PUBLIC RECORD. Record of Determinations. Medical Practitioner: Dates: 02/07/ /07/2018. GMC reference number:

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1 PUBLIC RECORD Dates: 02/07/ /07/2018 Medical Practitioner s name: Dr Magdalene Idu Ekpiken GMC reference number: Primary medical qualification: Type of case New - Misconduct MB BS 2005 University of Ibadan Outcome on impairment Impaired Summary of outcome Suspension, 6 months. Review hearing directed Immediate order imposed Tribunal: Legally Qualified Chair Lay Tribunal Member: Medical Tribunal Member: Mr Charles Thomas Mrs Joy Hamilton Dr Janet Nicholls Tribunal Clerk: Mr Michael Murphy Attendance and Representation: Medical Practitioner: Medical Practitioner s Representative: GMC Representative: Present and represented Ms Fiona Neale, Counsel, instructed by the MDU Ms Natasha Tahta, Counsel Attendance of Press / Public In accordance with Rule 41 of the General Medical Council (Fitness to Practise) Rules 2004 the hearing was held in public. 1

2 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 - 03/07/2018 Background 1. Dr Magdalene Idu Ekpiken qualified as doctor in 2005 at the University of Ibadan, Nigeria and gained her certificate of completion of GP training in February 2014 in the UK. At the time of the events leading to the allegation Dr Ekpiken was working for an out of hour s service conducting telephone triage. 2. The allegation that has led to Dr Ekpiken s hearing relates to the care and treatment provided to three patients via a telephone triage service. Dr Ekpiken took a phone call regarding an elderly lady (Patient A) with a chest infection from a nursing home in January It is stated that Patient A subsequently became worse, an ambulance was called, she was septic and she died later in hospital. There were concerns relating to Dr Ekpiken s treatment of Patients A, B and C where it is alleged that there were failings to carry out a number of actions that were required for the treatment and care of the patients. It is further alleged, in relation to Patients A, B and C, that Dr Ekpiken failed to give safety netting advice, failed to distinguish urgent cases, documented things that were not discussed, advised that red flag features were discussed when this was not the case and did not take a proper history from the patients and made false records. 3. The initial concerns were raised with the GMC on 9 May 2017 following a referral from NHS England. The Outcome of Applications Made during the Facts Stage 4. The Tribunal granted the GMC s application, made pursuant to Rule 17 (6) of the General Medical Council (Fitness to Practise Rules) 2004 as amended ( the Rules ), for amendments to be made to the allegation. Ms Neale, Counsel on behalf of Dr Ekpiken, supported this application. The Tribunal allowed this application as it could be made without any injustice. The Admitted Facts 5. The amended Allegation made against Dr Ekpiken is that being registered under the Medical Act 1983 (as amended): 2

3 Patient A 1. On 2 January 2016, you conducted a telephone triage consultation with Patient A and you: a. failed to obtain adequate details of the background to Patient A s presenting complaint including: i. associated symptoms; i iv. how systemically unwell Patient A was; the current status of any home care plan, including any advanced wishes; when Patient A s physiological observations had been taken; b. failed to adequately ascertain whether Patient A had any red flag features such as: i. chest pain; i iv. haemoptysis; reduced consciousness; inability to communicate, including speaking in full sentences; v. showing other visible signs of respiratory distress; c. failed to adequately consider Patient A s abnormal physiological observations including being: i. tachycardic; 3

4 i iv. tachypnoeic; febrile; hypoxic; d. failed to adequately consider the diagnosis of sepsis; e. failed to arrange either: i. an urgent 999 ambulance call; or an immediate GP home visit if Patient A was being managed palliatively; f. failed to advise to make further contact or call 999 if Patient A: i. experienced worsening shortness of breath; i iv. experienced chest pain; experienced drowsiness; was unresponsive; v. was increasingly unwell; g. inappropriately recorded: i. a history taken from Patient A, that you had not elicited during the telephone call; 4

5 that safety netting advice was given to Patient A, when you had not provided any such advice; Patient B 2. On 24 July 2016, you conducted a telephone triage consultation with Patient B and you: a. failed to obtain adequate details of the background to Patient B s presenting complaint including: i. any history of trauma to Patient B s leg; i iv. any similar previous episodes; any associated symptoms; whether Patient B was feeling systemically unwell, in particular feverish; v. whether Patient B had taken any analgesia; b. failed to adequately ascertain whether there were any red flag symptoms suggestive of Pulmonary Embolus; c. failed to give adequate consideration to alternative diagnoses. d. failed to arrange a two-hour urgent home visit for face to face review of Patient B; e. failed to adequately advise Patient B: i. regarding taking analgesia; to call back, or arrange for her daughter to call back if: 5

6 1. she had increased shortness of breath; 2. she experienced chest pain; 3. she was drowsy; 4. she was unresponsive; 5. she was increasingly unwell in herself; 6. there were any further carer concerns; f. inappropriately documented that Patient B: i. was well in herself when you did not ask any questions or have any conversations with Patient B to substantiate this; Patient C had been given safety netting advice when you had not provided any such advice. 3. On 24 September 2016, you conducted a telephone triage consultation with Patient C and you: a. failed to adequately ascertain whether there were any red flag features relating to Patient C s restrictive breathing including any: i. chest pain; pleuritic pain; 6

7 i iv. haemoptysis; dizziness; v. leg swelling; vi. rigors; b. failed to obtain adequate details of: i. whether Patient C s cough was productive or dry; i rigors; vomiting; c. failed to give adequate consideration to alternative diagnoses. d. failed to put yourself in a position to adequately judge the proper level of urgency for Patient C s management; e. failed to advise Patient C, if he experienced further symptoms of restrictive breathing, to: i. call back; attend the centre earlier; f. inappropriately recorded that: i. no red flags were present when this was not the case; 7

8 Patient C had been given safety netting advice when you had not provided any such advice. Patients A, B, C 4. You recorded information as outlined at paragraphs 1g, 2f and 3f which: a. was untrue; b. you knew to be untrue. 5. Your actions as described at paragraph 4 were dishonest. 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, through her Counsel, Ms Neale, Dr Ekpiken made admissions to the entirety of the amended Allegation, as set out above, in accordance with Rule 17(2)(d) of the General Medical Council (GMC) (Fitness to Practise) Rules 2004, as amended ( the Rules ). In accordance with Rule 17(2) (e) of the Rules, the Tribunal announced these paragraphs and subparagraphs of the Allegation as 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 it has found proved as set out before; Dr Ekpiken s fitness to practise is impaired by reason of misconduct. The Evidence Expert Witness Evidence 8. The Tribunal received evidence from the GMC in the form of an expert report completed by Dr E on 15 July Dr E is a qualified General Practitioner who is also a medical clinical lead for an urgent care centre. She also provided oral evidence in person at the hearing. Factual Witness Evidence 9. The Tribunal listened to the recordings of the three telephone consultations. 8

9 Documentary Evidence 10. The Tribunal had regard to the documentary evidence provided by the parties. This evidence included, but was not limited to; Patient A medical records, dated 2 January 2016; Patient A telephone transcript record, dated 2 January 2016; Patient B medical records, dated 24 July 2016; Patient B telephone transcript record, dated 24 July 2016; Patient C medical records, dated 24 September 2016; Patient C telephone transcript record, dated 24 September 2016; Expert report by Dr E, dated 15 July 2017; Dr Ekpiken s responses to Dr E s expert report as provided with Rule 7 responses, dated 21 September 2017; Dr Ekpiken s letter to the Assistant Registrar as provided with Rule 7 responses, dated 21 September 2017; Testimonials, including supervision reports; Continuing professional development; Appraisal for 2018; Letter from NHS England dated 3 January Submissions 11. On behalf of the GMC, Ms Tahta submitted that Dr Ekpiken is impaired as the facts found proved amount to serious misconduct. She submitted that the clinical failings fall seriously below the standard expected of a reasonably competent GP. She stated that the Tribunal has received insufficient evidence to be satisfied that Dr Ekpiken s clinical shortcomings have been remediated and that a finding of impairment is necessary to promote and maintain proper professional standards and conduct for the members of the profession. 12. On behalf of Dr Ekpiken, Ms Neale submitted that the Tribunal should consider Dr Ekpiken s evidence of good character presented in the respondents bundle and that the admissions of Dr Ekpiken show responsibility for her actions and that she has taken the first steps towards showing insight and remediation. 13. Ms Neale stated that the allegation can be considered with regard to its clinical and probity components. In relation to the clinical aspect, she submitted that Dr Ekpiken has been placed under supervision by the NHS and that the supervisory reports clearly show an improvement in her clinical practice. In relation to probity, she submitted that Dr Ekpiken has reflected on the importance of honestly and accurately documenting information. 14. Ms Neale made no submissions in relation to impairment. 9

10 The Relevant Legal Principles 15. The Tribunal received advice on the approach to take at the impairment stage from the Legally Qualified Chair which it accepted in full. The Tribunal reminded itself that at this stage of proceedings, there is no burden or standard of proof and the decision of impairment is a matter for the Tribunal s judgement alone. In exercising that judgement the Tribunal must give careful consideration to all of the evidence that has been adduced including submissions made by the GMC and on behalf of Dr Ekpiken. 16. In approaching the decision, the Tribunal was mindful of the two stage process to be adopted: first whether the facts found proved amounted to misconduct, including whether the misconduct was serious. Secondly, whether in the light of any serious misconduct, Dr Ekpiken s fitness to practise is currently impaired. In its deliberations on impairment, the Tribunal has been mindful of the overarching objective of the GMC as set out in the Act (as amended). 17. When considering the issue of impairment, the Tribunal took into account Dr Ekpiken s conduct at the time of the events and all relevant factors since then including her level of insight into her conduct and whether this conduct is remediable, has been remedied and whether it is likely to be repeated. The Tribunal s Determination on Impairment Misconduct 18. Where the Tribunal refers to the the standard it determined this to be the standard of a reasonably competent GP. In applying that standard the Tribunal referred to the standards of practice set out in Good Medical Practice (2013) ( GMP ). 19. The Tribunal first considered whether Dr Ekpiken s fitness to practise was impaired in relation to the clinical concerns raised and then moved onto to consider whether her fitness to practise was impaired in relation to the probity issues raised. 20. In considering the clinical concerns the Tribunal bore in mind certain paragraphs of GMP: 1) Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law. 15) You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. adequately assess the patient s conditions, taking account of their history (including the symptoms and psychological, 10

11 spiritual, social and cultural factors), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary 21. In relation to the clinical concerns the Tribunal noted Dr Ekpiken s medical background. It noted that she is a trained GP and this training would have covered the areas of expertise required to undertake a role in telephone triage for an out of hour s service. 22. The Tribunal had regard to the expert report of Dr E in particular where she states: The primary reason for taking a good history is to narrow down the list of differential diagnoses and assess how urgently a patient may need to be seen (or if this is required at all) and, by which method is the most appropriate e.g. home visit / ambulance / medical facility etc). The history taking and ruling out of red flag symptoms becomes more important with telephone triage as you do not have the luxury of the patient sitting in front of you when making the assessment and, it would arguably potentially be more apparent if they were seriously unwell face to face. 23. The Tribunal accepted the expert evidence of Dr E that taking an accurate medical history is critical in ascertaining the best clinical course of action to take and is one of the core competencies of every doctor. It noted that in each case Dr Ekpiken failed to respond to initial information that was provided by asking appropriate questions to ensure that a proper history was obtained. Further, Dr Ekpiken failed to make a proper note of the important information that had been given, most importantly in the case of Patient A when the abnormal physiological parameters were not recorded but also significantly in the case of Patient B where the notes were not sufficiently detailed and did not contain enough information to assist the next treating doctor. 24. The Tribunal was of the view that Patient C s note taking was not as seriously below the standard as the others and that there were no audible signs of breathing difficulties during the telephone consultation. However, it still viewed Dr Ekpiken as not taking an adequate history for Patient C. 25. The Tribunal would expect a doctor at Dr Ekpiken s level to have the necessary skills to take an adequate patient history and make clear and accurate notes. Dr Ekpiken has stated in her section 7 responses that she was lacking in the skills to do this and that she now realises that taking an accurate patient history is important and will now ensure that all of her notes are accurate. However, the 11

12 Tribunal has received no explanation as to the reasons why this was not done previously. 26. The Tribunal was of the view that Dr Ekpiken showed fundamental failures in respect of history taking and patient management with Patients A and B which demonstrate a lack of basic skills. It agreed with Dr E s view that these failures fell seriously below the expected standard of a reasonably competent GP. It bore in mind Dr E s expert report where she states: I have rated red flags, safety netting and record keeping for all three patients as seriously below standard as there is a lack of ruling out of red flags within the history for all three patients. There is little or no attempt in any of the cases to consider signs or symptoms which could potentially indicate serious illness and, which would require a more urgent treatment plan. In all three cases, the medical record indicates an attempt to give safety netting advice however, when comparing to the telephone transcript notes, this was in fact not discussed at all. For this reason, and due to other inaccuracies in the medical record, such as documenting no red flags or signs or systemic upset when in fact these had not been enquired about or discussed, I found the medical record to be a misrepresentation of the telephone consultation and not in keeping with the GMC Good Medical Practice Guidelines ,2 It is the seriousness of the inaccuracies and deficiencies in the performance which has led to the seriously below rather than below rating. 27. The Tribunal viewed the note taking with all three patients as extremely poor and agreed with Dr E s expert report that this fell seriously below the standard. The Tribunal concluded that Dr Ekpiken s clinical failings amounted to serious misconduct in relation to Patients A, B and C. 28. In relation to the probity issues raised the Tribunal gave regard to the following paragraphs of GMP: 65) You must make sure that your conduct justifies your patients trust in you and the public s trust in the profession. 71) You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write or sign are not false or misleading. 29. The Tribunal bore in mind that various parts of the notes, in respect of all three patients, have entries which Dr Ekpiken has admitted are dishonest. The Tribunal has been given no explanation why these dishonest notes were made. The effect of the dishonest entries was to make it appear that the consultations had been of better quality than they really were. The Tribunal noted that the dishonest entries were made on three separate occasions. It was in no doubt that a fellow practitioner would consider such conduct to be deplorable and that the admitted 12

13 dishonesty amounted to serious misconduct. Impairment 30. The Tribunal, having found that the facts found proved amounted to misconduct, went on to consider whether, as a result of that misconduct, Dr Ekpiken s fitness to practise is currently impaired. 31. The Tribunal considered all of the evidence produced by Dr Ekpiken in the respondent s bundle. It noted evidence of some improvement in her clinical practice. However, the Tribunal did not consider that the evidence provided demonstrated complete remediation or that there was no risk of repetition of the clinical failings. The supervision reports only covered a total of nine days work. In the first supervision report Dr Ekpiken s performance in the areas of clinical judgement and clinical record keeping was only rated as borderline although she herself rated her performance in these areas as acceptable. Save for one short reference, the Tribunal has no evidence regarding Dr Ekpiken s clinical performance since October It noted however, that she has undertaken a substantial amount of CPD in this period. 32. The Tribunal had regard to Dr Ekpiken s Rule 7 responses, which are at best ambiguous on the issue of dishonesty. The Tribunal noted that she does not appear to have discussed the dishonesty issues with her mentor. The Tribunal welcomes her admissions of dishonesty at this hearing as a first step towards insight. However, she has not given any evidence at the impairment stage of this hearing about her insight into her dishonesty and overall the Tribunal considers that the evidence of insight at this stage of the hearing is very limited. 33. The Tribunal concluded that Dr Ekpiken is currently impaired and that a finding of impairment in respect of both her fundamental clinical failings and her dishonesty, which breached a fundamental tenant of the profession, is necessary to protect and promote the health, safety and wellbeing of the public, maintain public confidence in the medical profession and to promote and maintain proper professional standards and conduct for the members of the profession. 34. The Tribunal determined that Dr Ekpiken s fitness to practise is impaired by reason of her misconduct. Determination on Sanction - 05/07/ Having determined that Dr Ekpiken s fitness to practise is impaired by reason of her 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. 13

14 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. It received further evidence on behalf of Dr Ekpiken including two supervision recording and reporting modules. Dr Ekpiken also gave oral evidence at this stage. Submissions 3. On behalf of the GMC, Ms Tahta submitted that taking no action or a sanction of conditions would be wholly inappropriate in this case. She submitted that there were no exceptional circumstances in this case and that dishonesty was not admitted to NHS England during their investigation. 4. Ms Tahta submitted that the appropriate sanction is one of suspension. She submitted that Dr Ekpiken has still not provided an explanation for why she behaved in the way she did. She accepted that Dr Ekpiken has shown some remorse. She submitted that a sanction of suspension would address the protection and promotion of the health, safety and wellbeing of the public and would promote and maintain public confidence in the medical profession. 5. On behalf of Dr Ekpiken, Ms Neale accepted that taking no action was not appropriate. She submitted that conditions would be appropriate in this case as NHS England has already imposed conditions after assessing if Dr Ekpiken is safe to practise and that it would give Dr Ekpiken the opportunity to embed the positive changes in her clinical practice which have already begun to become apparent. 6. Ms Neale submitted that a sanction of suspension would not ensure Dr Ekpiken did not act dishonestly any more than conditions would and that public confidence can be maintained with a level of supervision and with a future review hearing. She submitted that a sanction of suspension would be disproportionate in this case as it would cause a setback for Dr Ekpiken s clinical practice. She submitted that the various features of mitigation in this case meant that conditions would be a proportionate response to Dr Ekpiken s misconduct. The Tribunal s Determination on Sanction 7. The decision as to the appropriate sanction to impose, if any, is a matter for this Tribunal exercising its own judgement. 8. In reaching its decision, the Tribunal has taken account of the Sanctions Guidance (2018) and Good Medical Practice (2013). 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. 14

15 9. Throughout its deliberations, the Tribunal applied the principle of proportionality, balancing Dr Ekpiken s interests with the public interest. It has already given a detailed determination on impairment and has taken those matters into account during its deliberations on sanction. No action 10. In reaching its decision as to the appropriate sanction, if any, to impose in Dr Ekpiken s case, the Tribunal first considered whether to conclude the case by taking no action. It determined that were no exceptional circumstances in this case and as such it would not be in the public interest to take no action. Conditions 11. The Tribunal next considered whether it would be appropriate to impose conditions on Dr Ekpiken s registration. It bore in mind that any conditions imposed should be appropriate, proportionate, workable and measureable. 12. The Tribunal was of the view that conditions would be appropriate for the clinical concerns raised but not for the issue of probity. It noted that Dr Ekpiken has demonstrated some insight into her dishonesty. In her evidence she showed a complete inability to explain the reasons why she acted dishonestly. The Tribunal bore in mind Dr Ekpiken s admissions and that she has apologised for her misconduct but it considered that a risk of repetition is still present in the absence of a full understanding of the reasons for her dishonesty. Whilst the Tribunal notes the three day ethics course that Dr Ekpiken attended, there is an absence in the documentation received by the Tribunal of any reflective note or detailed discussion of why she behaved in the way that she did. 13. The Tribunal bore in mind that the conditions imposed by NHS England have supported her improving clinical practise but have considered that there are no measurable or workable conditions designed to address Dr Ekpiken s dishonesty. 14. The Tribunal had regard to paragraph 81 f the SG which states: Conditions might be most appropriate in cases: a) involving the doctor s health b) involving issues around the doctor s performance c) where there is evidence of shortcomings in a specific area or areas of the doctor s practice d) where a doctor lacks the necessary knowledge of English to practise medicine without direct supervision. 15. The Tribunal noted that none of the factors in paragraph 81 were relevant to the probity aspect of this case and therefore concluded that conditions are 15

16 insufficient to ensure the protection of patients, to meet the public interest and to maintain proper professional standards of conduct for the members of the profession. Suspension 16. The Tribunal then went on to consider whether a period of suspension of Dr Ekpiken s registration would be appropriate and proportionate. 17. The Tribunal bore in mind paragraphs 91 and 92 of the SG which state: Suspension has a deterrent effect and can be used to send out a signal to the doctor, the profession and public about what is regarded as behaviour unbefitting a registered doctor. Suspension from the medical register also has a punitive effect, in that it prevents the doctor from practising (and therefore from earning a living as a doctor) during the suspension, although this is not its intention. Suspension will be an appropriate response to misconduct that is so serious that action must be taken to protect members of the public and maintain public confidence in the profession. A period of suspension will be appropriate for conduct that is serious but falls short of being fundamentally incompatible with continued registration 18. In this case the dishonesty took place on three separate occasions over a period of months. It also occurred within a clinical context and had the effect of making the consultations look better than they really were. Bearing in mind, as stated above, that there is some, but by no means complete insight on the part of Dr Ekpiken, the Tribunal concluded that a period of suspension would work as a deterrent to dishonesty for Dr Ekpiken herself and send a clear message into the wider medical profession. It 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. 19. The Tribunal also had regard to paragraph 128 of the SG which states: Dishonesty, if persistent and/or covered up, is likely to result in erasure 20. Although the dishonesty in this case occurred on three separate occasions, the Tribunal bore in mind that Dr Ekpiken is of good character and that there has been no subsequent repetition of her dishonest behaviour. The Tribunal took the view that her dishonesty could not be called persistent. The Tribunal also bore in mind that Dr Ekpiken has admitted her dishonesty and has engaged well in trying to remediate her clinical failings. In all the circumstances, the Tribunal concluded that her conduct was not fundamentally incompatible with registration and that erasure would be 16

17 disproportionate and inappropriate. 21. In considering the appropriate period of suspension, the Tribunal was aware that the maximum period of suspension is 12 months. The Tribunal determined that a period of suspension for six months reflected the seriousness of the findings in this case and would also give Dr Ekpiken sufficient time to reflect on the reasons for her dishonesty. 22. The Tribunal determined to direct a review of Dr Ekpiken s case. A review hearing will convene shortly before the end of the period of suspension, unless an early review is sought. At the review hearing, the onus will be on Dr Ekpiken to demonstrate how she has remediated and developed insight. It therefore may assist the reviewing Tribunal if Dr Ekpiken provides: A reflective statement; Evidence of developing insight into her dishonest conduct through discussions with a workplace supervisor or mentor; Evidence of keeping her clinical knowledge and skills up to date; Any other information that she considers will assist. Determination on Immediate Order - 05/07/ Having determined to suspend Dr Ekpiken s registration for a period of six months, the Tribunal has considered, in accordance with Rule 17(2) (o) of the Rules, whether her registration should be subject to an immediate order. Submissions 2. On behalf of the GMC, Ms Tahta submitted that an immediate order of suspension is necessary to protect members of the public and it is in the public interest. She submitted that it is uncertain what will happen to the NHS England conditions if an immediate order of suspension is not imposed so Dr Ekpiken could be free to return to unrestricted practice. 3. On behalf of Dr Ekpiken, Ms Neale submitted that Dr Ekpiken has been subject to NHS England conditions for some time and has been fully compliant with no repetition of her misconduct. She submitted that an immediate order of suspension is not necessary to protect patients or the public interest as the substantive order of suspension will address this. The Tribunal s Determination 4. The Tribunal, in its deliberations, bore in mind that NHS England has relaxed the conditions it imposed upon Dr Ekpiken. The Tribunal noted that it has no authority over NHS England and can not speculate on what actions it would take with regard to the 17

18 conditions it has already put in place. The Tribunal has already determined that Dr Ekpiken is not fit to return to unrestricted practice 5. The Tribunal has determined that Dr Ekpiken has only shown limited insight into her dishonesty and that there is a risk of repetition of her misconduct. It concluded that because of these concerns an immediate order of suspension is necessary. The Tribunal was of the view that, in the light of Dr Ekpiken s clinical failings and incomplete insight into her dishonesty, an immediate order is necessary to protect patients. 6. The Tribunal has therefore determined to impose an immediate order of suspension on Dr Ekpiken s registration. 7. This means that Dr Ekpiken 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 Ekpiken, 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. 8. There is no interim order to revoke. 9. That concludes the case. Confirmed Date 05 July 2018 Mr Charles Thomas, Chair 18