Public Minutes of the Investigation Committee Date of hearing: 20 March 2018 Name of Doctor Dr Ali Khammas Doctor s UID 4451277 Committee Members Mr Ian Kennedy Mrs Toni Foers Dr John Jones Legal Assessor Panel Secretary Mr David Swinstead Mr Gareth Eaton Attendance and Representation GMC Representative Doctor s attendance Doctor s representative Mr Christopher Rose Dr Khammas did not attend but was represented Mr Andrew Hurst Outcome Warning
Determination Mr Hurst, 1 Dr Khammas is unable to attend today s hearing therefore this determination is addressed to you in his absence. 2 At today s hearing the Investigation Committee carefully considered all the material before it including the submissions made by you, and those made on behalf of the GMC by Mr Rose. It accepts the advice of the Legal Assessor. Background 3 On 8 November 2013 Dr Khammas was employed as a General Practitioner within the reception of HM Prison Belmarsh ( the prison ). 4 On 7 January 2016, the GMC received a referral from HM Coroner ( the coroner ) for Inner South District, Greater London. The referral was in the form of a Regulation 28 Report which raised concerns about the medical assessment performed by Dr Khammas on a prisoner ( Patient ID ), at the prison. 5 Patient ID had received a life prison sentence for murder with a minimum term of 18 years and was assessed at court as being at risk of suicide. The patient, prior to conviction, had been held in a Young Offenders Institution due to his age. It was his conviction for murder which led to him being detained at HMP Belmarsh, a Category A high-security prison. Dr Khammas assessed Patient ID on 8 November 2013 on the day of his transfer to the prison. The warning report by the court official appears to have been disregarded by the first nurse who saw the patient at the prison according to GMC submissions. It is unclear due to the passage of time whether or not the warning was seen by Dr Khammas. What is set out by the GMC is that Dr Khammas was asked by the nursing staff at the prison to see the patient to carry out a full mental health assessment. Dr Khammas recorded on his assessment that Patient A feels ok. It was alleged that there was no further documentary evidence, or record of this consultation. Patient ID was seen by a nurse on 11 November 2013 for a further assessment. He committed suicide on 13 November 2013. 6 The GMC obtained an expert report into the care Dr Khammas provided to Patient ID. The expert report, dated 3 May 2016 concluded; at the time of the consultation Patient A (ID) had a recent history of admission to a mental health hospital and therefore active assessment was indicated. Such an assessment should have been documented in the clinical records. Therefore having reviewed the bundle of papers
and from my experience of working for twenty years in general practice and almost thirteen years in prison general practice settings, I am of the opinion that Dr Khammas note keeping skills fell seriously below the standard expected of a reasonably competent GP. 7 In a letter dated 3 October 2017 the GMC wrote to Dr Khammas in accordance with Rule 7 of the GMC (Fitness to Practise) Rules 2004 ( the Rules ). Dr Khammas responded, via his legal representatives, in a letter dated 20 October 2017. In this letter whilst he agreed that the record he made of the consultation with Patient ID was unacceptable, he submitted that the only appropriate course of action would be for the Case Examiners to close the case with no further action. He based this on the fact that he had learnt from the experience, it was a one-off incident and that due to the on-going proceedings he had struggled to find work and medical insurance cover causing significant personal hardship and financial difficulties. 8. In a letter dated 19 December 2017 the GMC wrote to Dr Khammas in accordance with Rule 11 of the Rules and informed him that the Case Examiners were minded to issue a warning in this case. On 3 January 2018 Dr Khammas indicated that he was not prepared to accept the proposed warning and on 15 February 2018 the GMC advised him that his case had been referred to this Committee and included within the letter a re-drafted proposed warning focusing solely on Dr Khammas record keeping. GMC Submissions 9. At today s hearing Mr Rose submitted that a warning was an appropriate and proportionate outcome in this case. He submitted that on 8 November 2013 Dr Khammas undertook a mental health assessment with a vulnerable individual, of which he failed to make an adequate record of the consultation. Mr Rose said that anybody subsequently reading Dr Khammas record would not understand that an assessment had been carried out and it offered no assistance as to on-going care of this vulnerable patient. Mr Rose submitted that his response to questions concerning his record keeping at the Coroner s inquest accentuated his failure to make an adequate record of his assessment, by showing a disregard of the need for record keeping to inform others. 10. Mr Rose submitted that his conduct does not meet with the standards expected of a doctor. It risks bringing the profession into disrepute and must not be repeated. The required standards are set out in Good Medical Practice. Paragraph 21 in relation to maintaining clinical records is particularly relevant. Defence Submissions 11 Mr Hurst, on Dr Khammas behalf submitted that a warning was not an appropriate or proportionate response in this case and invited the Committee to conclude the matter with no further action. 2
12 Mr Hurst said that Dr Khammas accepted that his record keeping was not at the required standard for the assessment that he had conducted on Patient ID. He said it was Dr Khammas intention to write more detail in the records later on during that shift. He said that due to time constraints and the very highly pressured environment working as a General Practitioner in a high-security prison setting, meant that Dr Khammas had been unable to complete a full record at the time of the assessment. He set out that whilst Dr Khammas was not advancing it as a defence, he did feel pressured by other staff to finish his clinics so that they could leave. 13 Mr Hurst said that there was no causal link found between the suicide of Patient ID and Dr Khammas s assessment or related record keeping. Furthermore, he said that Dr Khammas felt the evidence he gave at the coroner s inquest was given whilst being un-prepared for the evidence he was asked to give, being unrepresented and was not a true reflection of Dr Khammas views on why a full and adequate record was not made and why it was necessary. 14 Mr Hurst submitted that whilst Dr Khammas does not down-play the significance of his actions in this case, they are not so significantly serious that if they were repeated a finding of impairment could be made. As such, they are therefore not so serious that a warning is necessary in this case. Mr Hurst submitted that the incident occurred four and a half years ago, Dr Khammas accepted his failings and has demonstrated genuine insight. He said that he had no previous GMC fitness to practise history and there is no risk of repetition. He also set out the significant adverse impact the case has had on Dr Khammas ability to find employment and medical indemnity cover. Committee Determination 15 The Committee is aware that it must have in mind the GMC s role of protecting the public, which includes: a. Protecting, promoting and maintaining the health, safety and well-being of the public b. Promoting and maintaining public confidence in the medical profession, and c. Promoting and maintaining proper professional standards and conduct for members of that profession 16 In deciding whether to issue a warning the Committee must apply the principle of proportionality, and balance the interests of the public with those of the practitioner. 17. The Committee notes that Patient ID had been sentenced to life imprisonment for murder and was being transferred from a Young Offenders Institution to a Category A high security prison. He was 18 years old and had a previous history of mental health concerns. He was vulnerable, in a high risk group and it had been noted by other staff that he was at risk of suicide. 3
18. The Committee considers that the record Dr Khammas made, given the context of the assessment, was totally inadequate. This was a critical assessment of a high-risk patient in a high-risk situation. It notes that none of the information that could have been captured by his assessment was recorded and this, therefore, prevented other professionals having the opportunity to benefit from the findings of that assessment. 19. The Committee concludes that Dr Khammas inadequate recording of this assessment is a significant departure from the standards expected of a doctor working in a prison setting. It accepts the opinion of the GMC expert that Dr Khammas note keeping skills fell seriously below the standard expected of a reasonably competent GP and considers any repetition of inadequate record keeping in similar serious circumstances could lead to a finding of impaired fitness to practise. 20. The Committee notes that the incident is isolated and that Dr Khammas has accepted that his record keeping was not at an adequate level. The Committee also notes that Dr Khammas has successfully undergone a full GMC assessment of his performance and it also had regard to the other mitigating factors that were placed before it. 21. However, the Committee considers that in the context of the assessment that Dr Khammas was asked to undertake, given the high-risk category Patient ID was in, it is an appropriate and proportionate response to issue him with the following warning in this case: On 8 November 2013 you undertook a mental health assessment with a vulnerable individual in a high risk prison setting. You failed to make adequate records of this consultation. This conduct does not meet with the standards required of a doctor. It risks bringing the profession into disrepute and it must not be repeated. The required standards are set out in Good medical practice and associated guidance. Paragraph 21 is particularly relevant: 21. Clinical records should include: a. relevant clinical findings b. the decisions made and actions agreed, and who is making the decisions and agreeing the actions c. the information given to patients d. any drugs prescribed or other investigation or treatment e. who is making the record and when. Whilst this failing in itself is not so serious as to require any restriction on your registration, it is necessary in response to issue this formal warning. This warning will be published on the List of Registered Medical Practitioners (LRMP) for two years. After two years it will cease to be published on the LRMP and are no longer disclosed to general enquirers. However, they are kept on record and disclosed to employers indefinitely on request. 4