PUBLIC RECORD. Record of Determinations Medical Practitioners Tribunal

Transcription

1 PUBLIC RECORD Dates: 02/10/ /10/2017 Medical Practitioner s name: Dr Abayomi Lukman SANUSI GMC reference number: Primary medical qualification: Type of case New - Misconduct Tip Doktoru 2003 Uludag Universitesi Outcome on impairment Impaired Summary of outcome Erasure Immediate order imposed Tribunal: Legally Qualified Chair Medical Tribunal Members: Mr Tim Bradbury Dr Keith Dunnett Dr Candida Borsada Tribunal Clerks: Ms Jennifer Hatch (02/10/ /10/2017 and 17/10/ /10/2017) Ms Jean Gleeson (11/10/ /10/2017) Attendance and Representation: Medical Practitioner: Medical Practitioner s Representative: GMC Representative: Not present and not represented N/A Miss Rosalind Emsley-Smith, Counsel Attendance of Press / Public The hearing was all heard in public. 1

2 Determination on Facts - 13/10/2017 Background 1. Dr Sanusi qualified as a medical practitioner in 2003 in Turkey. At the time of the events Dr Sanusi was practising as an on-call Surgical Specialist Registrar in the Accident and Emergency Department at The Friarage Hospital in Northallerton, which is part of South Tees NHS Foundation Trust (the South Tees Trust). He had been working there since 25 October The allegation that has led to Dr Sanusi s hearing relates to concerns regarding the standard of care delivered by Dr Sanusi to three patients Patient A, Patient C and Patient F at The Friarage Hospital. 3. It is alleged that Dr Sanusi failed to provide good clinical care to Patient A between 26 and 27 October 2012 in terms of his assessment, management and record keeping. 4. It is alleged that Dr Sanusi failed to provide good clinical care to Patient C in that he did not assess Patient C when requested to do so by colleagues, and did not communicate appropriately with those colleagues. 5. Further it is alleged that, between 25 and 26 December 2014, Dr Sanusi failed to provide good clinical care to Patient F in terms of his assessment and management. 6. Finally, it is alleged that Dr Sanusi engaged in misleading and dishonest conduct in relation to an application for employment with the Rotherham NHS Foundation Trust ( the Rotherham Trust ) and during an interview with that Trust. The Outcome of Application(s) Made during the Hearing 7. The Tribunal granted the GMC s application, made pursuant to Rule 31 of the General Medical Council (Fitness to Practise Rules) 2004 as amended ( the Rules ), to proceed in the absence of Dr Sanusi. The Tribunal s full decision on the application is included at Annex A. Application to Amend the Allegation 8. At the outset of the hearing, Miss Emsley-Smith made an application to amend the Allegation under Rule 17(6) of the Rules by changing the time in subparagraph 1.i.vii from 19:00 to 21:00 as follows: 1. Between October 2012, you failed to provide good clinical care to Patient A in that you did not: 2

3 i. maintain adequate records of the treatment provided to Patient A in that you did not record: vii. any re-examination of Patient A at approximately 19:00 21:00 on 26 October 2012; 9. Miss Emsley-Smith submitted that this was likely a typing error and the amendment would reflect the facts of the case. 10. The Tribunal was of the view that the proposed amendment reflected the evidence, did not alter the substance of the allegation in the paragraph and could be made without injustice. It therefore acceded to Miss Emsley-Smith s application and determined to amend the Allegation as above. Application to Hear Evidence via Video Link 11. Miss Emsley-Smith made an application under Rule 34(13) of the Rules for Dr D to give oral evidence via video link. She made this application on the basis that Dr D would have difficulties travelling to Manchester to attend in person as he is one of two GP partners at a surgery with a very busy patient list. She submitted that the Tribunal would nonetheless be able to assess his demeanour if he gave evidence via video link, and that it would be in the interests of justice to allow him to do so. 12. The Tribunal was of the view that Dr D s evidence may assist it in reaching a determination on the facts of this case. It concluded that it would be in the interests of justice to allow him to give oral evidence via video link, there could be no disadvantage to Dr Sanusi in the evidence being admitted via this means and so granted Miss Emsley-Smith s application. The Allegation and the Doctor s Response 13. The Allegation made against Dr Sanusi is as follows: That being registered under the Medical Act 1983 (as amended): Patient A 1. Between October 2012, you failed to provide good clinical care to Patient A in that you did not: 3

4 a. provide appropriate advice to Dr B in that you advised prescribing Furosemide, which was contra-indicated; To be determined b. arrange for 30 minute to 1 hour observations of Patient A in HDU/ITU; To be determined c. consider and/or discuss with colleagues the need for a central venous pressure line; To be determined d. arrange for estimates of Patient A s arterial blood gases to be taken; To be determined e. institute high flow oxygen at approximately 19:00 on 26 October 2012; To be determined f. urgently assess Patient A when contacted by Dr B at approximately 05:00 on 27 October 2012; To be determined g. arrange for the ITU Registrar to assess Patient A with a view to admission to ITU, following your telephone call with Dr B; To be determined h. inform the on-call Consultant Surgeon of Patient A s condition and/or obtain their advice; To be determined i. maintain adequate records of the treatment provided to Patient A in that you did not record: i. any differential diagnosis; To be determined ii. details of the analgesia required; To be determined iii. an instruction for Patient A s urine output to be monitored on an hourly basis; To be determined iv. details of the intravenous fluid regimen for resuscitation; To be determined v. the results of Patient A s CT scan; To be determined vi. any conversation(s) you had regarding Patient A s CT results with: 4

5 Patient C 1. Dr B; To be determined 2. the Radiologist; To be determined 3. Patient A and/or their spouse; To be determined vii. any re-examination of Patient A at approximately 19:00 21:00 on 26 October 2012; Amended under Rule 17(6). To be determined viii. details of Patient A s resuscitation management plan, including the: 1. quality of infused fluid; To be determined 2. rate of infused fluid; To be determined 3. parameters of when you were to be recalled; To be determined ix. the deterioration in Patient A s condition at approximately 06:00 on 27 October To be determined 2. On 17 January 2014, you failed to provide good clinical care to Patient C in that you did not: a. review Patient C when requested to do so by: i. Dr D; To be determined ii. Nurse Practitioner E; To be determined b. communicate appropriately with Dr D in that you: i. were abrupt; To be determined ii. slammed the phone down on him; To be determined 5

6 Patient F c. communicate appropriately with Nurse Practitioner E in that you: i. were aggressive; To be determined ii. hung up on her. To be determined 3. Between December 2014, you failed to provide good clinical care to Patient F in that you did not: a. personally assess Patient F upon their admission to the Accident & Emergency department; To be determined b. organise a management plan with appropriate priority given to: i. investigation with a CT scan; To be determined ii. Medical Registrar opinion; To be determined iii. admission of Patient F under either Physicians or Surgeons; To be determined iv. direct discussion with Dr G, with regards to Patient F s treatment plan; To be determined c. directly assess Patient F following a conversation with Dr G and Dr H at approximately 02:00 on 26 December 2014; To be determined d. arrange for an urgent out-of-hours CT scan of Patient F s chest, abdomen and pelvis, following the conversation with Dr G and Dr H referred to at paragraph 3(c); To be determined e. urgently attend to assess Patient F, following a deterioration in their clinical state, when requested to do so by: i. Dr G; To be determined ii. Nurse Practitioner I; To be determined 6

7 f. provide adequate clinical support to Dr G; To be determined g. communicate appropriately with Nurse Practitioner I in that you were patronising towards her. To be determined Rotherham NHS Foundation Trust 4. On 1 July 2015, you submitted an application form to Rotherham NHS Foundation Trust ( the Rotherham Trust ) for the position of Specialty Doctor in General Surgery in which you failed to disclose that you: a. had a live final written warning from your employment with South Tees Hospitals NHS Foundation Trust ( the South Tees Trust ); To be determined b. were dismissed from your employment with the South Tees Trust. To be determined 5. On 30 July 2015, you had an interview with the Rotherham Trust and you: a. failed to disclose that you: i. had a live final written warning from your employment with the South Tees Trust; To be determined ii. were dismissed from your employment with the South Tees Trust; To be determined b. stated that the South Tees Trust investigation was mainly down to personality clashes with colleagues, or words to that effect; To be determined c. failed to disclose that the South Tees Trust investigation had concluded; To be determined d. stated that you had resigned due to an intolerable working situation with a colleague, or words to that effect; To be determined e. gave the impression that the GMC investigation was a formality, or words to that effect. To be determined 7

8 6. The statements as described in paragraphs 5(b)-5(e) were: a. untrue; To be determined b. statements you knew to be untrue. To be determined 7. Your conduct, as described at paragraphs 4 and 5, was: a. misleading; To be determined b. dishonest. To be determined And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct. The Facts to be Determined 14. The Tribunal is required to determine whether Dr Sanusi failed to provide good clinical care in relation to Patient A, Patient C and Patient F, and whether his conduct was misleading and dishonest in relation to his application form to, and interview with, the Rotherham Trust. Factual Witness Evidence 15. The Tribunal received evidence on behalf of the GMC from the following witnesses: Mrs J, Nurse at The Friarage Hospital, in person; Miss K, Nurse Practitioner at The Friarage Hospital, in person; Ms M, Nurse Practitioner at The Friarage Hospital, in person; Dr L, Consultant General and Colorectal Surgeon at The Friarage Hospital, in person; Nurse Practitioner E (Nurse Practitioner E), Nurse Practitioner and Site Manager at The Friarage Hospital, in person; Dr D (Dr D), Medical Registrar at The Friarage Hospital, by video link; Dr G (Dr G), FY1 Doctor at The Friarage Hospital, in person; Mr N, Staff Nurse at The Friarage Hospital, in person; Nurse Practitioner I (Nurse Practitioner I), Nurse Practitioner at The Friarage Hospital, in person; Dr B (Dr B), FY2 Doctor at The Friarage Hospital, in person; Dr O, Consultant Surgeon in General Surgery at the Rotherham Trust, in person. 8

9 16. The above witnesses also provided witness statements. 17. The Tribunal also 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: Ms P, Health Care Assistant at The Friarage Hospital; Ms Q, Nurse at The Friarage Hospital; Dr H (Dr H), Medical Registrar at The Friarage Hospital; Ms R, HR Medical Staffing and Recruitment Advisor for The Rotherham Trust; Ms S, Workforce Coordinator for the Rotherham Trust. 18. Although not present or represented at the hearing, Dr Sanusi provided his own witness statement dated 15 September Expert Witness Evidence 19. The Tribunal also received evidence from Mr T, called as an expert witness on behalf of the GMC. He gave oral evidence to the Tribunal in person and also provided an expert report dated 14 January 2016, and supplemental reports dated 2 June 2017 and 8 August Mr T was appointed as a Consultant General Surgeon with a special interest in upper gastro-intestinal and hepato-biliary surgery at North Tees District General Hospital in 1977, having trained at Guy s, The Royal London, St Thomas s and St Mark s Hospitals in London. 21. Mr T assisted the Tribunal in understanding the professional standards to be expected of a competent Surgical Specialist Registrar. Documentary Evidence 22. In addition to the witness statements mentioned above, the Tribunal had regard to the documentary evidence provided by the parties. This evidence included, but was not limited to: Correspondence and documents relating to investigations at the South Tees Trust including records of interviews with Dr Sanusi during those investigations; Relevant medical records; Correspondence and documents relating to issues at The Rotherham Trust; Dr Sanusi s Rule 7 submissions together with testimonials; 9

10 Reports from Dr Sanusi s Consultant supervisors at Doncaster and Bassetlaw Hospitals NHS Trust. The Tribunal s Approach 23. 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 Sanusi 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. The seriousness of the Allegation is but one factor to be taken into account in determining the likelihood of it having occurred but does not alter the standard of proof. 24. The Tribunal also reminded itself that many of the allegations in relation to paragraphs 1,2,3 and 4 allege a failure to act by Dr Sanusi and that before any such allegation could be found proved by the Tribunal would first have to be satisfied that there was a duty to act. 25. The Tribunal also had regard to the fact that, as it had been told by Ms Emsley- Smith, Dr Sanusi is of previous good character and this was relevant to both his credibility (although he has not given evidence on oath) and his propensity towards misconduct. The Tribunal s Analysis of the Evidence and Findings 26. The Tribunal has considered each paragraph of the Allegation separately and has evaluated the evidence in order to make its findings on the facts. Patient A 27. Patient A was 67 years old and was admitted for elective repair of an incisional hernia, which was carried out laparoscopically on 25 October On the evening of 26 October 2012, Dr Sanusi reviewed Patient A, who had severe abdominal pain, tachycardia, hypotension and a low oxygen saturation with abdominal distension on examination. 28. Patient A had been handed over to Dr B, a Foundation Year 2 doctor, by the day staff at the hospital. Dr Sanusi was the senior surgical registrar on call and the Tribunal found he had a duty to provide good clinical care to the patient. 1. Between October 2012, you failed to provide good clinical care to Patient A in that you did not: a. provide appropriate advice to Dr B in that you advised prescribing Furosemide, which was contra-indicated; 10

11 29. The evidence of Dr B was clear that Dr Sanusi had given a verbal instruction to prescribe Furosemide to Patient A. Further in his disciplinary investigation interview which was held on Tuesday 6 November 2012, Dr Sanusi confirmed that he had started a small dose of furosemide. The evidence of Mr T was that it would be wrong, dangerous and a basic error to provide this drug in respect of a patient with septic shock who had developed hypotension. He stated that intravenous Furosemide, a diuretic the purpose of which is to increase urine output, would potentially further drop the blood pressure, increasing the risk of multi-organ failure. The Tribunal found that Dr Sanusi failed to provide good clinical care to Patient A as the advice he provided regarding the prescribing of furosemide was inappropriate and had the potential to cause the patient harm. It has therefore found this sub paragraph proved. b. arrange for 30 minute to 1 hour observations of Patient A in HDU/ITU; 30. It is clear that Patient A was very ill and in Mr T s opinion she should have been transferred to HDU/ITU following Dr Sanusi s examination at 19:37 based upon the clinical signs at that time and certainly after 21:00 following the CT scan and a further deterioration in Patient A s condition. The Tribunal accepted that at the very least a transfer to HDU/ITU should have been arranged after the CT scan and further deterioration of Patient A. Dr Sanusi did not refer the patient to the HDU or the ITU at any time. However, although the Tribunal concluded that Dr Sanusi should have arranged a transfer to HDU/ITU, once admitted there any necessary arrangements regarding observations would no longer have been his responsibility, rather it would have been the responsibility of the HDU/ITU team. The Tribunal therefore found this sub paragraph not proved. c. consider and/or discuss with colleagues the need for a central venous pressure line; 31. It is clear from the medical notes made by Dr B that at 06:00 on the morning of 27 October 2012 there had been a discussion about the need for a central venous pressure line ( CVP line ) with Dr Sanusi as it is recorded: Advised no need for a central line/anaesthetic R/V at present 32. The Tribunal noted that it was the evidence of Mr T that a CVP line should have been considered and inserted at a much earlier stage. However, the allegation is not that Dr Sanusi failed to direct the insertion of a CVP line but that he failed to consider or discuss the need for a CVP line. It is evident that Dr Sanusi did consider and discuss the need for a CVP line albeit he came to the wrong conclusion. Therefore the Tribunal has found this sub paragraph not proved. 11

12 d. arrange for estimates of Patient A s arterial blood gases to be taken; 33. During the relevant time Dr Sanusi did not arrange for estimates of the patient s blood gases to be taken. It was the evidence of Mr T that he should have done so as poor oxygenation can cause tissue damage. It is clear from the patient s medical records that at 19:37 her level of oxygenation was 93% on 2 litres of oxygen. It was the opinion of Mr T that a level of oxygenation below 96/97% is a cause for concern and requires action. Despite the fact that the oxygen provided to the patient was subsequently increased to 4 litres the patient s oxygen saturation level fell further to 87%. The Tribunal heard evidence from Dr B that he had made a number of calls to Dr Sanusi during the night. In the nursing notes recorded at 05:00 on 27 October 2012 it is recorded that the patients oxygen level was 90% on 3 litres and that the registrar has been informed but does not wish to attend. 34. Dr B gave evidence that during the course of the night he made a number of calls to Dr Sanusi regarding Patient A. Contemporaneous notes of these calls were not made, however Dr B acknowledged that his note at 06:00 may have been an amalgamation of the conversations he had had with Dr Sanusi and confirmed that he had discussed with Dr Sanusi the patient s pyrexia, deteriorating blood pressure and urine output. Further, in the nursing notes it was recorded at 05:00 that the patient s Early Warning Score ( EWS ) was 9, the most critical score that can be reached. In the circumstances the Tribunal concluded that Dr Sanusi had been kept informed as to the patient s deteriorating condition and for the reasons stated by Mr T, Dr Sanusi should have arranged for estimates of blood gases to be taken. By not doing so he failed to provide good clinical care to Patient A and the Tribunal has found this sub paragraph of the Allegation proved. e. institute high flow oxygen at approximately 19:00 on 26 October 2012; 35. At 19:30 on 26 October 2012 it is recorded in the nursing notes of Patient A that the oxygen level was increased from 2 litres to 4 litres on the direction of Dr Sanusi. The Tribunal received no evidence from the expert witness as to what constitutes high flow oxygen and accordingly was not satisfied that this sub paragraph was proved. f. urgently assess Patient A when contacted by Dr B at approximately 05:00 on 27 October 2012; 36. The Tribunal noted Dr Sanusi s response in his Rule 7 letter that he had not been made aware of Patient A s deteriorating condition. The Tribunal does not accept this assertion; it has accepted the evidence of Dr B that he had spoken to him on a number of occasions during the night in question. Further the Tribunal had regard to the nursing note made at 05:00 which recorded that despite the patient s 12

13 reported deteriorating condition registrar has been informed but does not wish to attend. 37. The Tribunal also had regard to the evidence of Mr T that the decision to review the patient should not in any case have depended solely on what Dr B had said to him. Dr Sanusi should have recognised by the information being given to him regarding the patient s clinical observations that she was seriously ill and even if Dr B had indicated that he did not require Dr Sanusi s support he should have assessed this very ill patient in any event. Mr T said that it was incumbent upon Dr Sanusi to provide support to junior doctors in the case of such a seriously ill patient and in no circumstances would it be acceptable for a registrar not to attend when a junior doctor has specifically had asked him to do so. The Tribunal also accepted that Dr B was evidently worried by the patient s condition and he felt unsupported hence his calls to Dr Sanusi during the night. The Tribunal concluded that even if Dr Sanusi did not appreciate this at the time he should have done. The Tribunal has therefore found this sub paragraph proved. g. arrange for the ITU Registrar to assess Patient A with a view to admission to ITU, following your telephone call with Dr B; 38. The evidence of Mr T was that an ITU Registrar should have been asked to assess to Patient A much earlier. The patient had an elevated heart rate, her blood pressure and urine output was reduced and she had spiked temperatures at various points during the night, features which indicated the patient was in shock and at risk of organ failure. It is recorded in the medical notes that Dr B was advised by Dr Sanusi that there was no need for a central line/anaesthetic R/V at present and there is no indication that the possibility of admission to HDU/ITU was ever considered by Dr Sanusi, let alone arranged despite the fact that the patient s condition, as the Tribunal has found, called for it at that time. The Tribunal has therefore found this sub paragraph proved. h. inform the on-call Consultant Surgeon of Patient A s condition and/or obtain their advice; 39. It was the evidence of Mr T that it would be obligatory for Dr Sanusi to do this. The Tribunal noted Dr Sanusi s Rule 7 response in which he gave the reason for not having done so as being that he felt intimidated by the on call Consultant Surgeon Dr L. However, the Tribunal accepted the opinion of Mr T that Dr Sanusi s primary duty should have been the care of his patient. Therefore Dr Sanusi should have overcome any issues or anxieties he had with his seniors particularly given the clinical urgency of the situation. The Tribunal has therefore found this sub paragraph proved. i. maintain adequate records of the treatment provided to Patient A in that you did not record: 13

14 i. any differential diagnosis; 40. The Tribunal had regard to the medical notes of Patient A in which it is recorded at 19:37: URGENT CT SCAN (? INTERNAL HERNIATION MESH, BOWEL, ANT ABDO [Anterior Abdomen] WALL SUTURING) Whilst the Tribunal noted the evidence of Mr T that this was an inadequate differential diagnosis, the Tribunal concluded that it was nonetheless a differential diagnosis and accordingly has found this sub paragraph not proved. ii. details of the analgesia required; 41. Patient A was in severe pain and in need of pain relief. In her drug chart she was written up for a variety of analgesics including opiates, however no details were recorded in her medical notes as to the type, frequency or amount to be provided. In her evidence Mrs J stated that Dr Sanusi said to give the patient lots of analgesia. It was the opinion of Mr T that there should have been details of the required analgesia within the medical notes so as to provide clarity to the junior doctors and nursing staff and to not do so was very concerning. The Tribunal has found this sub paragraph proved. iii. an instruction for Patient A s urine output to be monitored on an hourly basis; 42. The Tribunal noted that it is correct that there was no instruction recorded that Patient A s urine output was to be monitored and recorded on an hourly basis, however, in fact urine output was being recorded by the nurses on an approximately half hourly basis in the EWS chart. The nursing staff were plainly alive to the need to monitor urine output and the Tribunal was not satisfied that Dr Sanusi was necessarily under a duty to record an instruction to do something that was already being done. In the circumstances of this case the Tribunal finds this sub paragraph not proved. iv. details of the intravenous fluid regimen for resuscitation; 43. The Tribunal had regard to Dr Sanusi s Rule 7 letter in which he outlines that it is normal to do this verbally and by recording on the fluid chart. The Tribunal had regard to the infusions chart and it determined that the details of the intravenous fluid regime for resuscitation were not recorded in this chart or in the medical notes. Given the urgent need for Patient A to undergo fluid resuscitation the Tribunal was 14

15 of the view that Dr Sanusi did not provide good clinical care to Patient A by failing to record this important detail and found this paragraph proved. v. the results of Patient A s CT scan; 44. Dr Sanusi has accepted in his statement and Rule 7 response that he was made aware of the results of the CT scan and found them reassuring. It is clear from the patient management plan which he recorded at 19:37 that the management plan was dependent on the outcome of the CT scan and therefore the recording of the results was of the utmost importance and should have been at the forefront of Dr Sanusi s mind yet at no time did Dr Sanusi make a record of the CT results. The only record of the results of the scan was by Dr B at 06:00, recording what he had been told by Dr Sanusi. The Tribunal noted the evidence of Mr T that whatever the result of the CT scan it should be recorded as it was essential for it be considered in conjunction with other clinical observations. The Tribunal has therefore found this paragraph proved. vi. any conversation(s) you had regarding Patient A s CT results with: 1. Dr B; 2. the Radiologist; 45. The Tribunal noted that despite Dr Sanusi having spoken to Dr B on a number of occasions he made no record of these conversations. It is apparent from Dr B s entries at 06:00 that these conversations included reference to the CT scan results: spoke with registrar advised that has intra-abdominal/ subcutaneous fluid on CT. The evidence establishes that following the CT scan Dr Sanusi discussed it with the radiologist. The Tribunal concluded that given the importance attached to the scan results Dr Sanusi should have recorded this conversation. 46. The Tribunal was of the view that given the potential importance of the results of the CT scan and Dr Sanusi s stated intention to manage the patient based upon the results of the CT scan, it was imperative that records of any conversations with Dr B or the radiologist about the same should have been recorded in the medical notes. They were not. Further, the Tribunal noted that Dr Sanusi, in his Rule 7 letter, outlined that he had had a battle to get the radiologist to undertake and review the CT scan. The Tribunal was of the view given the considerable efforts that Dr Sanusi seemed to have had to go to get the CT scan it was inexplicable that he did not record the results. The Tribunal has therefore found these two sub paragraphs proved. 15

16 3. Patient A and/or their spouse; 47. The Tribunal accepted that if Dr Sanusi had discussed Patient A s CT scan results with her or her spouse such a discussion should have been recorded. However, although in the nursing notes it is recorded that Dr Sanusi did speak to the patient and her husband, there is no evidence as to what this conversation was about or whether the CT results were discussed. Therefore the Tribunal was not satisfied that the results had been discussed. Accordingly the Tribunal has not found this paragraph proved. vii. any re-examination of Patient A at approximately 19:00 21:00 on 26 October 2012; Amended under Rule 17(6) 48. There is insufficient evidence to conclude that there was in fact a reexamination of the patient at this time and the Tribunal was not satisfied that one took place. Accordingly has found the sub paragraph not proved. viii. details of Patient A s resuscitation management plan, including the: 1. quality of infused fluid; 2. rate of infused fluid; 3. parameters of when you were to be recalled; 49. The Tribunal found that none of these were recorded in the medical notes of Patient A. For the same reasons given in relation to sub paragraph 1(i)(iv) the Tribunal concluded that they should have been and has accordingly found each sub paragraph proved. ix. the deterioration in Patient A s condition at approximately 06:00 on 27 October The Tribunal noted that Dr Sanusi was not in attendance at the time of this deterioration. A record of the deterioration was made by Dr B who was in fact present on the ward at the relevant time. Accordingly the Tribunal did not consider that it was either necessary or Dr Sanusi s responsibility to make a record of the patient s deterioration at this time. Therefore the Tribunal found this sub paragraph not proved. Patient C 16

17 51. Patient C was 92 years old and was admitted on 15 January Dr Sanusi was asked by the Medical SHO on-call (Dr D) to assess Patient C on 17 January 2014, as she had developed severe pain and a haematoma on her right calf. Dr Sanusi was the senior surgical registrar on call and, the Tribunal has found, he had a duty to provide good clinical care to the patient. 2. On 17 January 2014, you failed to provide good clinical care to Patient C in that you did not: a. review Patient C when requested to do so by: i. Dr D; 52. The Tribunal had regard to the contemporaneous note which was made by Dr D at 02:30 on 17 January 2014 in which he recorded: Contacted Surgical SpR on- call Mr Sanusi and asked for his input He was extremely rude and refused to come and see He slammed the phone down. Contacted [Nurse Practitioner E] Night Practitioner and explained the situation, who kindly contacted Mr Sanusi herself who still refused to attend. [Nurse Practitioner E] contacted [Dr L] Consultant Surgeon on-call who will kindly review 53. The Tribunal did not accept the version of events put forward by Dr Sanusi in his Rule 7 letter that when he spoke to Dr D he was trying to be helpful and that he believed that Dr D had not conducted an examination of the patient and was simply reading from handover sheets. The medical notes make it clear that this call to Dr Sanusi occurred at around 02:30, a long time after the patient handover would have taken place and following Dr D having conducted and recorded a thorough examination of the patient prior to contacting Dr Sanusi. This is corroborated by the entries made in the nursing notes. The Tribunal found Dr D to be an honest witness who did not have an axe to grind and he had not met Dr Sanusi prior to this incident. The Tribunal accepted Dr D s evidence that the call with Dr Sanusi was memorable because he had never been spoken to by a colleague in this manner either before or since. 54. The Tribunal also had regard to the evidence of Mr T that Dr Sanusi was under a duty to attend the patient regardless of any perceived shortcomings in medical history taking. Dr Sanusi had the vital facts and had been asked to attend by a junior doctor. The Tribunal found that Dr Sanusi had failed to provide good clinical care to Patient C by not reviewing the patient when asked to do so by Dr D. ii. Nurse Practitioner E; 17

18 55. Nurse Practitioner E gave evidence that she had spoken to Dr Sanusi on the telephone following Dr Sanusi s refusal to attend at Dr D s request. This is corroborated by the note made in the medical notes by Dr D as outlined above. The Tribunal found that Dr Sanusi had failed to provide good clinical care to Patient C by not reviewing the patient when asked to do so by Nurse Practitioner E. b. communicate appropriately with Dr D in that you: i. were abrupt; ii. slammed the phone down on him; 56. The Tribunal has accepted that the contents of the contemporaneous note made by Dr D are accurate. Further it noted in the undated sent to Dr U (Head of HOOT Team, Friarage hospital), following this incident Dr D recorded: I was the medical SHO On-call on Thurs 16 January Night shift when I experienced a most unprofessional & unpleasant encounter with the On-Call Dr Sanusi I sought Dr Sanusi s Surgical advise, Unfortunately he was most unprofessional, & unhelpful & rude over the phone & refused to come & review our patient who was in a surgical emergency. I was most shocked by his behaviour. 57. The contents of the Datix incident form also corroborates Dr D s version of events. Accordingly it has found these sub paragraphs of the Allegation proved. c. communicate appropriately with Nurse Practitioner E in that you: i. were aggressive; ii. hung up on her. 58. In her evidence Nurse Practitioner E stated that Dr Sanusi was loud and aggressive when he spoke with her. The Tribunal has found her evidence in this regard to be credible and was supported by the evidence provided by Dr D regarding Dr Sanusi s tone and manner at the relevant time. Further the Tribunal noted that as a result of this incident Nurse Practitioner E had to resort to calling the Surgical Consultant to come and review the patient. It was the view of the Tribunal that Nurse Practitioner E would not have made this decision lightly and that she would only have done so if she felt that she had exhausted all options to get Dr Sanusi to attend to review the patient. Accordingly the Tribunal has found these sub paragraphs proved. 18

19 Patient F 59. Patient F was a 72 year old who was admitted as an emergency on 25 December 2014 with a 48 hour history of abdominal pain and constipation. Dr Sanusi was the senior surgical registrar on call accordingly the Tribunal has found that he did have a duty to provide good clinical care to the patient. 3. Between December 2014, you failed to provide good clinical care to Patient F in that you did not: a. personally assess Patient F upon their admission to the Accident & Emergency department; 60. Dr Sanusi does not dispute that he did not personally review the patient. The patient was referred by the Accident and Emergency Department and following a phone call with Dr Sanusi was accepted for admission as a surgical patient on the condition that the Medical Registrar would review the patient as she was presenting with respiratory problems (medical) and abdominal problems (surgical). The Tribunal accepted the evidence of Mr T that ideally Dr Sanusi should have reviewed the patient personally however Dr Sanusi had discussed the patient with the Accident and Emergency doctor and agreed to accept the patient as a surgical patient specifying that the patient should also have a medical review. The Tribunal further noted the evidence of Dr G, the surgical Foundation Year 1 on-call, who stated that it was normal practice for patients to be assessed by junior doctors at the Friarage Hospital. In these circumstances the Tribunal was not satisfied that Dr Sanusi was under a duty to personally assess the patient upon admission to the Accident and Emergency department and has therefore found this sub paragraph not proved. b. organise a management plan with appropriate priority given to: i. investigation with a CT scan; 61. It is clear from the medical notes and the evidence of Mr T that Patient F was very unwell and had a Modified Glasgow Severity Score for Pancreatitis of 3 indicating the need for urgent investigation. Therefore her treatment should have been a priority. However Dr Sanusi did not assess Patient F at any time and did not put himself in a position where he was able to properly assess the urgent need for a CT scan. During the course of the night the Tribunal heard, Patient F s symptoms had been communicated to Dr Sanusi by Dr G. It was the evidence of Mr T that a CT scan should have been a priority for guiding the management of the patient and it should not have been left to the morning. By failing to organise a management plan with appropriate priority given to investigation with a CT scan Dr Sanusi had not provided good clinical care to the patient and the Tribunal has found this sub paragraph proved. 19

20 ii. Medical Registrar opinion; 62. The Tribunal noted that it is clear from the medical notes when Patient F was admitted to the surgical ward that Dr Sanusi had requested a Medical Registrar s opinion. Accordingly the Tribunal has found this sub paragraph not proved. iii. admission of Patient F under either Physicians or Surgeons; 63. As outlined under the reasoning for sub paragraph 3(a) Dr Sanusi did this when the patient was in the Accident and Emergency Department. Accordingly the Tribunal has found this sub paragraph not proved iv. direct discussion with Dr G, with regards to Patient F s treatment plan; 64. In his evidence Mr T stated that it was his opinion that the telephone call that Dr Sanusi had with Dr G regarding Patient F s treatment plan as documented by Dr G sometime after 2:00 on 26 December 2014 was ok. The Tribunal has therefore found that this sub paragraph has been found not proved. c. directly assess Patient F following a conversation with Dr G and Dr H at approximately 02:00 on 26 December 2014; 65. The Tribunal had regard to the evidence of Dr G that when she called Dr Sanusi he spoke with her and Dr H. She stated that after this phone call she felt frustrated as she did not agree with his decision that the patient could wait until the morning for a CT scan. In the note of the disciplinary meeting which took place on 26 January 2015 Dr G outlined that she contacted Dr Sanusi during the early morning of 26 December 2014 requesting that he come and assess the patient. The Tribunal noted that he was the senior registrar and Dr G was an inexperienced junior doctor who was clearly concerned about a patient. He refused to come and assist her and review the patient. It was the view of Mr T that at this point in time Dr Sanusi should have gone and assessed the patient and that in fact he was obliged to have done so. 66. Having earlier in the evening accepted Patient F s admission to the surgical ward and having not previously assessed her, when Dr Sansui spoke with Dr H and Dr G in the early morning of 26 December 2014 when they were expressing concerns about the patient, it was the view of the Tribunal that he should have come and assessed the patient himself. His failure to do so meant that he was not in a position to make an informed clinical judgement about a very unwell patient. The Tribunal has therefore found this sub paragraph proved. 20

21 d. arrange for an urgent out-of-hours CT scan of Patient F s chest, abdomen and pelvis, following the conversation with Dr G and Dr H referred to at paragraph 3(c); 67. Following on from the reasoning as outlined in paragraph 3(c) the Tribunal was of the view that Dr Sanusi should have personally assessed the patient. It was the opinion of Mr T that it should have been clear to Dr Sanusi at this point that an urgent CT scan was required. He should not have indicated that such a scan could wait until the morning of 26 December The Tribunal has accordingly found this sub paragraph proved. e. urgently attend to assess Patient F, following a deterioration in their clinical state, when requested to do so by: i. Dr G; 68. It is clear from the observations taken at 05:26 that Patient F s clinical state had deteriorated significantly. It is noted in the of Nurse Practitioner I dated 30 December 2014 that at this point Dr G again contacted Dr Sanusi and requested that he come in to review the patient, to which he replied that he would be in at 7:00. The Tribunal finds on the evidence provided that he attended shortly before 07:00. The Tribunal has accordingly found this sub paragraph proved. ii. Nurse Practitioner I; 69. In her dated 30 December 2014 Nurse Practitioner I outlined that she bleeped Dr Sanusi shortly after concerns were raised at about 05:50. She said that she asked him why he would not come and see the patient and she stated that he abruptly told her that a plan was already in place (ie for a CT scan to be performed later that morning). She stated that she then informed him that the patient had further deteriorated and asked him to come in and review the patient. She stated that he told her he would be in at 7:00. Nurse Practitioner I then stated that she advised him that this was not acceptable and that she would be reporting his reluctance to the Surgical Consultant. To the extent that Dr Sanusi s account of this telephone call in his Rule 7 response is at odds with the description given by Nurse Practitioner I, the Tribunal prefer her account as given in evidence. The Tribunal found to be a credible and honest witness. It was confident that she made the urgency of the situation clear to Dr Sanusi when she spoke to him on the telephone. The Tribunal has accordingly found this sub paragraph proved. f. provide adequate clinical support to Dr G; 70. The Tribunal also found Dr G to be an honest and credible witness who answered questions to the best of her ability, though she conceded that she did not have a detailed recollection of events now due to the passage of time. In December 21

22 2014 she was an inexperienced doctor. She accepted that she may not have articulated the urgency of the situation to Dr Sanusi as well as she might have done with more experience. This was supported by Dr G s written reflections on the incident made on 26 January In this reflection she also recorded that Dr Sanusi had made some crucial decisions about the patient s care without reviewing the patient. Dr G did not feel supported by Dr Sanusi despite asking for help a number of times. She was a Foundation Year 1 doctor who was only three weeks into a new post. The Tribunal was of the view that she should rightly have expected that Dr Sanusi as a senior registrar would be expected to support her. Further the Tribunal was of the view that Dr Sanusi should have recognised that Dr G was newly qualified, inexperienced and repeatedly seeking support which he failed to provide. Accordingly the Tribunal has found this sub paragraph proved. g. communicate appropriately with Nurse Practitioner I in that you were patronising towards her. 71. The Tribunal has already found that Nurse Practitioner I was a credible witness. In her witness statement she stated that he was very patronising and was questioning her clinical ability. However, this was said to have occurred during a meeting in a ward office and in the presence of Mr N. Mr N gave evidence and although he described Dr Sanusi s attitude as being defensive in contrast to Nurse Practitioner I who appeared to be calm and professional, he did not describe Dr Sanusi as behaving in a manner that could be said to be patronising. In these circumstances the Tribunal was of the view that Nurse Practitioner I may have perceived Dr Sanusi was being patronising when he was seeking to defend his position and was not in fact seeking to patronise her. Accordingly the Tribunal has found this sub paragraph not proved. General Observations on the Evidence 72. Further to the Tribunal s findings in relation to paragraphs 1, 2 and 3, the Tribunal would wish to record that in considering both the written and oral evidence presented by the GMC, the Tribunal has had close regard to the representations made by Dr Sanusi in his Rule 7 response and statement of 15 September 2017.In particular, the Tribunal considered whether there was any substance to Dr Sanusi s contention that he had been the subject of victimisation, harassment or malicious allegations by colleagues as well as the suggestion that the surgical consultant Mr L had a personal animus towards Dr Sanusi and had encouraged others to make complaints against Dr Sanusi or otherwise treated him unfairly. 73. The Tribunal having considered and tested the evidence in the light of these assertions found that there was no evidence to support them. Further the Tribunal found that without exception the witnesses from whom it heard were honest and, despite having at times good reason to be frustrated by Dr Sanusi s conduct, behaved professionally throughout and did not bear him any ill will. Further, the 22

23 Tribunal found that Mr L had behaved properly throughout and in the circumstances showed considerable patience towards Dr Sanusi during the period in which these incidences had occurred. Rotherham NHS Foundation Trust 74. The South Tees Trust terminated Dr Sanusi s employment following a Trust investigation into the incident which occurred in December 2014 concerning Patient F. Although the investigation Panel concluded that the appropriate sanction would be a final written warning, Dr Sanusi already had a live final written warning on his file, consequent upon a disciplinary hearing relating to the incident in January 2014 concerning Patient C and the decision was therefore made to dismiss Dr Sanusi with notice. This decision was communicated to Dr Sanusi via letter dated 3 July He was reported to the GMC by the South Tees Trust following this. 75. It is alleged that, on 1 July 2015, Dr Sanusi submitted an application form to the Rotherham Trust for the position of Specialty Doctor in General Surgery in which he failed to disclose relevant details about his employment and dismissal from the South Tees Trust. Further, it is alleged that, on 30 July 2015, Dr Sanusi had an interview with the Rotherham Trust and failed to give accurate information about his employment and dismissal from the South Tees Trust. 4. On 1 July 2015, you submitted an application form to Rotherham NHS Foundation Trust ( the Rotherham Trust ) for the position of Specialty Doctor in General Surgery in which you failed to disclose that you: a. had a live final written warning from your employment with South Tees Hospitals NHS Foundation Trust ( the South Tees Trust ); 76. The Tribunal had regard to the electronic application form which Dr Sanusi had to fill out for this position. It noted that nowhere on the form was he specifically asked whether he had any written warnings or his disciplinary history generally. There is nothing recorded on the form by Dr Sanusi to give the impression that he had not previously had any written warnings. 77. The Tribunal was of the view that there may have been some lack of candour on Dr Sanusi s behalf in not disclosing that he had a live written warning from his employment with the South Tees Trust in his application. No specific question was asked within the application form in this regard or misleading impression given by the omission to mention the written warning. The Tribunal has therefore found this paragraph not proved. 23

24 b. were dismissed from your employment with the South Tees Trust. 78. The Tribunal noted that this application form was submitted on 1 July The letter that was sent to Dr Sanusi informing him of his dismissal was dated 3 July Although the application form refers to termination of contract the Tribunal was not satisfied that Dr Sanusi would necessarily have been aware that he had been dismissed at the time the application form was submitted. Accordingly the Tribunal finds that this sub paragraph is not proved. 5. On 30 July 2015, you had an interview with the Rotherham Trust and you: a. failed to disclose that you: i. had a live final written warning from your employment with the South Tees Trust; 79. The Tribunal noted the evidence of Dr O that a direct question regarding this was not asked of Dr Sanusi during the interview. It was the view of the Tribunal that if such a question was not asked of the doctor then he would not be under a duty to disclose the fact that he was subject to a written warning. The Tribunal has found this sub paragraph not proved. ii. were dismissed from your employment with the South Tees Trust; 80. By the time of this interview on 30 July 2015 Dr Sanusi had been informed by letter dated 3 July 2015 that he had been dismissed with notice from his employment. In his witness statement Dr O stated that Dr Sansui had stated that there was an ongoing investigation in relation to one incident and that Dr Sanusi made it clear during the interview that he had chosen resign his post in the South Tees Trust. The Tribunal noted that Dr O s witness statement was made about four months after the interview and he remembered it clearly. The Tribunal concluded that having been asked about the reasons for leaving his previous employer Dr Sanusi was under an obligation to answer truthfully. The Tribunal has therefore found this sub paragraph proved. b. stated that the South Tees Trust investigation was mainly down to personality clashes with colleagues, or words to that effect; 81. It is clear from the evidence of Dr O, which the Tribunal has accepted, that Dr Sanusi stated that the South Tees Trust investigation was mainly down to 24