Record of Determinations – Medical Practitioners Tribunal

PUBLIC RECORD Dates: 06/01/2016 – 03/02/2016 Medical Practitioner’s name: Dr Ahmed Abdul Latif Hamed LOUTFI GMC reference number:

4455635

Primary medical qualification:

MB ChB 1980 University of Alexandria

Type of case New - Misconduct

Outcome on impairment Impaired

Summary of outcome Erasure Immediate order imposed Tribunal: Medical Tribunal Member (Chair)

Dr Nigel Callaghan

Lay Tribunal Member:

Mrs Lucy Reid

Lay Tribunal Member:

Ms Lisa Smith

Legal Assessor:

Mr Duncan Smith

Tribunal Clerk:

Ms Jan Smith

Attendance and Representation: Medical Practitioner:

Present and not represented

Medical Practitioner’s Representative: GMC Representative:

N/A Ms Catherine Cundy, Counsel

FTP: Dr LOUTFI

1

Record of Determinations – Medical Practitioners Tribunal Allegation and Findings of Fact That being registered under the Medical Act 1983 (as amended): Patient A 1.

On 29 April 2010, while working at the Liverpool Women's Hospital you: a. incorrectly diagnosed Patient A with an incomplete miscarriage; Found proved b. formed an inappropriate initial management plan to discharge Patient A; Found proved c. were dismissive of the information Patient A gave you about her planned admission; Found proved d. refused to prescribe Patient A stronger analgesia despite her pain. Found not proved

2.

On 1 May 2010 you: a. incorrectly diagnosed Patient A with an incomplete miscarriage; Found proved b. failed to ensure that Patient A was appropriately followed up; Found proved c. spoke to Patient A in an inappropriately manner in that you told her to go home and try for another baby. As amended, found proved

Patient B 3. On 5 February 2012, while working at St Mary's Hospital, Manchester you proposed an inappropriate management plan for Patient B to commence a syntocinon infusion at 15:50 hours. Withdrawn by the GMC Patient C 4.

On 30 October 2011, while working at St Mary's Hospital, Manchester you:

FTP: Dr LOUTFI

2

Record of Determinations – Medical Practitioners Tribunal a. made an inappropriate initial decision to proceed with a trial of operative vaginal delivery under spinal anaesthesia for Patient C; As amended, found proved b. failed to advise immediate delivery by Caesarean section under general anaesthesia; Found proved c. misdiagnosed full dilation of Patient C’s cervix. Found proved Patient D 5.

On 26 May 2013, while working at Birmingham Women's Hospital, you: a. inappropriately rotated the fetal head of Patient D's baby to the occipitoposterior position when rotation to the occipito-anterior position had failed; Found proved b. applied inappropriate force to deliver Patient D’s baby. Found not proved

6. In a letter dated 25 July 2013 to Miss E you stated you had ‘delivered another patient by Kielland's forceps after rotation to occipito-posterior position when anterior rotation was difficult under direct supervision of Mr F’, when you knew this was untrue. Found proved Central Manchester University Hospitals NHS Foundation Trust (‘the Trust’) 7. On 3 January 2012 you completed an application form for the post of Locum Consultant Obstetrician and Gynaecologist at the Trust in which you failed to disclose that you: a. were subject to a warning issued by the Investigation Committee of the GMC on 14 December 2010; Found proved b. had been the subject of separate GMC fitness to practise proceedings in 2010 which were subsequently closed with advice. Found proved 8. On 25 May 2012, during an appraisal with Dr G at the Trust, you were asked if you were involved in any complaints, critical incidents or legal cases at which time you failed to disclose that you were involved in:

FTP: Dr LOUTFI

3

Record of Determinations – Medical Practitioners Tribunal a. an investigation by the Parliamentary Health Services Ombudsman arising out of a patient complaint, when you knew this to be the case; Found proved b. two High Level Incident ("HLI") investigations into serious untoward incidents at the Trust which occurred on 30 October 2011 and 5 February 2012, when you knew this to be the case. Found proved 9. On 1 February 2013, you sent an inappropriate email to Dr G at 06:44 and 07:30 in which you asked her to tell the GMC Interim Orders Panel ("IOP") that she was aware of the two HLIs and their outcome and as a result they were not mentioned in the appraisal on 25 May 2012: a. when you had not established this with her; Found proved b. when you knew that you had not mentioned them. Found proved 10. On 7 February 2013, you sent an inappropriate email to Dr G at 14:08 and 14:38 in which you asked her to amend her statement to the IOP to state that you had told her during your appraisal that you were not involved in any critical incidents due to your performance or with any further action as far as you were concerned, and that was why she had not included it in your appraisal, when you knew this was untrue. As amended, found proved Hull and East Yorkshire Women & Children’s Hospital 11. In August 2012 you submitted an application form for the position of CCT Fellow in Obstetrics and Gynaecology at Hull and East Yorkshire Women and Children's Hospital in August in which you: a. answered ‘No’ to the question ‘Are you currently the subject of a fitness to practise investigation or proceedings...by a regulatory body in the UK...’ when you knew this was untrue; Found proved b. stated that the ‘GMC hearing committee on 13/12/10 investigated allegation that I assaulted a colleague on 17/03/10 (sic). He is in fact assaulted me. GMC issued a warning for me despite their decision was quashed by High Court’ when you knew that:

FTP: Dr LOUTFI

4

Record of Determinations – Medical Practitioners Tribunal i. the assault took place in March 2009; Found proved ii. the original warning was imposed on your registration in November 2009; Found proved iii. the High Court had remitted the matter back to the GMC and you were again issued with a warning; Found proved c. failed to state that the warning imposed on your registration on 14 December 2010 would remain on your registration for five years; Found proved d.

failed to record under the heading of ‘Employment History’ details of: i. your most recent employment at St. Mary's Hospital, Manchester; Found proved ii. your previous employment in 2009 with Mid Yorkshire Hospitals NHS Trust. Found proved

12. Your intention at paragraph 11d) above was to deny Hull and East Yorkshire Women & Children's Hospital the opportunity of contacting those institutions, knowing that they may disclose information relating to adverse incidents. Found not proved 13. You were subsequently interviewed for the position of CCT Fellow on 7 September 2012, at which time you stated that there were no other issues with the GMC, or words to that effect, when you knew that you were the subject of a GMC fitness to practise investigation. As amended, found proved a. failed to disclose that you were still subject to a GMC warning on your registration; Withdrawn b. stated that there were no other issues with the GMC, or words to that effect, when you knew that you were the subject of a GMC fitness to practise investigation. Inserted in stem of Paragraph 13

FTP: Dr LOUTFI

5

Record of Determinations – Medical Practitioners Tribunal 14. During an investigatory meeting on 2 January 2013 you falsely stated that with the knowledge you had at the time, you were not subject to a fitness to practise investigation at the time of your application and interview, and that what had happened had been completed and concluded, or words to that effect, when you knew this was untrue. Found proved 15. Your acts and omissions at paragraphs 6, 7, 8, 9, 10, 11, 13 and 14 above were: a. misleading; Found proved in relation to paragraphs 6, 7(a), 7(b), 8(a), 8(b), 9(a), 9(b), 10, 11(a), (b), (c), (d), 13 and 14 b. dishonest. Found proved in relation to paragraphs 6, 7(a), 7(b), 8(a), 8(b), 9(a), 9(b), 10, 11(a), (b), (c), 13 and 14 Found not proved in relation to paragraph 11(d) And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct. Attendance of Press / Public The hearing was all heard in public. Determination on the Admission of Hearsay Evidence Ms Cundy: 1. You made an application, on behalf of the General Medical Council (GMC), to call Ms H to give evidence by telephone. The Tribunal has noted the cogent medical evidence provided by you and that there was no objection from Dr Loutfi as to the use of telephone evidence in this particular instance. The Tribunal is therefore minded to allow Ms H to present her oral evidence by telephone link. 2. You made an application, to admit into evidence the witness statement and other documentary evidence from Ms I. The basis of your application was that Ms I is not well enough to give evidence to this tribunal in any other form. You submitted that the evidence in the statement is both relevant and fair. 3. Dr Loutfi did not take issue with the relevance of the evidence but advanced arguments against its fairness.

FTP: Dr LOUTFI

6

Record of Determinations – Medical Practitioners Tribunal 4. The Legal Assessor advised that the Tribunal should approach the issue in two stages; the first stage being to consider the strength of the evidence to support your contention that Ms I is not well enough to participate further; the second, to apply the principle of proportionality, weighing in the balance the respective interests of the GMC and those of Dr Loutfi. 5. The evidence in support of your application is contained in a three-page document (C7) comprising an email chain between your instructing solicitor, Mrs K, and the witness herself, and a letter, dated 14 December 2015 from the witness’ GP, Dr J. 6. The effect of the evidence you have adduced establishes that Ms I was certified unfit for work as early as September 2015 (due to work-related stress). She has since, at the turn of the year, returned to work albeit on a phased basis. Dr J offered no opinion as to the effect upon the witness of her participating in these proceedings; the evidence that she is unfit to attend comes from Ms I alone. Ms I states in her email of 14 December 2015 “I would like to confirm that I will be unable to attend as discussed.” Dr J reports in his letter of 14 December 2015 that Ms I “feels [attending the GMC hearing] may exacerbate her stress and hinder her return to work”. The Tribunal notes that Ms I has informed you that she is currently engaged in a phased return to work. 7. The Tribunal has weighed the interests of the GMC with those of Dr Loutfi. You raised the issue of patient safety, Dr Loutfi the principle of fairness. His case is that to admit the evidence unchallenged would constitute a significant degree of unfairness which would seriously disadvantage him in defending the case he has to meet. 8. The tribunal has considered the balance of fairness and has determined that, due to the potential importance of this evidence to the case advanced by the GMC, the interests of fairness require that Dr Loutfi be afforded the opportunity to challenge it by cross-examination. The Tribunal, having considered the material at C7, has determined that it is insufficient to support your contention that Ms I is not fit enough to participate. The balance, therefore, falls in favour of Dr Loutfi’s interests in being able to secure a fair hearing. 9.

This application is dismissed.

Determination on Facts Dr Loutfi: 1. Ms Cundy outlined the background to this case thereafter making an application under Rule 17(6) of the General Medical Council (GMC) (Fitness to Practise) Rules 2004 (the Rules), as amended, to make amendments to paragraphs

FTP: Dr LOUTFI

7

Record of Determinations – Medical Practitioners Tribunal 2(c), 4(a) and 13 of the allegation in the interests of accuracy. She submitted that the amendments would more correctly define the allegation against you and could be made without any injustice to you. 2. The Tribunal considered this and noted that you did not oppose the application. Ms Cundy’s application was granted on the basis that it was in the interests of fairness and accuracy and that there would be no injustice to you in doing so. 3. During the course of presenting her case on behalf of the GMC, Ms Cundy made a further application under Rule 17(6) to withdraw paragraph 3 of the allegation which relates solely to Patient B. She submitted that the evidence before the Tribunal was insufficient on which it could make a finding. You did not oppose this application. The Tribunal acceded to this. 4.

Paragraph 3 of the allegation was withdrawn.

5. The allegation was amended accordingly as shown in the findings of fact set out later on in this determination. Witness Evidence by Telephone Conference Call / Video Link 6. Ms Cundy made application for the Tribunal to hear the evidence of two GMC witnesses, Dr L and Ms H by telephone conference call, in accordance with Rule 34(13). 7. Ms Cundy told the Tribunal that Dr L had declined to travel to Manchester to appear in person. Ms Cundy outlined that the area of Eire in which Dr L resided had poor internet connection which precluded her giving evidence via video link and was concerned that in travelling to Manchester or an acceptable centre to facilitate a video link would inconvenience her elderly parents for whom she was the main carer. 8. In relation to the evidence of Ms H, Ms Cundy told the Tribunal that Ms H was unwell and she was genuinely concerned that attending to give live evidence would cause her a significant setback. 9.

You did not oppose the application in relation to either of these witnesses.

10. The Tribunal was mindful of the professional and personal circumstances of these two witnesses and considered that it was unfair to ask them to make themselves available in person at this time. The Tribunal was aware that the giving of evidence by telephone is a commonly used method in these hearings and that they wished to hear the witnesses’ accounts of the material events. 11. In all the circumstances the Tribunal determined that it would be in the interests of the efficient and effective administration of justice to hear the evidence

FTP: Dr LOUTFI

8

Record of Determinations – Medical Practitioners Tribunal of the GMC witnesses by telephone conference call and it therefore granted Ms Cundy’s application. 12. You also made an application for two of your witnesses to give their evidence by either telephone conference call or by video link. You told the Tribunal that Dr M was based in Portsmouth and had professional commitments from which he could not absent himself, although he could make himself available for a short period to give evidence on your behalf by telephone. 13. In relation to your second witness, Dr N, you told the Tribunal that he is now residing in Riyadh, Saudi Arabia, and could not be expected to travel to Manchester to give evidence on your behalf. You said that you believed that Dr N would be available to give evidence by telephone or video link if a suitable facility could be located. 14. Ms Cundy did not oppose your application. 15. The Tribunal noted that you had not provided formal witness statements from either Dr M or Dr N. It made it clear that you would be expected to provide the Tribunal with those statements prior to the two witnesses giving their evidence. The Tribunal considered the circumstances which, you submitted, prevented your witnesses attending these proceedings, and determined that, in principle, it would be reasonable to allow them to give evidence by either telephone or video link. However, the Tribunal stressed that this would only be accommodated after signed witness statements had been received from Drs M and N. It also stressed that it was your responsibility to organise the attendance, one way or another, of your witnesses and obtain their contact details. Evidence 16. Ms Cundy made an application under Rule 34 to admit into evidence the witness statement and other documentary evidence from Ms I on the basis that Ms I has declined to be present at these proceedings and that her evidence is relevant to these proceedings. The Tribunal did not grant Ms Cundy’s application for the reasons given in its written determination issued previously. 17. The Tribunal gave careful consideration to all the evidence adduced in this case, both oral and documentary, including your witness statement, your own bundle of supporting documents and your closing submission document dated 25 January 2016. The Tribunal has taken account of the submissions made by Ms Cundy, on behalf of the GMC, and those made by you. 18. The Tribunal also considered the oral evidence of the following witnesses on behalf of the GMC, together with their signed witness statements:

FTP: Dr LOUTFI

9

Record of Determinations – Medical Practitioners Tribunal                 

Patient A, treated at Liverpool Women’s Hospital Dr O, ST3 Trainee Anaesthetist at St Mary’s Hospital, Manchester at the time of the events in question Ms P, Band 6 Midwife at St Mary’s Hospital, Manchester Ms Q, Band 7 Midwife at St Mary’s Hospital, Manchester Dr L, Junior Registrar in Obstetrics & Gynaecology at St Mary’s Hospital, Manchester at the time of the events in question (via telephone conference call) Dr R, ST4 in Obstetrics & Gynaecology at St Mary’s Hospital, Manchester, at the time of the events in question Ms S, Band 6 Midwife at St Mary’s Hospital, Manchester Ms H, Band 7 Midwife at St Mary’s Hospital, Manchester (via telephone conference call) Dr T, Consultant Obstetrician at St Mary’s Hospital, Manchester Dr U, Consultant Obstetrician and Gynaecologist and Clinical Director for Women’s Health at Hull and East Yorkshire Women & Children’s Hospital Ms V, Human Resources Manager at Hull and East Yorkshire Hospitals NHS Trust at the time of the events in question. Dr W, Consultant Obstetrician at St Mary’s Hospital, Manchester and Clinical Director of Obstetrics at the Central Manchester University Hospitals NHS Foundation Trust Dr G, Consultant in Obstetrics and Gynaecology at the Central Manchester University Hospitals NHS Foundation Trust Dr X, Consultant Obstetrician at St Mary’s Hospital, Manchester Mr F, Consultant Obstetrician and Medical Director at the Birmingham Women’s NHS Foundation Trust Mr Y, Consultant in Obstetrics and Maternal Medicine at the Birmingham Women’s Hospital (via video link) Mr Z, Consultant in Obstetrics & Gynaecology and the GMC expert witness

19. The Tribunal considered the oral evidence of Mr C2, Consultant Gynaecologist and Clinical Director of Gynaecology at Liverpool Women’s Hospital, together with his written testimonial. It has also carefully considered your oral evidence, as well as the written statement that you provided to the Tribunal. Witnesses Mr Z 20. The GMC engaged Mr Z as an Expert witness in these proceedings. The Tribunal was mindful that the role of an expert is to assist the Tribunal on specialist or technical matters that are within that witness’s area of expertise and that to fulfil that role, the witness will have had to consider all the evidence available, including statements and reports from other parties to the proceedings before providing an opinion to the Tribunal.

FTP: Dr LOUTFI

10

Record of Determinations – Medical Practitioners Tribunal 21. Mr Z is a practising Consultant in Obstetrics and Gynaecology whose CV and Reports had been available for scrutiny by you for a sufficient time to enable you to have raised any challenge to his standing as an expert. At no time, prior to you being cross examined by Ms Cundy did you take issue with his standing as an expert in these proceedings. You called no third party evidence to rebut Mr Z’s opinions, neither did you submit in closing your case that his standing as an expert was in any way questionable. That notwithstanding, since you raised a challenge the Tribunal went onto consider afresh Mr Z’s qualification as an Expert. 22. Having considered his CV and the manner in which he addressed all the issues falling within his area of apparent expertise, the Tribunal determined that there was insufficient force in your challenge to undermine in any way Mr Z’s qualifying as an expert witness. Dr Ahmed Loutfi 23. In assessing you, Dr Loutfi, as a witness, the Tribunal was faced with the situation made less than straightforward in two significant respects. As to reliability, the Tribunal has scrutinised the various instances in which you have reported your recollection of events. References to these instances are to be found in this determination wherever it has proved appropriate to deploy them for the purpose of explaining the Tribunal’s reasoning. In particular, the Tribunal has noted frequently that your versions of events lack consistency. Furthermore, they are, more often than not, contradicted by the evidence adduced by the GMC, either by oral testimony or contemporaneous records, or by both. 24. This lack of consistency leads the Tribunal to conclude that you are not a reliable historian; and it has looked at the independent evidence to find support for the assertions you have made throughout these proceedings. Where it has been unable to find evidence and support, it has favoured the reliability of the evidence which contradicts that which you assert. The effect of this is that the Tribunal has frequently preferred the evidence of others to that of you. 25. As to your honesty as a witness, the Tribunal has listened to your explanations for your own acts and omissions and has determined that some of them are unburdened by the probability of their being true. The Tribunal has identified these instances, where appropriate to do so, elsewhere in this determination. Background

Patient A 26. In 2010 you were working at the Liverpool Women’s Hospital (LWH) as a Locum Senior Registrar in Obstetrics and Gynaecology.

FTP: Dr LOUTFI

11

Record of Determinations – Medical Practitioners Tribunal 27. Patient A attended the emergency room at LWH on 25 April 2010 in early pregnancy with vaginal bleeding where she was assessed and an appointment made for a trans-vaginal ultrasound scan on 29 April. As planned, she attended for the scan which disclosed the existence of an intrauterine gestational sac with no foetal pole. A further plan was made to undertake a beta HCG blood test that day and for her to return two days later for a further beta HCG blood test. 28. Later on 29 April Patient A had to re-attend as the severity of her symptoms had increased with the additional symptoms of pain in her right breast and shoulder. Patient A was seen by Miss B2 (Consultant Obstetrician) who performed a Trans vaginal ultrasound scan which demonstrated a ‘mass inferior to R (right) ovary? Ectopic’. Miss B2 appraised patient A of this and informed patient A that she was to be admitted to the hospital as an in-patient for intramuscular pain relief and a further beta HCG blood test. Patient A was also made aware that, depending upon the results of the blood test, she may need to be taken to theatre for operative intervention. 29. Whilst she was waiting to be admitted to a ward, you attended patient A, further examined her and told her that she did not have an ectopic pregnancy and that she was probably having another miscarriage and that the additional symptoms she was experiencing, namely her shoulder pain, were probably due to a pulled muscle. According to Patient A’s account, you then advised Patient A that she be discharged home with paracetamol for pain relief despite Patient A’s challenging your diagnosis and management plan in light of what Miss B2 had already diagnosed and advised. 30. You saw Patient A again on 1 May 2010 where you again diagnosed her with an incomplete miscarriage and discharged her with the advice to return in three weeks for another pregnancy test and, according to Patient A’s account, to go home and try for another baby. 31. On 3 May 2010, Patient A was taken to theatre to be operated on by Mr C2 who performed a right sided salpingectomy (removal of the right fallopian tube) secondary to the presence of a Right sided ectopic (tubal) pregnancy. Histology of the tissue removed by Mr C2 confirmed ’Fallopian tube, right: Ectopic gestation’. 32. Patient A made a complaint to the hospital about the care and treatment she had received. LWH undertook an investigation but the complaint was not resolved to Patient A’s satisfaction and she referred it to the Parliamentary Health Service Ombudsman who carried out their own independent investigation into the complaint.

Patient C 33. In October 2011 you were working as a locum specialist registrar at St Mary’s Hospital in Manchester, part of Central Manchester University Hospitals NHS Foundation Trust (CMFT). You were dealing with the delivery of the baby of Patient

FTP: Dr LOUTFI

12

Record of Determinations – Medical Practitioners Tribunal C. You were presented with a foetal blood sample result which showed severe foetal distress giving a clear indication that the baby needed to be delivered urgently. 34. It is alleged that, on examination, you concluded that Patient C’s cervix was fully dilated and you decided that the patient should go to theatre for a trial of delivery by forceps under spinal anaesthesia. Midwives in attendance raised concerns at your decision and informed the on call consultant, Dr X of your decision. The consultant instructed that Patient C should be taken to theatre and, if the patient was fully dilated and the baby was immediately deliverable, then a vaginal delivery could be undertaken. If this was not the case, then delivery by caesarean section should be carried out under general anaesthesia. A delivery by forceps was not possible and the baby was delivered by caesarean section under general anaesthesia. During this delivery it became apparent that Patient C’s uterus had ruptured and she required an emergency hysterectomy.

Patient D 35. On 26 May 2013 you were working as a locum Senior Registrar at Birmingham Women’s Hospital (BWH). Patient D had been admitted to hospital for induction of labour due to hypertension. It appeared that the foetal head was in the occipito-transverse position and you used Kiellands forceps to attempt to rotate the foetal head to the occipito-anterior position which was unsuccessful. You then rotated the foetal head to the occipito-posterior position to deliver the baby which involved two pulls of the forceps. Subsequent to delivery, an ischaemic injury to the left side of the baby’s brain was identified as well as a right-sided depressed skull fracture. It is alleged that your actions in this regard were inappropriate. 36. During the subsequent investigation into this incident, you had told a colleague that you had previously performed this manoeuvre and procedure, using Kiellands forceps, under the direct supervision of a consultant at the hospital. 37. On 3 January 2012, you applied for the post of Locum Consultant Obstetrician and Gynaecologist at CMFT. In your application, it is alleged you failed to disclose information relating to your registration status and previous GMC investigations. 38. In August 2012 you applied for the post of CCT Fellow in Obstetrics and Gynaecology at Hull and East Yorkshire Women and Children’s Hospital (HEY). It is alleged that, again, you failed to disclose details of your registration status and ongoing GMC investigations. It is further alleged that you omitted to include details of your previous employment with Mid Yorkshire Hospitals NHS Trust and your most recent employment at St Mary’s Hospital Manchester. 39. It is alleged that your actions and omissions in relation to the two employment applications in January 2012 and August 2012 were misleading and dishonest.

FTP: Dr LOUTFI

13

Record of Determinations – Medical Practitioners Tribunal Tribunal Approach 40. The Tribunal has borne in mind that the burden of proof rests on the GMC and that the standard of proof is that applicable to civil proceedings, which is the balance of probabilities. The standard is met if the Tribunal is satisfied that, based on the evidence, it is more likely than not that what is alleged to have occurred did occur. 41. In relation to the allegation of dishonesty, the Tribunal accepted the advice of the Legal Assessor and has considered whether, according to the ordinary standards of reasonable and honest people, what you did was dishonest, and whether you realised at the time that what you were doing was dishonest by those standards. The Legal Assessor advised that if the Tribunal finds an act or omission to have been dishonest it can only properly do so on the evidence admissible to the specific paragraph to which the dishonesty allegation applies. In this way the Tribunal has judged each allegation of dishonesty on its own merits and by reference to evidence only specifically relevant. 42. In respect of the use of the word “failed” in a number of paragraphs of the allegation, the Tribunal has borne in mind that, in order to prove that someone has failed to do something, it is necessary to prove not only that it was not done but that there is a requirement that it be done. 43. The Tribunal has accepted the advice of the Legal Assessor that it must avoid speculation at all time, although it is entitled to draw inference from the evidence before it; that is to say to reach common sense conclusions from that which the Tribunal has heard. Such common sense conclusions must be reasonably capable of being reached from a proper evaluation of the evidence. 44. In relation to the GMC’s expert witness evidence, the Legal Assessor told the Tribunal that expert evidence is called with a view to assisting it and that the opinion of an expert is admissible to furnish the Tribunal with information which is likely to be outside its experience and knowledge. He advised that the expert evidence is opinion evidence and the Tribunal is not bound by that opinion. However, he advised that a coherent reasoned opinion expressed by a suitably qualified expert should be the subject of a coherent reasoned rebuttal, i.e. the Tribunal should provide an explanation as to why it has rejected that opinion. Tribunal Findings 45. The Tribunal has considered each paragraph of the allegation separately and has made the following findings on the facts:

FTP: Dr LOUTFI

14

Record of Determinations – Medical Practitioners Tribunal

Patient A Paragraph 1 On 29 April 2010, while working at the Liverpool Women's Hospital you: a. incorrectly diagnosed Patient A with an incomplete miscarriage; Found proved 46. The facts of this case are outlined in paragraphs 24 to 28 above. There is clear reference to Miss B2, prior to your seeing Patient A, having diagnosed a possible ectopic pregnancy and having formulated a management plan for the patient to be followed which included admitting the patient to hospital. 47. The Tribunal has noted from the hospital records that, on 29 April, despite Miss B2’s diagnosis, you initially gave a provisional diagnosis of “incomplete miscarriage.” Subsequently, you gave a final diagnosis of “incomplete miscarriage” with a treatment plan of “reassurance”. In your oral evidence, you told the Tribunal that it was Miss B2 who had made this diagnosis. However, the Tribunal does not accept this as the only reference to “incomplete miscarriage” annotated in the records is by you. 48. The Tribunal has had regard to the triage assessment form in respect of Patient A which referred to a positive pregnancy test, right shoulder tip pain, vaginal bleeding, and that the diagnosis, at best, was a pregnancy of unknown location (PUL). Later that day, the hospital records show that there was an increase in right shoulder tip pain, which Mr Z addresses in his report of 12 April 2014, re-emphasising that, at the time of your diagnosis of Patient A, the location of the pregnancy had not been established and an ectopic pregnancy could not and should not have been discounted. In his oral evidence, Mr Z told the Tribunal that Patient A presented with symptoms which were typical of a ruptured ectopic pregnancy. b. formed an inappropriate initial management plan to discharge Patient A; Found proved 49. According to Patient A, you told her that she did not have an ectopic pregnancy, but was probably having a miscarriage, and that the shoulder pain was probably due to a pulled muscle. You then told Patient A that she could be discharged with pain relief. 50. Patient A was a midwife at LWH and was well aware that an ectopic pregnancy could be life-threatening. She challenged your conclusions and asked you to check the care management plan with Miss B2, the consultant in charge. According to Patient A you then went to see Miss B2 and, on your return, confirmed the plan. The Tribunal accepted the evidence of Patient A. Her various reportings of events were unwavering; neither were they inconsistent with any of the contemporaneously made records. For reasons which are explained elsewhere in this

FTP: Dr LOUTFI

15

Record of Determinations – Medical Practitioners Tribunal determination, the fact of patient A’s evidence being at odds with your case is not a matter which troubled the Tribunal to conclude she was anything other than a reliable witness to the events to which she testified. Despite your accusing her of lying, the tribunal is content to treat her as a truthful witness. 51. Mr Z’s evidence was that your initial management plan was not appropriate because Patient A’s condition was classed as PUL and she had increasing right shoulder tip pain as evidenced by her medical records. It was his opinion that your plan to discharge this patient was completely inappropriate, particularly as a reasonable care plan was already in place. Furthermore, the risk of discharge at that point was maternal death. 52. The Tribunal accepted the evidence of Mr Z which was clear and emphatic that the initial management plan to discharge Patient A on 29 April 2010 was highly inappropriate. c. were dismissive of the information Patient A gave you about her planned admission; Found proved 53. It is clear to the Tribunal that the clinical signs and symptoms at that time suggested that admission would have been the only reasonable course of action to follow. Despite the evidence of the recordings made by colleagues you arrogated to yourself the certainty of the accuracy of your diagnosis to the exclusion of the differential diagnoses expressed by colleagues, strongly supported, as they were, by empirical evidence. When Patient A told you that she had already been seen by Miss B2 and described Miss B2’s management plan to you, you did not accept this from Patient A. It was only after you had spoken directly to Miss B2 that you agreed to admit Patient A. d. refused to prescribe Patient A stronger analgesia despite her pain. Found not proved 54. Patient A told the Tribunal that she had asked for stronger pain relief but you had refused her request. You told the Tribunal that you had restricted her analgesia to paracetamol because any stronger pain relief could have masked any signs of internal bleeding. It is clear from the medical notes that it is recorded that the Patient did not pursue the issue of stronger analgesia. On 7 February 2013 in an email to the GMC, she agreed that she eventually received an injection of morphine some six hours following her admission to hospital. On the evidence provided to it, the Tribunal is not satisfied that you “refused” to prescribe stronger analgesia to Patient A. Paragraph 2 On 1 May 2010 you:

FTP: Dr LOUTFI

16

Record of Determinations – Medical Practitioners Tribunal a. incorrectly diagnosed Patient A with an incomplete miscarriage; Found proved 55. The Tribunal has noted the entry in Patient A’s medical notes of 1 May 2010 of “incomplete miscarriage” which was signed and dated by you. It has also had regard to paragraph 21 of your witness statement which states: “I next met with Patient A on 1 May 2010 and having assessed her notes and

considered her care, I concluded a diagnosis of incomplete miscarriage was the most likely diagnosis based on Patient A’s clinical findings, scan results and investigation results.” 56. In your oral evidence you were adamant that this was an incomplete miscarriage and that Miss B2 had “got it wrong”, despite Miss B2 recording in the patient’s medical records “? Ectopic – Admit”. Also, in an e mail of 24 November 2012 (06:26) you remained adamant that the diagnosis of incomplete miscarriage was the most likely, despite overwhelming conclusive evidence that this was indeed an ectopic pregnancy. Mr C2’s operative intervention on 3 May 2010, the resultant operation note, intraoperative photographs and resultant histology on tissue removed indicated beyond all reasonable doubt that Patient A had an ectopic pregnancy. On the basis of the documentary evidence before it, the Tribunal is satisfied that you incorrectly diagnosed Patient A with an incomplete miscarriage. b. failed to ensure that Patient A was appropriately followed up; Found proved 57. The Tribunal has noted your entry in Patient A’s medical records that Patient A should undergo a further pregnancy test after three weeks. It was the evidence of Mr Z and Mr C2 that, if it had been a miscarriage, she could have been discharged home but should return one week later for a further pregnancy test. This policy is also confirmed in the hospital’s guidelines. The Tribunal has had regard to Mr Z’s initial report in which he stated that the decision to repeat the pregnancy test after three weeks was inappropriate and did not ensure timely follow up. It was his opinion that, as a minimum, a urine pregnancy test after one week should have been advised. He reiterated this opinion in his oral evidence. The Tribunal accepted the evidence of Mr Z and Mr C2 on this point. c. spoke to Patient A in an inappropriately manner in that you told her to go home and try for another baby. As amended, found proved 58. The Tribunal accepted the clear and consistent evidence of Patient A that you told her to go home and try for another baby. Mr Z and Mr C2 agreed that it was inappropriate and that the patient should wait until after her next menstrual cycle before trying to conceive. In their oral evidence, Mr C2 and Mr Z concurred that it was inappropriate to suggest that, if the pregnancy test was negative, Patient A

FTP: Dr LOUTFI

17

Record of Determinations – Medical Practitioners Tribunal could try for another baby straight away. In your evidence you told the Tribunal that you had never heard of the practice of a patient waiting for her next menstrual cycle before attempting to conceive. The Tribunal is satisfied that your advice to Patient A to go home and try for another baby was inappropriate. Patient B 1.On 5 February 2012, while working at St Mary's Hospital, Manchester you proposed an inappropriate management plan for Patient B to commence a syntocinon infusion at 15:50 hours. Withdrawn by the GMC

Patient C Paragraph 4 On 30 October 2011, while working at St Mary's Hospital, Manchester you: a. made an inappropriate initial decision to proceed with a trial of operative vaginal delivery under spinal anaesthesia for Patient C; As amended, found proved 59. Patient C was a woman who was expecting her fifth child. She presented with a recognised severe foetal acidosis at 9cm dilation at the time of the handover of her care to you. At handover, a foetal scalp blood test had shown the pH level was at 6.97 which was very low. According to the evidence of the two midwives present at the time, delivery was planned in the operating theatre and you were happy for the patient to be given a spinal anaesthetic before attempting instrumental delivery. 60. In his report Dr Z stated that the decision to proceed with a spinal anaesthetic was flawed and inappropriate. In his opinion there was a need for rapid intervention that was failsafe, and that an attempt at undertaking a spinal anaesthetic in this situation could potentially have failed and there would then have been a need to proceed to general anaesthetic which would have wasted time in an emergency situation and ultimately cause harm to the baby. However, Mr Z conceded that when you took over the care of Patient C you were placed in an unenviable position as there had already been a series of obstetric interventions and assessments by others. 61. In your evidence you told the Tribunal that you had not made the decision for a spinal anaesthetic to be given to Patient C and that it was not your job to decide on the type of anaesthesia to be administered. The Tribunal did not accept your assertion that the decision was for the anaesthetist alone to make. Consultation and cooperation between the doctor carrying out the procedure and the anaesthetist are not only common sense propositions but Mr Z spoke of the need for the specialisms to pool their experience in such a situation. Mr Z went on to say that in his opinion it would be the obstetrician’s decision that would hold sway absent any objections

FTP: Dr LOUTFI

18

Record of Determinations – Medical Practitioners Tribunal raised by reason of the anaesthetist’s specialism in how best the patient could be appropriately anaesthetised. The Tribunal was of the opinion that, given the very low pH level, it was your responsibility to alert the anaesthetist to the urgency of the situation to ensure the safety of both mother and baby. Whilst accepting an anaesthetist will have the final say in what form of anaesthesia he/she will perform, his /her decision can only be made when the urgency and relevant clinical facts are shared with him/her. In these circumstances, the Tribunal is satisfied that, by your abrogating responsibility to the anaesthetist, your initial decision to proceed with delivery under spinal anaesthetic was inappropriate. b. failed to advise immediate delivery by Caesarean section under general anaesthesia; Found proved 62. On the evidence provided to the Tribunal, it is clear that you did not request an immediate delivery by Caesarean section under general anaesthesia and there is no witness evidence to support your claim that it was not you who had requested spinal anaesthesia. Mr Z’s evidence was that the very low pH level indicated that an urgent delivery was required by Category 1 caesarean section, ie delivery within 30 minutes. In her oral evidence, Dr X told the Tribunal that Midwife I had called her urgently because of your decision to proceed with delivery under spinal anaesthetic when the pH level was 6.97. The Tribunal is satisfied that you failed to advise immediate delivery by caesarean section and that it was your duty to have done so. Paragraphs 4(a) and 4(b) are facets of the same allegation. c. misdiagnosed full dilation of Patient C’s cervix. Found proved 63. When you examined Patient C prior to transfer to the operating theatre you thought that her cervix was fully dilated. You stated that your first examination of Patient C was conducted whilst she was in a sitting position and you thought she was fully dilated. On arrival in the operating theatre you examined her again and concluded that the cervix was not fully dilated. 64. Throughout this hearing you have held yourself out to be a very experienced obstetrician. Mr Z stated that he would find it difficult to accept that an obstetrician of such experience could have made a mistake as to whether the cervix was fully dilated or not, regardless of the position of the patient. Whilst it did not affect the outcome of this particular case, Mr Z was critical of the fact that an obstetrician of your experience could have made such a simple error.

Patient D Paragraph 5 On 26 May 2013, while working at Birmingham Women's Hospital, you:

FTP: Dr LOUTFI

19

Record of Determinations – Medical Practitioners Tribunal a. inappropriately rotated the fetal head of Patient D's baby to the occipito-posterior position when rotation to the occipito-anterior position had failed; Found proved 65. Patient D was admitted for induction of labour and was consented for a trial of forceps delivery or caesarean section, if necessary. After approximately 18 hours in theatre and with a developing pathological cardiotocograph (CTG), vaginal delivery was attempted. At the time of delivery you were of the opinion that the foetal head was “very low in the pelvis”; this is not borne out by the medical records which confirmed that the foetal head was in the mid cavity. In your oral evidence you concluded that “by UK definition it was mid cavity.” The foetal head was in the right occipito-transverse position. Using Kielland’s forceps you attempted to rotate the foetal head to the occipito-anterior position which failed. You then rotated the foetal head to the occipito-posterior position. 66. Mr Z was adamant that this should not have been done. Although the Tribunal recognised that Mr Z was not a current Kielland’s forceps practitioner, he had used the instruments in the past and was aware of the relevant guidance and technicalities of when and when not to use the instrument. The Tribunal also had regard to the evidence of Mr F who stated that, during the investigation in this matter, the hospital had asked all Kielland’s forceps practitioners whether it was appropriate to rotate the foetal head to the occipito-posterior position after rotation to the occipito-anterior position had failed. It was their unanimous opinion that this would not be good practice and that the foetal head was not low enough in the pelvic cavity to undertake successfully a manoeuvre such as this. 67. In his report, Mr Z was critical of your contemporaneous documentation in which you described the foetal head as being at least 1 cm below the ischial spines which is not in keeping with a head being “very low”. In his opinion, the rotation to the posterior position was inappropriate. 68. Mr Y, who was an experienced Kielland’s forceps practitioner at the Birmingham Hospital, told the Tribunal that “generally we do not rotate mid cavity; if we did, we could get the position wrong”. Mr Y’s opinion indicates to the Tribunal that this is not an acceptable procedure and it certainly was not in the case of Patient D. b. applied inappropriate force to deliver Patient D’s baby. Found not proved 69. The Tribunal has noted from Mr Z’s report that he is of the opinion that, given the diagnosis of a skull fracture and the manner in which the forceps delivery was conducted, the level of force used by you to deliver the baby was inappropriate. However the Tribunal has not been provided with any evidence to confirm the level of force used. It is not clear whether it was the rotation or the level of force used

FTP: Dr LOUTFI

20

Record of Determinations – Medical Practitioners Tribunal that was inappropriate in the delivery of this baby. Therefore the Tribunal is not satisfied that this paragraph of the allegation can be found proved to the requisite standard. Paragraph 6 In a letter dated 25 July 2013 to Miss E you stated you had ‘delivered another patient by Kielland's forceps after rotation to occipito-posterior position when anterior rotation was difficult under direct supervision of Mr F’, when you knew this was untrue. Found proved 70. The Tribunal has had sight of your letter to Ms E, Consultant in Foetal Medicine at BWH, dated 25 July 2013, in which you stated: “I remember that the patient delivered on 26/05/13 with approval and indirect

supervision of Mr Y. The head was very low and impacted in the pelvis and rotation to anterior position was not easy and abundant. Rotation to posterior position was very easy and the patient delivery smoothly with reasonable force and maybe within two tractions with episiotomy and without vaginal lacerations or third stage complications. I told Mr Y about the rotation to occipito-posterior position and the delivery and he did not criticise my practice and in fact appreciated my skills.” “I remember that I delivered another patient by Kielland’s forceps after rotation

to occipito-posterior position when anterior rotation was difficult under direct supervision of Mr F without any criticism and in fact Mr F always trusted my Kielland’s forceps skills” The Tribunal has also had regard to your email, dated 22 September 2013, to Miss E. In your email you stated:

“You are right I was supervised indirectly by Mr F using Kielland’s forceps but I

was supervised directly by Mr Y using Kielland’s forceps at least in two occasions.”

71. In your oral evidence, you said that you had been supervised directly by Mr F when you delivered another baby by Kielland’s forceps after rotation to the occipitoposterior position when rotation to the occipito-anterior position was difficult. Mr F stated that he was not a Kielland’s forceps practitioner and would not have supervised anybody in a procedure involving their use. Mr Y stated that he had never supervised you using Kielland’s forceps to rotate to the occipito-posterior position although he had supervised you using Kielland’s forceps on one or two occasions. 72. You admitted that Mr F was at the doorway of the theatre and you said that you had discussed with him specifically the matter of rotation. You said that it was a

FTP: Dr LOUTFI

21

Record of Determinations – Medical Practitioners Tribunal rare procedure but that you had undertaken two such procedures within a six-week period. In his evidence Mr F stated that, whilst he recalled a conversation with you, he did not recall any discussion about this rotation to the occipito-posterior position and, in any event, he would not have supervised somebody using Kielland’s forceps because it was such a long time since he had used them. The Tribunal also accepted the evidence of Mr F that, from where he was standing, he would have been unable to observe the delivery. 73. The Tribunal accepts the evidence of Mr F and Mr Y on this issue. The Tribunal is satisfied that when you claimed that you had delivered another patient by Kielland’s forceps after rotation to occipito-posterior position when anterior rotation was difficult, under the direct supervision of Mr F, you knew that it was untrue.

Central Manchester University Hospitals NHS Foundation Trust (‘CMHT) Paragraph 7 On 3 January 2012 you completed an application form for the post of Locum Consultant Obstetrician and Gynaecologist at the Trust in which you failed to disclose that you: a. were subject to a warning issued by the Investigation Committee of the GMC on 14 December 2010; Found proved 74. A warning was reimposed on your registration on 14 December 2010 for a period of five years until 13 December 2015. You did not disclose the warning on your application form although the wording on the form imparted a clear obligation to do so. You told the Tribunal that you did not agree to the imposition of the warning and that you had “put the warning out of [your] head.” The Tribunal rejects your explanation as being incredible. b. had been the subject of separate GMC fitness to practise proceedings in 2010 which were subsequently closed with advice. Found proved 75. The Tribunal has been provided with a copy of the application form in which there is a question “Have you been or are you currently subject to any fitness to practise proceedings by an appropriate licensing or regulatory body in the UK or in any other country?” You did not answer either “yes” or “no” and left this section blank. 76. The Tribunal has had regard to the GMC’s letter to you, dated 15 November 2010. In this letter the GMC referred to another allegation that you failed to disclose details of the GMC investigation on an application form for employment at another Trust which specifically asked whether or not you were under investigation. At that time you admitted that you had failed to include the ongoing investigation in your

FTP: Dr LOUTFI

22

Record of Determinations – Medical Practitioners Tribunal application because you had appeared before an Interim Orders Panel and no action was taken on your registration. As a result, you believed that the investigation had concluded and that there was no necessity to include it in an employment application. 77. In their letter of 15 November 2010, the GMC stated: “Probity is very important in the relationship between doctors, patients and

employers. It is possible that Dr Loutfi would not have been employed in Liverpool had he properly declared the ongoing GMC process”

In the GMC’s opinion you should have sought to clarify matters before only partially completing your application form. In its letter you were directed to the relevant paragraphs of Good Medical Practice which stated: “You must always be honest about your experience qualifications and position

particularly when applying for posts” and

“You must do your best to make sure that any documents you write or sign are

not false or misleading.”

The GMC’s letter went on to say: “Good Medical Practice requires doctors to be honest and trustworthy at all

times, in order to maintain public trust in the profession, therefore you must respond appropriately if asked for information about your fitness to practise history. This duty will continue to apply where an Interim Order is removed from LRMP following case closure with no adverse finding.” 78. It is the Tribunal’s view that this letter is clear and unambiguous and you were well aware of your responsibilities when completing the application for employment at CMHT. It is satisfied that you failed to disclose that you had been the subject of GMC fitness to practise proceedings in 2010 and that you had a duty to do so. Paragraph 8 On 25 May 2012, during an appraisal with Dr G at the Trust, you were asked if you were involved in any complaints, critical incidents or legal cases at which time you failed to disclose that you were involved in: a. an investigation by the Parliamentary Health Services Ombudsman arising out of a patient complaint, when you knew this to be the case; Found proved 79. On 6 April 2011 Patient A referred her complaint about the care she had received at Liverpool Women’s Hospital to the Parliamentary Health Services

FTP: Dr LOUTFI

23

Record of Determinations – Medical Practitioners Tribunal Ombudsman (PHSO). The PHSO wrote to you on 16 February 2012 enclosing a copy of its draft report and informing you that it proposed to uphold Patient A’s complaint. In its letter the PHSO suggested that you and the Hospital should consider changes to policy and procedure and appropriate supervision and training to prevent a recurrence of Patient A’s experience in the future. The final report was submitted to the Liverpool Women’s Hospital on 20 March 2012. The Hospital wrote to Patient A and told her that it accepted the PHSO’s findings that there had been a service failure in her care and treatment. 80. The PHSO wrote to you on 4 May 2012 to inform you that the following recommendation would be included in its final report: “Within three months of the date of the final report, the doctor concerned (Dr

Loutfi) should reflect on the findings of this report and work with his Responsible Officer to agree and implement an action plan describing what he has done to ensure that he has learnt the lessons from the service failure identified by this upheld complaint and details what he plans to do, including timescales, to avoid a recurrence of this service failure in the future. Dr Loutfi should share his action plan with his Responsible Officer and Miss A and the Ombudsman and he should ensure his Responsible Officer and Miss A are updated regularly on progress against the action plan.” The PHSO went on to say that, in light of the clinical advisers’ concerns about your actions, as identified in the draft report, and in the interests of the health and safety of patients, it was considering sharing its concerns with the GMC. It asked for your response to the above proposed recommendation. 81. The Tribunal has had regard to the appraisal document, dated 25 May 2012. In the section marked Summary of Appraisal Discussion the appraiser has written: “Not involved with any complaints / critical incidents / legal cases

No concerns re relations with patients”

You were aware in May 2012 of the concerns which the PHSO had about your clinical practice and its recommendation that you implement an action plan to demonstrate what you had done to ensure that you had learnt the lessons from the incident involving Patient A. You had your appraisal with Dr G in May 2012 and the Tribunal is in no doubt that you did not disclose the findings and recommendations of the PHSO to Dr G and that you had a duty to do so. b. two High Level Incident ("HLI") investigations into serious untoward incidents at the Trust which occurred on 30 October 2011 and 5 February 2012, when you knew this to be the case. Found proved

FTP: Dr LOUTFI

24

Record of Determinations – Medical Practitioners Tribunal 82. You have told the Tribunal throughout this hearing that you had done nothing wrong and, regardless of the investigations taking place around you, you made a conscious decision to put these two incidents out of your mind and behave as if nothing had happened and, therefore, had no reason to give them any further consideration. You thought that CMHT was well aware of these HLIs because it was investigating them. The Tribunal noted that they had heard evidence that the HLIs referred to had been anonymised and took the view that this put a greater onus on you to disclose your involvement in these incidents with your appraiser 83. The Tribunal was of the view that it was your responsibility to raise these matters with your appraiser in order to demonstrate adequate reflective and learning objectives and to produce an appropriate personal development plan in preparation for revalidation. The Tribunal is satisfied that you failed to disclose the two HLIs to Dr G in circumstances in which you had a duty to do so. Paragraph 9 On 1 February 2013, you sent an inappropriate email to Dr G at 06:44 and 07:30 in which you asked her to tell the GMC Interim Orders Panel ("IOP") that she was aware of the two HLIs and their outcome and as a result they were not mentioned in the appraisal on 25 May 2012: a. when you had not established this with her; Found proved 84. The Tribunal has been provided with a copy of the email, dated 1 February 2013 and timed at 06:44, in which you told Dr G that you had been invited to attend a GMC hearing for an early review of your case. You asked Dr G to accompany you to the hearing and “tell the panel that during my appraisal you were aware about

those two incidenses [sic] and you were aware that no further action was needed as far as I am concerned and accordingly those two incidenses [sic] were not mentioned in my appraisal.” 85. The Tribunal has also been provided with a copy of your second email, also dated 1 February 2013 but timed at 07:30, the contents of which are almost the same as the email sent at 06:44.

86. In her oral evidence, Dr G was clear that she did not know about your involvement in the two HLIs. She told the Tribunal that a report had been issued for each incident but they had been anonymised and she was not aware that you were involved in both of them. According to your evidence, you did not see why you should have mentioned the two HLIs at your appraisal because you had done nothing wrong. The Tribunal is of the view that this demonstrated that you did not attempt to establish with Dr G whether or not she was aware of them. b. when you knew that you had not mentioned them. Found proved

FTP: Dr LOUTFI

25

Record of Determinations – Medical Practitioners Tribunal 87. The Tribunal has had regard to your email to Dr G, dated 5 February 2013, in which you stated: “I am sorry that you were not aware about the critical incidences which were

extensively discussed during my work in St Mary’s Hospital for 8 months. I did not mention them in my appraisal because of my belief that you were fully aware of them and investigation consultants told me no further actions are required as far as I am concerned.” The Tribunal is of the view that, as stated in this email, you knew you had not mentioned the two HLIs in your appraisal. Paragraph 10 On 7 February 2013, you sent an inappropriate email to Dr G at 14:08 and 14:38 in which you asked her to amend her statement to the IOP to state that you had told her during your appraisal that you were not involved in any critical incidents due to your performance or with any further action as far as you were concerned; and that was why she had not included it in your appraisal, when you knew this was untrue. As amended, found proved 88. You knew you were involved in two critical incidents due to your performance when you sent two emails to Dr G on 7 February 2013. In the first email, timed at 14:08, you stated: “I did not receive your statement yet. I can come to TGH to collect it from

your secretary. Please add to it that I mentioned to you during my appraisal that I was not involved in critical incidences due to my performance or with any further action as far as I am concerned and subsequently you did not include critical incidences in my appraisal form and you were ready to support your statement in front of the GMC IOP on 12/2/13 …” In your second email, timed at 14:38, you further stated: “One of GMC allegations against me is my failure to inform you about two

critical incidences and my GMC warning during my appraisal. During appraisal I said that I was not involved in critical incidences due to my performance or with any further action as far as I am concerned and subsequently no critical incidences were included in my appraisal and you mentioned my GMC warning without further comments. “Please provide me with your witness reflection about my appraisal to help me

in my defence and help GMC IOP to make decisions.”

89. The Tribunal has noted that both of the HLI reports contain an action plan with specific actions for you to undertake. In your oral evidence you told the Tribunal

FTP: Dr LOUTFI

26

Record of Determinations – Medical Practitioners Tribunal that you chose to erase these incidents from your mind as you did not believe that you had done anything wrong and therefore you had done nothing about the actions recommended by the HLIs. 90. In her oral evidence Dr G clearly stated that she was not aware of your involvement in the two critical incidents at the time of your appraisal as you had failed to mention them during your appraisal. She would not have known of your involvement from the critical incident reports because they were anonymised and therefore she would have been unable to associate the incidents with you. 91. You knew that you had been involved in the two critical incidents as you had provided statements for them. The incidents were not discussed during your appraisal as you admitted in your email of 5 February, quoted above. When you emailed Dr G to ask her to amend her statement to state that there had been such a discussion, you knew that it was not true. The Tribunal is satisfied that this paragraph is proved to the requisite standard.

Hull and East Yorkshire Women & Children’s Hospital Paragraph 11 In August 2012 you submitted an application form for the position of CCT Fellow in Obstetrics and Gynaecology at Hull and East Yorkshire Women and Children's Hospital in August in which you: a. answered ‘No’ to the question ‘Are you currently the subject of a fitness to practise investigation or proceedings...by a regulatory body in the UK...’ when you knew this was untrue; Found proved 92. In August 2012 you submitted an application form to the Hull and East Yorkshire Women and Children’s Hospital. In June 2012 you had appeared before an Interim Orders Panel although no order was made. A complaint had been submitted by Patient A to the PHSO in April 2011. The Ombudsman’s draft report was sent to you on 16 February 2012 and its final report was disclosed to you by way of a letter, dated May 2012. The report raised serious concerns about your clinical practice and recommended actions you should undertake in order to prevent further concerns being raised. This was the matter under investigation by the GMC. 93. In your oral evidence you clearly stated that you believed that you had done nothing wrong and should not have been criticised, which was contrary to the Ombudsman’s report. 94. The Tribunal has had regard to the email sent to you by the GMC on 1 March 2010 in relation to a previous investigation, which stated:

FTP: Dr LOUTFI

27

Record of Determinations – Medical Practitioners Tribunal “The Interim orders Panel (IOP) convenes to consider cases in which it may be

necessary to restrict a doctor’s registration whilst we carry out our investigation. They are not responsible for making decisions on cases. “In this case the IOP decided not to restrict your registration whilst we

undertake our investigation; however the investigation was not concluded.” 95. It is clear that you knew from your previous experience that you were being investigated under the GMC’s fitness to practise procedures and that the investigation would continue even though no action had been taken on your registration by the IOP. Furthermore you had already been told by the GMC in its letter of 15 November 2010 of the need to be honest about your experience and qualifications and you had been specifically directed to the relevant paragraphs of Good Medical Practice in this regard. The GMC stated clearly and unambiguously in its letter to you that: “Good Medical Practice requires doctors to be honest and trustworthy at all

times, in order to maintain public trust in the profession, therefore you must respond appropriately if asked for information about your fitness to practise history. This duty will continue to apply where an Interim Order is removed from LRMP following case closure with no adverse finding.” 96. The Tribunal finds it is beyond belief that, having received the GMC’s letter of 15 November 2010, you would answer “no” to the question ‘Are you currently the

subject of a fitness to practise investigation or proceedings...by a regulatory body in the UK...’. It is satisfied that there is sufficient cogent evidence to find this paragraph of the allegation proved.

b. stated that the ‘GMC hearing committee on 13/12/10 investigated allegation that I assaulted a colleague on 17/03/10 (sic). He is in fact assaulted me. GMC issued a warning for me despite their decision was quashed by High Court’ when you knew that: i. the assault took place in March 2009; Found proved ii. the original warning was imposed on your registration in November 2009; Found proved iii. the High Court had remitted the matter back to the GMC and you were again issued with a warning; Found proved

FTP: Dr LOUTFI

28

Record of Determinations – Medical Practitioners Tribunal c. failed to state that the warning imposed on your registration on 14 December 2010 would remain on your registration for five years; Found proved 97. You did make the statement on your application form as set out in 11(b) above when you knew that the assault had taken place in March 2009. It is a matter of record that a warning was imposed on your registration in November 2009. The warning was quashed by the High Court and your case was remitted back to the GMC. A warning was again issued on 14 December 2010 which remained on your registration for five years until 13 December 2015. d.

failed to record under the heading of ‘Employment History’ details of: i. your most recent employment at St. Mary's Hospital, Manchester; Found proved ii. your previous employment in 2009 with Mid Yorkshire Hospitals NHS Trust. Found proved

98. In your oral evidence you told the Tribunal that, when you completed the application form in August 2012 it was on a form that you had completed previously but had not updated it with all of your posts. The Tribunal did not accept your explanation as you had managed to update other aspects of the application form, eg the Expiry/Renewal Date for your inclusion in the Specialist Register. Furthermore, you had updated your referee details to include Dr G. 99. You also told the Tribunal that you had only listed the substantive posts you had held and not any of your locum posts. The Tribunal did not accept this assertion as you had included your post at the Liverpool Women’s Hospital where you worked as a locum senior registrar whereas you did not include your post at St Mary’s Hospital, which was also a locum post. Paragraph 12 Your intention at paragraph 11d) above was to deny Hull and East Yorkshire Women & Children's Hospital the opportunity of contacting those institutions, knowing that they may disclose information relating to adverse incidents. Found not proved 100. In your oral evidence you told the Tribunal “I did not want people to know

what had happened at Mid Yorkshire Trust and I did not want it to affect my career.” However, the Tribunal has noted that you did give Dr G as a referee, along with her contact details. The Hull Trust could have contacted Dr G and learned about the incidents which had occurred at St Mary’s. The Tribunal is not satisfied that you intended to deny the Hull Trust the opportunity of contacting St Mary’s Hospital.

FTP: Dr LOUTFI

29

Record of Determinations – Medical Practitioners Tribunal Paragraph 13 You were subsequently interviewed for the position of CCT Fellow on 7 September 2012, at which time you stated that there were no other issues with the GMC, or words to that effect, when you knew that you were the subject of a GMC fitness to practise investigation. As amended, found proved a. failed to disclose that you were still subject to a GMC warning on your registration; Withdrawn by the GMC b. stated that there were no other issues with the GMC, or words to that effect, when you knew that you were the subject of a GMC fitness to practise investigation. Inserted in stem of Paragraph 13 101. The Tribunal has noted from the signed witness statement of Mrs U that you had been interviewed for the post of CCT Fellow on 7 September 2012. In her statement Mrs U stated: “I specifically recall that Dr Loutfi was asked whether there were any other

GMC issues that he was aware of and he said that there were no other issues with the GMC during his time of work which I have recorded in my notes during the interview.” The Tribunal has had sight of Mrs U’s interview notes in which she wrote “no other

issues in time of working.”

102. It is clear that you were aware of the GMC’s fitness to practise proceedings and that the investigation would continue even though no action had been taken on your registration. Furthermore you had already been told by the GMC in its letter of 15 November 2010 of the need to be honest about your fitness to practise history and you had been specifically directed to the relevant paragraphs of Good Medical Practice in relation to honesty and probity. The GMC stated clearly and unambiguously in its letter to you that: “Good Medical Practice requires doctors to be honest and trustworthy at all

times, in order to maintain public trust in the profession, therefore you must respond appropriately if asked for information about your fitness to practise history. This duty will continue to apply where an Interim Order is removed from LRMP following case closure with no adverse finding.” 103. It is clear to the Tribunal that a discussion took place at your interview in relation to issues you may have had with the GMC. It was your opportunity to be open, honest and truthful with the Hull Trust. Instead you chose to tell Mrs U that

FTP: Dr LOUTFI

30

Record of Determinations – Medical Practitioners Tribunal there were no issues with the GMC when you were well aware that you were the subject of a fitness to practise investigation. Paragraph 14 During an investigatory meeting on 2 January 2013 you falsely stated that with the knowledge you had at the time, you were not subject to a fitness to practise investigation at the time of your application and interview, and that what had happened had been completed and concluded, or words to that effect, when you knew this was untrue. Found proved 104. The Tribunal has been provided with a copy of the notes of an investigatory meeting with you which was held on Wednesday 2 January 2013. The purpose of the meeting was to establish the facts surrounding your failure to disclose something which was materially relevant to your appointment at the Hull Trust. The Tribunal has noted your response when asked why you had ticked “no” on your application form to the question “Are you currently the subject of a fitness to practise

investigation or proceedings by a licensing or regulatory body in the UK or in any other country.” You stated:

“With the knowledge I had at the time I was not subject to fitness to practise

investigation at that time. What had happened had been completed and concluded. There had been some allegations from Ombudsman to the GMC which I was not happy with. I did not agree with the Ombudsman’s expert opinion that was given to GMC panel …”

105. The Tribunal has had regard to the letter from the GMC to you, dated 8 June 2012, in which you were invited to appear before an Interim Orders Panel because information received from PHSO suggested that your fitness to practise may be impaired. Attached to the letter was some literature in relation to Imposing Interim Orders and Investigating Concerns. When asked at this hearing if you had read any of the literature you replied “I may have read some of it, for example the purpose of

the investigation.”

106. In her witness statement Mrs U stated that she had first become aware that you were the subject of a GMC investigation when you went to see her on 22 November 2012 which was the day before you were due to appear before an Interim Orders Panel. You had commenced your post in October 2012. In her statement, Mrs U also stated that you informed her of the outcome of the IOP hearing by way of email on the same day of the hearing (23 November 2012). 107. It is clear to the Tribunal that, on 2 January 2013, you were aware that you were the subject of a fitness to practise investigation at the time of your application and interview and when you told the Hull Trust that what had happened had been completed and concluded, you did not tell the truth.

FTP: Dr LOUTFI

31

Record of Determinations – Medical Practitioners Tribunal Paragraph 15 Your acts and omissions at paragraphs 6, 7, 8, 9, 10, 11, 13 and 14 above were: a. misleading; Found proved in relation to paragraphs 6, 7(a), 7(b), 8(a), 8(b), 9(a), 9(b), 10, 11(a), 11(b), 11(c), 11(d), 13 and 14 b. dishonest. Found proved in relation to paragraphs 6, 7(a), 7(b), 8(a), 8(b), 9(a), 9(b), 10, 11(a), 11(b), 11(c), 13 and 14 Found not proved in relation to paragraph 11(d) Paragraph 15(a) in relation to paragraph 6 108. In your letter, dated 25 July 2013 to Ms E, you stated that you had delivered a baby by Kielland’s forceps after rotation to occipito-posterior position when anterior rotation had failed and that you had been directly supervised by Mr F. You knew that you had not been directly supervised by Mr F. During this procedure you had seen Mr F in the doorway which does not constitute direct supervision. Furthermore, in your email of 22 September 2013, you admitted “you are right, I was supervised indirectly by Mr F using Kielland’s forceps.” Furthermore, Mr F told the Tribunal that he would not have supervised anyone using Kielland’s forceps as he was not a current Kielland’s practitioner and it had been a long time since he had used them. The Tribunal is satisfied that it was your intention to mislead Ms E. Paragraph 15(b) in relation to paragraph 6 109. The Tribunal has already found proved that your statement to Ms E was untrue. It is of the view that your intention in putting this statement in your letter to Ms E was to divert criticism from yourself, having been told that consultants at the Trust did not agree with your attempting such a rotation. The Tribunal has already found that your statement to Ms E was misleading and it considers that you deliberately made a false statement which can only be regarded as dishonest. Paragraph 15(a) in relation to paragraph 7 110. It is a matter of record that a warning was imposed on your registration on 14 December 2010 for five years until 13 December 2015. In the Tribunal’s view, by failing to disclose this information on your application form for a post at CMHT you misled the Trust. Paragraph 15(b) in relation to paragraph 7 111. You were given clear advice by the GMC in 2010 regarding your failure to disclose information on application forms. You were advised of the need for

FTP: Dr LOUTFI

32

Record of Determinations – Medical Practitioners Tribunal honesty, particularly in relation to your fitness to practise. You were directed to the relevant paragraphs of Good Medical Practise relating to honesty and probity. The Tribunal is of the view that your failure to disclose information about your fitness to practise history on your application form was intentional and, therefore, dishonest. Paragraph 15(a) in relation to paragraph 8(a) 112. You had received a letter from the PHSO, dated 4 May 2012, which stated that, given the seriousness of the omissions in care identified in its draft report and their clinical advisers’ concerns about these, a further recommendation would be included in the final report. The PHSO recommended that you implement an action plan detailing what you intended to do to avoid a recurrence of your failures. 113. The appraisal form includes a section specifically asking for details of “any complaints, critical incidents or legal cases”. Your appraisal form of May 2012 recorded “Not involved with any complaints / critical incidents / legal cases. No concerns re relations with patients.” You failed to inform Dr G, your appraiser, that you were the subject of a complaint which had been referred to the PHSO. You did not mention that you had received a letter from the PHSO advising you that concerns had been raised about your care of Patient A and that an action plan had been recommended for you to follow. 114. You said, during your oral evidence before the Tribunal, that you had discussed the issues relating to the care of Patient A with Dr Reid, Consultant Gynaecologist, “on a daily basis”. However, in your evidence you claimed that, during your appraisal, you had completely forgotten about the incident involving Patient A and it had never come to mind. In the Tribunal’s view, this was misleading and Dr G was misled. Paragraph 15(b) in relation to paragraph 8(a) 115. Given that the PHSO investigation had been ongoing for a number of months, that you had received the draft report and the timing of the letter from the PHSO, which was sent in the same month as you had your appraisal, the Tribunal rejects your assertion that such a serious incident did not “come to mind”. It has concluded that you intended to deceive Dr G during your appraisal and that your actions were dishonest. Paragraph 15(a) in relation to paragraph 8(b) 116. The Tribunal has already found that, during your appraisal, you had failed to disclose that you were involved in two HLIs. In your oral evidence you maintained that, despite having given written statements during the investigation of these HLIs and despite the conclusions of the investigators, you maintained that you had done nothing wrong and that you had erased the incidents from your mind. The Tribunal

FTP: Dr LOUTFI

33

Record of Determinations – Medical Practitioners Tribunal is of the opinion that it was misleading not to mention these incidents during your appraisal and Dr G indeed was misled. Paragraph 15(b) in relation to paragraph 8(b) 117. The Tribunal has concluded that your actions during your appraisal were deliberate and your intention was to conceal the incidents, and the concerns raised as a result, from Dr G. It would have been reasonable to discuss them with her during an appraisal of your clinical practice but you chose to conceal them. The Tribunal is in no doubt that your actions during your appraisal were dishonest. 118. The Tribunal has also noted that you had produced two statements to CMHT in respect of the HLIs, dated 3 November 2011 and 21 March 2012. In your witness statement to the Tribunal, dated 20 December 2015, you stated “I was not aware

about High Level Investigation procedures or reports. I was not even asked to write a statement.” In the Tribunal’s view, your actions were clearly dishonest in this regard.

Paragraph 15(a) in relation to paragraph 9 119. In your emails to Dr G on 1 February 2013, you asked her to make a statement to the effect that she was aware of the two HLIs and their outcome. You were asking her to write a statement to be put before an Interim Orders Panel reporting that she was aware of something when you did not know whether she was aware or not because you had not established that with her. In so doing the Tribunal has concluded that your actions were misleading. Paragraph 15(b) in relation to paragraph 9 120. Your evidence can only be described as dishonest in that you were attempting to coerce Dr G into saying that something had happened, when it had not. Paragraph 15(a) in relation to paragraph 10 121. In your email to Dr G of 5 February 2013, you told her that you did not mention them during your appraisal because you thought she was already aware of them. In your email of 7 February 2013 to Dr G, you asked her to add to her statement that you had discussed the two HLIs during your appraisal. You sent emails to Dr G in which you asked her to amend her statement to your advantage when you knew that such an amendment would be misleading and untrue. It was clearly misleading to ask Dr G to state something which you knew to be untrue.

FTP: Dr LOUTFI

34

Record of Determinations – Medical Practitioners Tribunal Paragraph 15(b) in relation to paragraph 10 122. In her oral evidence, Dr G stated that she had concluded from your email of 7 February that you were asking her to lie. The Tribunal is in no doubt that your actions in this regard were deliberately dishonest. Paragraph 15(a) in relation to paragraphs 11(a), (b), (c) 123. The impression you gave when completing your application form in August 2012 was that you were not subject to fitness to practise proceedings when you were and you therefore misled the reasonable reader of the form into believing that the warning on your registration was incorrect as it had been quashed by the High Court. The form of words that you used was misleading. Paragraph 15(b) in relation to paragraphs 11(a), (b), (c) 124. The Tribunal has determined that you intended to conceal information about your warning and that was dishonest. Paragraph 15(a) in relation to paragraph 11(d) 125. In your application form you failed to record your employment at St Mary’s Hospital and the Mid Yorkshire Trust. Your explanation was that you had only included substantive posts in your employment history, although you had included your employment at Liverpool Women’s Hospital which was a locum post. You told the Tribunal that you did not want the Hull Trust to know what had happened at the Mid Yorkshire Trust because you did not want your career to be affected. You did not give a complete employment history on your application form in August 2012 and the Tribunal has found that your actions were misleading. Paragraph 15(b) in relation to paragraph 11(d) 126. The Tribunal noted that, although you had not included your employment at St Mary’s Hospital, you gave Dr G’s name as a referee and included her contact details at St Mary’s Hospital. Therefore the Tribunal has not found dishonesty on this paragraph of the allegation. Paragraph 15(a) in relation to paragraph 13 127. You were fully aware that you were the subject of a GMC fitness to practise investigation. At your interview on 7 September 2012, you chose to assert that there were no other issues with the GMC when you knew that this was not the case. This can only be seen as misleading and the interviewers were misled. Paragraph 15(b) in relation to paragraph 13 128. In 2010 you had been told by the GMC about the need for honesty and probity and had been referred to the relevant paragraphs of Good Medical Practice in this

FTP: Dr LOUTFI

35

Record of Determinations – Medical Practitioners Tribunal regard. You knew that you must respond appropriately if asked for information about your fitness to practise history. The Tribunal has determined that it was your intention to deceive the interviewers about your previous fitness to practise issues in order to obtain employment at the Hull Trust. Your actions were deliberate and the Tribunal has concluded that they were dishonest. Paragraph 15(a) in relation to paragraph 14 129. The Tribunal has already found that when you falsely stated that, with the knowledge you had at the time, you were not subject to a fitness to practise investigation at the time of your application for employment, you knew that this was untrue. You had been advised by the GMC in its letter of 15 November 2010 of the need for honesty and probity and had been referred to the relevant paragraphs of Good Medical Practice in this regard. You had also been advised that you must respond appropriately if asked for information about your fitness to practise history. The Tribunal is in no doubt that your actions in this regard were misleading. Paragraph 15(b) in relation to paragraph 14 130. The Tribunal considers that it was made abundantly clear to you in November 2010 of the need for honesty and probity at all times and you were directed to the relevant paragraphs of Good Medical Practice. You were fully aware that you were the subject of a GMC fitness to practise investigation. You knew that you must respond appropriately if asked for information about your fitness to practise history. When you attended the investigatory meeting you deliberately concealed the fact that you knew you were the subject of a GMC fitness to practise investigation. The Tribunal is in no doubt that your actions were clearly and deliberately dishonest. Determination on Impairment Dr Loutfi: 1. The Tribunal has considered, in accordance with Rule 17(2) whether, on the basis of the facts found proved, your fitness to practise is impaired by reason of your misconduct. In considering the question of impairment, the Tribunal has taken account of all the oral and documentary evidence adduced during these proceedings. It has also taken into account the submissions made by Ms Cundy, Counsel, on behalf of the GMC, and those made by you, including your written document, dated 29 January 2016. 2. Ms Cundy referred to Lady Justice Smith’s remarks in the Fifth Shipman Inquiry Report (2004), as follows:

FTP: Dr LOUTFI

36

Record of Determinations – Medical Practitioners Tribunal “Do our findings of fact in respect of the doctor’s misconduct, deficient

professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that he/she: a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or d. has in the past acted dishonestly and/or is liable to act dishonestly in the future.” It was Ms Cundy’s submission that the Tribunal’s findings demonstrate that all four questions are answered in the affirmative in your case. 3. Ms Cundy submitted that the allegations relate to both clinical issues and issues of probity. In respect of the clinical issues, she submitted that you have breached a number of the principles of Good Medical Practice. In relation to your care of Patients A and C, the November 2006 issue was in force at that time and Ms Cundy referred to relevant paragraphs as follows:

2 adequately assessing the patient’s conditions, taking account of the history (including the symptoms and psychological and social factors), the patient’s views, and where necessary examining the patient 3(i) consult and take advice from colleagues, when appropriate 12 you must keep your knowledge and skills up to date throughout your working life. You should be familiar with relevant guidelines and developments that affect your work. You should regularly take part in educational activities that maintain and further develop your competence and performance 14(b) reflect regularly on your standards of medical practice in accordance with GMC guidance on licensing and revalidation 14(g) contribute to confidential inquiries and adverse event recognition and reporting, to help reduce risk to patients 4.

Ms Cundy submitted that: 

in the case of Patient A you did not listen to or accept the views of the patient;

FTP: Dr LOUTFI

37

Record of Determinations – Medical Practitioners Tribunal 

in the case of Patient C you defended your choice to use spinal anaesthesia to Dr R;



there was some confusion on your part about the Liverpool Women’s Hospital guidelines;



there is no real evidence of your reflection on the key incidents in this case; indeed you failed to mention the two High Level Incidents in your appraisal in 2012 with Dr G; and



you failed to acknowledge your clinical shortcomings throughout the investigation of the two High Level Incidents.

5. In respect of the issues relating to probity, Ms Cundy referred the Tribunal to paragraphs 56 and 57 of Good Medical Practice (November 2006) and paragraphs 65 and 68 of the April 2013 guidance which are relevant to honesty and probity. She reminded the Tribunal that when you were issued with advice in November 2010 you were specifically reminded always to be honest, particularly when applying for posts, and to ensure that documents were neither false nor misleading. Furthermore, a month after the advice was given, a warning was imposed on your registration and you were again referred to paragraph 57 of Good Medical Practice and reminded that serious or persistent failures to follow that guidance would put your registration at risk. 6. Ms Cundy reminded the Tribunal that it is well established that consideration of impairment is a two stage process. The Tribunal should ask itself if the facts found proved amount to misconduct and, if so, then it should go on to consider whether your fitness to practise is impaired as a result. In relation to misconduct, Ms Cundy referred the Tribunal to the case of The Queen (on the Application of Remedy UK) v GMC [2010] EWHC 1245 (Admin) which states at paragraph 37: “(1) Misconduct is of two principal kinds. First, it may involve sufficiently

serious misconduct in the exercise of professional practice such that it can properly be described as misconduct going to fitness to practise. Second, it can involve conduct of a morally culpable or otherwise disgraceful kind which may, and often will, occur outwith the course of professional practice itself, but which brings disgrace upon the doctor and thereby prejudices the reputation of the profession. (2) Misconduct falling within the first limb need not arise in the context of a doctor exercising his clinical practice, but it must be in the exercise of the doctor's medical calling.” Ms Cundy submitted that, in this case, the Tribunal is considering not only the clinical issues but your dishonest actions which are directly related to your practice

FTP: Dr LOUTFI

38

Record of Determinations – Medical Practitioners Tribunal as a doctor. In relation to the clinical issues, she reminded the Tribunal that it may be guided by the expert witness, Mr Z, who was of the opinion that your standard of care fell seriously below the requisite standard in a number of areas. Ms Cundy contended that you are not someone who keeps up to date, you have said that your management of your cases was appropriate and that you saved the lives of Patients C and D. She submitted that this demonstrates an absence of insight on your part. 7. Ms Cundy referred to the findings of dishonesty and submitted that the issue of insight, or its absence, is central to these concerns as well. She further submitted that, if you had understood the need to be honest and truthful and had reflected on the advice given to you by the GMC in 2010, you would have made it your first concern to ensure that all your documents were factually accurate and beyond reproach. 8. Ms Cundy questioned whether you have remedied your failings and if there is a risk of similar conduct in the future. She told the Tribunal that it is open to you to demonstrate that you have taken steps to remedy your failings to prevent a recurrence but suggested that you are not capable of such reflection and remediation. Ms Cundy submitted that you are a man of unshakeable convictions who defended them by calling those of differing opinions “liars”. Further, you have not said that you would do things any differently in the future. Indeed, in a response to the PHSO, who had investigated and upheld the complaint of Patient A, you sent an email on 5 July 2012 saying “I believe I deserve an apology and removal of your recommendations from my records”. 9. Ms Cundy reminded the Tribunal that, in considering impairment of fitness to practise, it is required to protect the public interest which includes not only the protection of patients but the maintenance of public confidence in the profession, and the declaring and upholding of proper standards of conduct and behaviour. She submitted that all these elements are engaged in your case and that dishonesty, in particular, requires a finding of impairment because of the damage it does to the reputation of, and public confidence in, the profession. 10. Ms Cundy submitted that, in all the circumstances and for all the reasons she has outlined, the Tribunal should now find that your fitness to practise is currently impaired by reason of your misconduct. 11. You submitted initially that, in the light of the Tribunal’s findings, a conclusion of impairment is inevitable. You told the Tribunal that, whilst many of the paragraphs of the allegation were contested, nevertheless you have demonstrated a degree of insight which, in view of the findings made, will increase upon further reflection. 12. You submitted that the findings of dishonesty were committed against an unusual background where previous proceedings had been rendered null and void.

FTP: Dr LOUTFI

39

Record of Determinations – Medical Practitioners Tribunal It was your contention that you had been given little guidance about how you should approach disclosure of these matters and that you were under stress during the previous proceedings which clearly contributed to an error in judgement. 13. You referred to the testimonial letters from Mr A2, and Mr M, both Consultant Obstetricians and Gynaecologists at Portsmouth Hospitals NHS Trust. These letters, you submitted, highlighted that you are keen to keep up to date and to learn and improve your knowledge and skills and that you are reliable. 14. You accepted that the findings of dishonesty are “troubling” but urged the Tribunal to consider the extraordinary circumstances in which they arose. You submitted that there were no motives to act dishonestly. 15. You apologised for your mistakes and told the Tribunal that you will learn from them and make sure that they will not happen again. 16. In conclusion you submitted that your fitness to practise is not impaired because you have admitted your mistakes and you will learn and keep improving Tribunal Decision 17. Whilst the Tribunal has borne in mind the submissions made, the decision as to whether your fitness to practise is impaired is one for it to reach, exercising its own judgement. 18. Throughout its deliberations, the Tribunal has borne in mind its duty to protect the public interest. The public interest includes not only the protection of patients but, of particular relevance in this case, the maintenance of public confidence in the profession, and the declaring and upholding of proper standards of conduct and behaviour.

Misconduct 19. The Tribunal first considered whether the facts found proved amount to misconduct, such that it represents serious misconduct. It has borne in mind the facts it has found proved in relation to your clinical practice. The Tribunal accepted the opinion that your care and treatment of Patients A, C and D fell below the standard of a reasonably competent Senior Registrar in Obstetrics and Gynaecology, and that it fell seriously below the requisite standard in a number of areas. In all three cases, there was an adverse outcome. In the case of Patient A, you did not listen to the view of the patient and you did not meet her basic needs. There was a risk of potential harm to this patient, in particular the risk of maternal death. You made a diagnosis of an incomplete miscarriage and you continued to insist for three years that it was a miscarriage, despite overwhelming evidence to the contrary.

FTP: Dr LOUTFI

40

Record of Determinations – Medical Practitioners Tribunal 20. In the cases of Patients C and D, your actions caused direct harm. However, you have consistently maintained that you did no wrong. In the case of Patient C, you misdiagnosed full dilation of the patient’s cervix and you failed to advise immediate delivery by caesarean section under general anaesthetic, which is the accepted protocol in an emergency situation. In the case of Patient D, you were of the opinion that the foetal head was very low in the pelvis when in fact it was in the mid cavity. Further, you inappropriately rotated the foetal head of the baby to the occipito-posterior position when rotation to the occipito-anterior position had failed. It was the unanimous opinion of your colleagues that this was not good practice as the foetal head was not low enough in the pelvic cavity to undertake such a manoeuvre. In making a decision to deliver this baby as you did, that is to say, rotating the head deliberately to the occipito-posterior position whilst in the pelvic mid cavity, you caused harm to the baby and put the mother at serious risk of harm. 21. You have persistently held yourself out as a very experienced practitioner in obstetrics and gynaecology. The Tribunal finds it worrying that such an experienced doctor could make these mistakes. It is also of concern that you have made no attempt to address the failings in your clinical practice. 22. The Tribunal has also borne in mind its findings that you acted dishonestly on numerous occasions over a significant period of time. The Tribunal considers such dishonest actions were serious and persistent. It has had particular regard to paragraphs 56 and 57 of Good Medical Practice (November 2006) to which you were referred in 2010 and have subsequently ignored, which state:

56. Probity means being honest and trustworthy, and acting with integrity: this is at the heart of medical professionalism. 57. You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession. The Tribunal has also had regard to paragraph 65 and 68 of Good Medical Practice (2013) which deal with honesty and communicating information:

65. You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession. 68. You must be honest and trustworthy in all your communication with patients and colleagues. This means you must make clear the limits of your knowledge and make reasonable checks to make sure any information you give is accurate. 23. In the Tribunal’s view, you have completely disregarded the principles laid down in the GMC guidance. It considers that your dishonest behaviour amounts to serious misconduct which would be considered deplorable by fellow practitioners.

FTP: Dr LOUTFI

41

Record of Determinations – Medical Practitioners Tribunal 24. In all the above circumstances, the Tribunal is in no doubt that your clinical shortcomings and your dishonesty amount to misconduct and that the misconduct is serious.

Impairment 25. The Tribunal next considered whether, by reason of your misconduct, your fitness to practise is currently impaired. 26. In reaching its decision, the Tribunal has considered the issues of insight, remediation and the likelihood of repetition. 27. In respect of insight, the Tribunal considers that you have demonstrated a lack of insight into your clinical deficiencies. There is overwhelming evidence before the Tribunal that you did not take any steps to reflect on the care of Patients A, C and D or to reflect on the impact your errors have had on them. You have failed to demonstrate that you have learnt from your mistakes and during this hearing you have continually maintained that you did nothing wrong. Even in the face of ample evidence to the contrary, you were not prepared to change your views stating that since you had done nothing wrong, you put these incidents out of your mind and deliberately forgot about them. 28. The Tribunal acknowledges your misconduct in relation to your clinical failings is, in principle, capable of being remedied. In considering whether you have remedied your misconduct, the Tribunal has taken into account the testimonial evidence provided by Mr A2 and Mr M at the Portsmouth Trust who said that you were keen to learn and to improve your skills. The Tribunal notes that you were closely supervised during your employment at Portsmouth, as required by your regulatory body. In light of your responses to criticisms raised about your handling of the cases of Patients A, C and D, the Tribunal rejects the contentions you now make that you have admitted your mistakes and that you will learn and keep improving. These assertions are incongruous and at odds with the clear impression that you conveyed to this Tribunal when giving evidence. You refused to accept that the mistakes were yours; you demonstrated an inability to reflect on and learn from the mistakes you made; and you showed a propensity to blame others for your own failings. The Tribunal is of the view that you have not offered a genuine expression of apology or regret for your failings. It was only in your submissions at the impairment stage that you offered any apology. In these circumstances, the Tribunal cannot be confident that your misconduct has been remedied and that you would not repeat your misconduct. 29. In respect of its findings in relation to your dishonesty, the Tribunal has noted that dishonesty by its nature is difficult to remediate and it has received no evidence of remediation; on the contrary, it has heard your continued denials of having done wrong. The Tribunal has borne in mind the relevant principles of Good Medical Practice and has determined that you have breached the principles of probity

FTP: Dr LOUTFI

42

Record of Determinations – Medical Practitioners Tribunal contained within that guidance. In the Tribunal’s view, doctors occupy a position of privilege in society and members of the public are entitled to trust that medical practitioners will act at all times with absolute honesty and integrity. 30. Having considered all the evidence placed before it, the Tribunal has concluded that your dishonesty in 2012 and 2013 amounts to a course of conduct falling seriously below the standards of conduct that the public and patients are entitled to expect from all registered medical practitioners. It is satisfied that: (a) (b) (c) (d)

you have presented a risk to patients; you have brought the profession into disrepute; you have breached one of the fundamental tenets of the profession; and your integrity cannot be relied upon.

31. In all the circumstances, the Tribunal has concluded that public confidence in the profession would be undermined if a finding of impairment was not made. Accordingly, the Tribunal has concluded that your fitness to practise is currently impaired by reason of your misconduct. Determination on Sanction Dr Loutfi: 1. Having determined that your fitness to practise is impaired by reason of your misconduct, the Tribunal has now considered under Rule 17(2)(l) of the Rules what sanction, if any, should be imposed on your registration. The Tribunal has taken into account all the evidence in this case, together with Ms Cundy’s submissions, on behalf of the GMC, and those made by you, including the document you provided to the Tribunal, dated 1 February 2016. Submissions 2. Ms Cundy submitted that the only appropriate sanction in this case is one of erasure. She further submitted that the Tribunal’s findings in relation to your clinical deficiencies and your repeated dishonesty have put patients at unwarranted risk of harm; have brought the profession into disrepute; and have breached one of the fundamental tenets of the medical profession. Further, you have acted dishonestly in the past and may be liable to act dishonestly in the future. 3. Ms Cundy submitted that you have demonstrated a blatant disregard for the principles of Good Medical Practice in relation to your clinical practice and your dishonesty has been serious and persistent. 4. Ms Cundy submitted that to take no action in your case would be wholly inappropriate in the light of the Tribunal’s findings. She reminded the Tribunal that,

FTP: Dr LOUTFI

43

Record of Determinations – Medical Practitioners Tribunal where a finding of impairment has been made, a Tribunal may take no further action in exceptional circumstances. It was her submission that this is not such a case. 5. Ms Cundy referred the Tribunal to paragraph 63 of the Sanctions Guidance which states that conditions are likely to be appropriate and workable where the doctor has insight into the concerns and has the potential to respond positively to remediation or retraining. She submitted that your behaviour was incapable of remediation as evidenced by your refusal to acknowledge or willingly address the areas of concern. She further submitted that a period of conditional registration cannot apply where there are issues relating to dishonesty as there are no conditions which could be formulated which would address this issue or mark the seriousness of the dishonesty. 6. In relation to a period of suspension, Ms Cundy referred the Tribunal to paragraph 73 of the Sanctions Guidance “Suspension will be an appropriate response to misconduct which is sufficiently

serious that action is required in order 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 (ie for which erasure is more likely to be the appropriate sanction because the tribunal considers that the doctor should not practise again either for public safety reasons or in order to protect the reputation of the profession). Suspension may be appropriate, for example, where there may have been acknowledgement of fault and where the tribunal is satisfied that the behaviour or incident is unlikely to be repeated. The tribunal may wish to see evidence that the doctor has taken steps to mitigate their actions” She reminded the Tribunal of the advice you had been given by the GMC Case Examiners and the Investigation Committee in 2010 and contended that such advice should have had a deterrent effect and should have prevented further breaches of Good Medical Practice. Furthermore, a period of suspension would fail to address the issue of the absence of any genuine apology or expression of regret. She submitted that suspension is insufficient in the particular circumstances of this case. In respect of erasure, Ms Cundy referred to paragraph 87 of the Sanctions Guidance which states: 7.

“Erasure may be appropriate even where the doctor does not present a risk to

patient safety, but where this action is necessary to maintain public confidence in the profession. For example if a doctor has shown a blatant disregard for the safeguards designed to protect members of the public and maintain high standards within the profession that is incompatible with continued registration as a doctor.”

FTP: Dr LOUTFI

44

Record of Determinations – Medical Practitioners Tribunal Ms Cundy also referred to paragraph 88 which lists a number of factors, any of which may indicate that erasure is the appropriate sanction. She submitted that the following two factors were present in your case: “(b) a deliberate or reckless disregard for the principles set out in Good

medical practice and/or patient safety.”

She reminded the Tribunal of your actions in the three clinical cases of Patients A, C and D where you ignored the principles of good clinical care and the importance of keeping your knowledge and skills up to date and submitted that you have breached the principles of Good Medical Practice in all three cases. “(h) dishonesty, especially where persistent and/or covered up” Ms Cundy submitted that your dishonesty had been persistent, particularly against the background of the advice you were given by the GMC in 2010. Despite that advice, she submitted, you continued to act dishonestly as evidenced by: (a) your application form for a post at CMHT in January 2012 when you failed to disclose your full fitness to practise history; (b) your appraisal with Dr G in May 2012 where you failed to disclose that you were involved in an investigation by the PHSO and investigations into two High Level Incidents; (c) your application form for a post at the Hull Trust in August 2012 when you did not disclose your fitness to practise history, that a warning had been imposed on your registration for five years, or your previous employment at CMHT and the Mid Yorkshire Trust; (d) your statement to the investigatory meeting at the Hull Trust in January 2013 that you were not subject to a fitness to practise investigation at the time of your application and interview; and (e) your correspondence with regard to Patient D in July 2013 in which you claim to have been directly supervised by Mr F when you had not. 8. Ms Cundy referred to paragraphs 133 and 134 of the Sanctions Guidance which deal with dishonesty. She submitted that you have failed to acknowledge where you could have, and should have, acted differently and there has been a failure to accept responsibility in those cases where errors were made. Ms Cundy contended that there remains a real risk of similar conduct in the future which could place patients at risk as well undermining public confidence in the profession.

FTP: Dr LOUTFI

45

Record of Determinations – Medical Practitioners Tribunal 9. In the light of all the reasons given above, Ms Cundy submitted that erasure is the only appropriate sanction in your case. 10. You submitted that not all the paragraphs of the allegation were found proved and, while it is accepted there were findings of dishonesty, you submitted that a proportionate approach can be taken in your case which will protect the public, uphold the standards of the profession and allow you to continue with your career. You told the Tribunal that the allegations are now historic and that you have provided evidence to demonstrate that you are progressing well in your career and practising appropriately. 11. You referred the Tribunal to paragraph 43 of the Sanctions Guidance which deal with aggravating factors which are likely to lead a Tribunal to consider taking more serious action on a doctor’s registration. You submitted that there are no such aggravating factors in your case. 12. You accepted that the findings of dishonesty are troubling but urged the Tribunal, once again, to consider the extraordinary circumstances in which the dishonesty arose. You told the Tribunal that you had not disclosed your employment at Mid Yorkshire because you had a disagreement with a midwife about her delivery of a baby. The disagreement resulted in your dismissal from the Trust and you were taken ill after this appointment and advised to forget about the incident for the sake of your health. 13. You submitted that, during this hearing, you apologised for your mistakes ‘very early and in front of the Panel’, in particular you had apologised for your care of Patient A. During your submissions you admitted that, in the case of Patient C, you should have disagreed with the suggestion of a single trial of spinal anaesthesia. In respect of your forceps delivery of the baby of Patient D, you submitted that you had noted the recommendations and advice of Dr Y, and eventually conceded that your practice had not been acceptable. You submitted that this was not a case where you have shown blatant disregard for safeguards. According to you, Patient A was admitted and handed over appropriately; Patient C’s baby was delivered by caesarean section under general anaesthesia; and Patient D delivered her baby in four minutes with no harm related to the delivery. 14. You told the Tribunal that you would like to apologise for your mistakes and that you will learn from them. You said that, in future, you will ask for appropriate induction before commencing a new post and will only accept contracts which allow such training. You stated to the Tribunal that you will not fill out any application forms without formal training on how to do so. 15. You reminded the Tribunal that it has a wide discretion to impose a combination of conditions or a period of suspension and submitted that it would be appropriate to impose conditions in your case.

FTP: Dr LOUTFI

46

Record of Determinations – Medical Practitioners Tribunal Tribunal Approach 16. Whilst the Tribunal has borne in mind the submissions made, it has exercised its own judgement as to the appropriate sanction, if any, to impose on your registration. Throughout its deliberations, the Tribunal has taken account of the guidance provided within Good Medical Practice and the Sanctions Guidance. As set out in paragraph 13 of the Sanctions Guidance, the Tribunal must honour the statutory overarching objective when considering sanction, as follows:   

Protecting the health, safety and wellbeing of the public, Maintaining confidence in the profession, Promoting and maintaining proper professional standards and conduct for the members of the profession.

17. The Tribunal has also applied the principle of proportionality, weighing the public interest against your own interests. The Tribunal recognised that sanctions are not imposed to punish or discipline doctors, but they may have a punitive effect. 18. The Tribunal accepted the advice of the Legal Assessor who advised it to consider the motive for your dishonesty. He advised that motive is something which lies behind every deliberate act and that the Tribunal should make its own decision as to what the motive behind your dishonesty was likely to have been. The Legal Assessor added that the finding of a motive will assist the Tribunal in deciding on what sanction, if any, to impose. 19. The Tribunal has already given detailed determinations at the facts and impairment stages and it has taken those matters into account during its deliberations on sanction.

No Action 20. The Tribunal first considered whether to conclude your case by taking no action. In the light of the serious misconduct which has been found, including numerous instances of dishonesty, the Tribunal considers that it would be wholly inappropriate, insufficient and not in the public interest to decline to take any action. Furthermore, it did not consider there to be any exceptional circumstances in your case that might justify its taking no action.

Conditions 21. The Tribunal next considered whether it would be sufficient to place conditions on your registration. It has borne in mind that any conditions would need to be appropriate, proportionate, workable and measurable.

FTP: Dr LOUTFI

47

Record of Determinations – Medical Practitioners Tribunal 22. The Tribunal has had regard to paragraph 65 of the Sanctions Guidance which sets out the criteria which should be met for the imposition of conditions on a doctor’s registration, in particular sub-paragraphs (a), (c) and (d): “(a) no evidence of harmful deep-seated personality or attitudinal

problems

The Tribunal considers that your clinical failings and your persistent dishonesty were in serious breach of the principles of Good Medical Practice. Furthermore your continued refusal to accept responsibility for the mistakes you made and your attempts to apportion blame to others demonstrates to this Tribunal that you do have deep-seated attitudinal problems.

(c) willing to respond positively to retraining, with evidence that they are committed to keeping their knowledge and skills up to date throughout their working life, improving the quality of their work and promoting patient safety In the absence of your acknowledging fault on your part the Tribunal considers that you are unlikely to be able to respond positively to retraining.

(d) willing to be open and honest with patients if things go wrong.” The Tribunal noted that your response to Patient A’s complaint in your evidence was to accuse her of “lying” with regard to her care and to suggest her motive was personal financial gain. This demonstrates an unwillingness to be open and honest with patients when things go wrong. 23. The Tribunal was of the opinion that the imposition of conditions on your registration could not adequately address the nature of your misconduct, given its findings of multiple instances of dishonesty. 24. The Tribunal has determined, therefore, that the imposition of conditions on your registration would be insufficient, inappropriate and disproportionate in your case.

Suspension 25. The Tribunal then went on to consider whether a period of suspension would be the appropriate sanction. It has had regard to paragraphs 72 and 73 of the Sanctions Guidance. In its view, there had been no acknowledgement of fault until this late stage of your Tribunal hearing; which is in direct contradiction to what you have been asserting from the date of the incidents up until this point in the hearing. You have demonstrated an utter disregard for the principles of Good Medical Practice and have not attempted to take steps to rectify the deficiencies in your clinical performance. The Tribunal considered your approach to all the issues addressed in your evidence to be blinkered, that you were fixated on your own ideas of what you considered correct and proper and that any element of culpability was

FTP: Dr LOUTFI

48

Record of Determinations – Medical Practitioners Tribunal as a direct result of another’s or others’ mistakes or inability to tell the truth. You apologised for your mistakes in your oral and written submissions today. Previously, there had been no genuine expression of remorse or apology or any evidence that you have reflected on your conduct or would generally do so in the future. 26. In relation to your dishonesty the Tribunal has considered the possible motive for your dishonesty. In relation to the incorrect and inaccurate application forms you completed, it is clear that you gained employment after you had concealed the truth about your fitness to practise history. You concealed your involvement in the two High Level Incidents and in an investigation by the PHSO in order to deceive your appraiser. You have been in denial in relation to the previous fitness to practise proceedings in which you were involved and said that you had “deliberately put them out of your mind” and you believed that you had done no wrong. You ignored a warning imposed by your professional regulator and the advice it gave to you in 2010 in relation to relevant paragraphs of Good Medical Practice. 27. Honesty is an integral part of the profession of medicine. You should not need to be trained as to how to fill in an application form honestly. The Tribunal has considered paragraph 80 of the Sanctions Guidance which details the factors which may indicate that suspension would be appropriate and has had particular regard to: “(e) no evidence of harmful, deep-seated personality or attitudinal problems” As stated above, the Tribunal considers that you do have deep-seated attitudinal problems. “(f) no evidence of repetition of similar behaviour since incident” The Tribunal recognises that your case does not relate to a single isolated incident, rather to a pattern of clinical errors for which you did not accept any responsibility at the time and about which you have not been open and honest. The Tribunal notes that at no point prior to this stage of the proceedings have you reflected on your conduct nor taken any opportunity to demonstrate a willingness to remediate such. “(g) the Tribunal is satisfied the doctor has insight and does not pose a

significant risk of repeating behaviour”

In the Tribunal’s view, you have continued to insist that you were not at fault and it is not satisfied that you have any insight into your failings or the impact they have had, or may have had, on your patients. 28. In all the above circumstances, the Tribunal does not consider that a period of suspension would be either appropriate or proportionate and would be insufficient to maintain public confidence in the profession or to protect the reputation of the profession.

FTP: Dr LOUTFI

49

Record of Determinations – Medical Practitioners Tribunal

Erasure 29. The Tribunal has had regard to paragraph 88 of the Sanctions Guidance which sets out a number of factors, any of which may make erasure the appropriate sanction. It has found that a number of these factors are met in your case, as follows: “(b) a reckless disregard for the principles set out in Good Medical Practice

and/or patient safety (h)

dishonesty, especially where persistent and/or covered up

(i) putting own interests before those of patients (see Good Medical Practice – “make the care of your patient your first concern” at paragraph 1) … (j)

persistent lack of insight into seriousness of actions or consequences.

30. The Tribunal considers that your departures from the principles of Good Medical Practice and your subsequent misconduct and dishonest behaviour reveal a character which is fundamentally incompatible with, and unsuited to, membership of the medical profession. Throughout this hearing you have continued to assert that you were not at fault. You have shown an inflexible attitude as demonstrated by your refusal to heed advice from colleagues, in particular senior consultant colleagues. 31. In the Tribunal’s view you have put your career and own interests before those of your patients and the reputation of the profession. You believe you have done no wrong and, worryingly, can do no wrong, going on to assert that others, not you, were responsible for the errors. Throughout the evidence you have expressed neither contrition nor remorse for your failings which could have had catastrophic outcomes for your patients. It was not until you made your submissions on sanction that you offered an apology for the adverse outcomes in the cases of Patients A, C and D. This does not demonstrate insight; it represents an empty gesture calculated to take on the appearance of remorse in the light of the Tribunal’s findings. 32. The Tribunal recognises that all doctors make mistakes; however, most doctors who make mistakes are prepared to acknowledge and take responsibility for them. You have persistently failed to do so. That fact itself presents a particular danger to patients. 33. The Tribunal has made findings of dishonesty against you and it considers that your dishonesty was serious and persistent. The Tribunal is of the view that the public interest requires that it be made clear that your repeated dishonest behaviour is unacceptable and will not be tolerated.

FTP: Dr LOUTFI

50

Record of Determinations – Medical Practitioners Tribunal 34. For all the reasons outlined above, the Tribunal has determined that your misconduct is fundamentally incompatible with your continuing to practise medicine. 35. Having taken account of all the evidence put before it, the Tribunal is satisfied that erasure is the only proportionate sanction in order to protect patients and the public interest, to uphold public confidence in the profession and to maintain the reputation of the profession. Accordingly, the Tribunal has determined to erase your name from the Medical Register. Determination on Immediate Order Dr Loutfi: 1. Having determined that your name be erased from the Medical Register the Tribunal has now considered, in accordance with Section 38(1) of the Medical Act 1983, as amended, whether to impose an immediate order of suspension on your registration. 2. The Tribunal has considered all of the circumstances of this case and has taken account of Ms Cundy’s submission that an immediate order of suspension is necessary given the seriousness of the Tribunal’s findings and the seriousness of the sanction it has determined to impose. She further submitted that such an order is necessary for the protection of patients and to maintain public confidence in the profession. 3. The Tribunal has also taken account of your submissions. You submitted that, throughout this hearing, you disagreed with the evidence of all the witnesses and you have apologised for your mistakes which, in your opinion, were minor. You further submitted that you have highlighted to the Tribunal that there was no motive for your dishonesty in not disclosing relevant information to your employers. 4. You told the Tribunal that you intend to lodge an appeal against the Tribunal’s decision to erase your name from the Medical Register. In the meantime you told the Tribunal that you have commenced a very important audit for your employer and that you need the time to finish this work. You submitted that it would be appropriate to delay imposing any sanction for 28 days to allow you to conclude your audit. 5. In making its determination, the Tribunal has exercised its own judgement and has taken account of the principle of proportionality. It has also had regard to paragraphs 148 – 152 of the Sanctions Guidance which relate to immediate orders. 6. The Tribunal has considered whether it is necessary for the protection of the public or otherwise in the public interest to impose an immediate order of suspension. Given its findings of fact and your complete disregard for those

FTP: Dr LOUTFI

51

Record of Determinations – Medical Practitioners Tribunal findings, the Tribunal has determined that an immediate order for suspension is necessary in the public interest, in particular to protect patients and maintain public confidence in the profession. In light of your refusal to accept any of the Tribunal’s reasoned findings and your propensity to realign the history of events by suggesting that your mistakes were only minor and that you have apologised, neither assertion withstanding scrutiny, the Tribunal is of the view that the public would be outraged if you were allowed to return to unrestricted practice pending the substantive order taking effect or the outcome of any appeal. 7. The interim order of conditions currently in force will be revoked when written notice of this decision is deemed to have been served on you. 8. The immediate order of suspension will remain in force until the substantive sanction takes effect, or until the outcome of any appeal is decided. The substantive sanction of erasure, as already announced, will take effect 28 days from when written notice is deemed to have been served upon you, unless an appeal is lodged in the interim. 9.

That concludes this case.

Confirmed: Date 03 February 2016

FTP: Dr LOUTFI

Dr Nigel Callaghan, Chair

52