficulty on it.  The Panel should be satisfied in all the circumstances that there may be impairment of the practitioner’s fitness to practise which poses a real risk to members of the public or may adversely affect the public interest or the interests of the practitioner and, after balancing the interests of the practitioner and the interests of public that an interim order is necessary to guard against such risk, then an appropriate interim order should be made.  You have heard the submissions of both counsel and you take that into account in making your determination.  I do not think there is any further advice I need to give to the Panel.  Do both sides agree with that?  (Concurrence)  Thank you.

THE CHAIRMAN:  We will go into private session. 

THE PARTIES WITHDREW, BY DIRECTION OF THE CHARGE

AND THE PANEL DELIBERATED IN PRIVATE

THE PARTIES HAVING BEEN READMITTED

D E T E R M I N A T I O N

THE CHAIRMAN:  Dr Skinner: When the Interim Orders Panel considered your case on 29 June 2005 it determined that it was necessary for the protection of members of the public and in the public interest to make an order imposing conditions on your registration for a period of 18 months. The Panel reviewed and maintained the order restricting your registration on 2 December 2005 and 21 March 2006.

The Panel has carefully considered the case today, in doing so it has considered all the information before it and the submissions made by Mr Glasgow, on behalf of the GMC, and by Mr Jenkins, on your behalf, including the submission that you consent to the order remaining in place subject to minor modifications. The Panel has taken account of the advice of the Legal Assessor and the transcripts of the previous hearings.

The Panel notes that it is unable to resolve any conflict of evidence or to determine fact.  The Panel has also reminded itself of the test it must apply and of its nature, function and powers, as well as the GMC’s guidance Good Medical Practice and the Duties of a Doctor contained therein.  The Panel has also had regard to the GMC’s guidance Imposing Interim Orders.  Patients’ relationships with their general practitioners are ones founded on trust and it is imperative that this trust be maintained.

Having considered all the information, the Panel has determined that it remains necessary for your registration to remain subject to an interim order. The Panel has determined that this is necessary for the protection of members of the public, in the public interest and in your own interests.

In light of the submissions made, the Panel has determined that it is necessary to vary the conditions imposed on your registration.  Accordingly, in complying with the conditions below, each condition must be supported by a separate bundle.  However, the pagination should be continuous throughout and a comprehensive and detailed index be provided to cross reference each bundle with a supplementary index listing patients by initials and NHS number and recording the relevant pagination in each bundle against patient:

1.  You shall only accept new patients for endocrine treatment if they have been referred to you by a fully registered medical practitioner.  At least 21 days prior to any review of the order, you must provide the Panel with anonymised copies of the patients’ referral letter in a separate, paginated and indexed bundle.  Patients should only be identified by their initials and NHS number.

2.  Prior to initiating any or varying any treatment regime you shall ensure that you have communicated your diagnosis and suggested care plan to the patient’s general practitioner and, if different, the referring medical practitioner.  At least 21 days prior to any review of the order, you must provide the Panel with copies of the letter sent to the patients’ general practitioners and, if different, the referring medical practitioner in a separate paginated and indexed bundle.  The copies should identify the patients only by their initials and NHS number.

3.  You shall keep a contemporaneous logbook of all patients seen in relation to work carried out as a registered medical practitioner.  This book must identify the patient only by their initials and NHS number and the name and contact number of the referring general practitioner.  The logbook should be initialled and dated by the patient.  The logbook must also indicate that this is a new patient, the reason for consultation and, if applicable, the reason for any prescribing outside of recommended guidelines.  At least 21 days prior to any review of the order, you must provide the Panel with copies of the logbook.  The original logbook should also be provided 21 days prior to any review.

4.  You shall keep, clear, contemporaneous and accurate medical records in addition to your logbook, and ensure that your reasons for prescribing outside of recommended guidelines are recorded and clinically justified having had regard to such guidelines.  At least 21 days prior to any review of the order, you must provide the Panel with typed and anonymised copies of the patients’ records and the full details as to your reasons for your care plan in a separate, paginated and indexed bundle.  Patients should be identified by their initials and NHS number.

5.    You shall notify all employers and all contractors and all prospective employers and contractors, whether for paid or voluntary employment for which registration with the GMC is required, of the matters under consideration by the GMC and of these conditions.  In the case of prospective employers or contractors, this notification must be given at the time of application.

6.  You shall inform, in writing, the IOP Secretariat of the GMC before undertaking any position for which registration is required.

In reaching its decision to restrict your registration the Panel has determined that there is information before it today which suggests that your fitness to practise may be impaired on the basis of the allegations made against you. These include, irregularities surrounding his prescribing practice which may have potentially harmful consequences and a failure to notify some of your patients’ general practitioners about their treatment.

In all the circumstances, the Panel considers that if your registration was to remain unrestricted you may pose a risk to patients and the confidence that the public are entitled to place in the medical profession and its practitioners would be undermined.

The Panel has noted the circumstances surrounding the complaints made against you by patients and other professional colleagues.  The Panel has concluded that these are serious allegations which indicate that your professional practice and conduct may have fallen short of the standard expected of a medical practitioner.  The Panel is therefore satisfied that in all the circumstances it is necessary to impose an order restricting your registration.

The Panel would remind you that you must at all times comply fully with the conditions imposed on your registration.  It notes that this may on occasion put you in a situation to which you are not accustomed.  However, a failure to comply with either the requirements of these conditions and/or the spirit of these conditions may indicate a serious lack of judgment on your part and a repeating pattern which could have grave consequences both for patients and your registration.

The Panel has taken into account the issue of proportionality.  It has balanced the need to protect members of the public, the public interest and your own interests against the consequences for you of the restriction of you registration.  Whilst it notes that its order has restricted your ability to practise medicine, the Panel considered the matters before it are of such a serious nature that these conditions are the minimum required to protect adequately members of the public and provide sufficient safeguards both for the public interest and, owing to a potential lack of insight and judgment, your own interests. 

The Panel has determined that the circumstances surrounding this case may have grave consequences, and in the light of the information provided has determined that it would be appropriate to consider this matter again at a further meeting of the Panel to be held within three months.  The Panel reminds you that in complying with the conditions imposed, you must always consider the issue of patient confidentiality.

Notification of this decision will be served upon you in accordance with the Medical Act 1983, as amended.

(The hearing concluded)