Thread by @tribunaltweets

My apologies but I had an issue from about 12.30 so I'll try to summarise Dr Agnew's evidence. We are in the lunchtime adjournment now - back at 2.00 pm

In summary only - SJ asked Dr Agnew to distinguish between an MDT and the arrangement which existed between Dr Webberley and Dr Pasterski. Dr Agnew states that two professionals does not make an MDT. Dr Agnew would describe the Webberley/Pasterski model as a referral arrangement

An arrangement where an opinion is sought but no arrangement is made to give continuing care, no ongoing provision. The provision of appropriate MDT teams is derived from WPATH guidelines and NHS knowledge base. Agrees it is not easy without NICE guidance but

the standards must be adhered to. SJ asks what should happen when a patient "drops out" of e.g. a Tavistock pathway or structure? Dr Agnew says very important to integrate any new provision with what has already happened to that patient and every effort should be made to ...

continue the care offered previously. SJ asks about the accessibility of services from CAMHS. Dr Agnew says it is difficult to get a quick responsive answer - typical waits with autism of 18 months. Parents may elect to get low quality reports

Dr Agnew accepts GPs would probably say they do not have good access. In relation to breaks in care very important to go back to the previous clinician especially where there is a history of disengagement. Treating doctor has to fulfil his/her duty of care to provide safe

and continuing care for patients with significant psychological needs. General question arising from Dr Pasterski's descriptions of MDT model as oppressive/too big. Dr Agnew commenting he wasn't sure about the point Dr Pasterski was trying to make.

Says MDT members don't all descend on the patient and gather round the bed. There may be nine clinicians who all have a role to play in assessing and supporting the patient. Yes there will be lots of contacts, but all one at a time. Many long discussions about the patient will

be between the clinicians. So important to deal with the patient sensitively but it must be safe. An MDT done well should never be coercive or oppressive as suggested by Dr Pasterski.

Further questions re Patient C where Dr Agnew has said that Dr Pasterski did not follow the diagnostic process for ADHD and said the patient did not suffer from this. There were indicators ( inter alia auditory disorder and in utero exposure to opiods) which of themselves raised

concerns and required an exploration of possible ADHD. This should have been part of Dr Pasterski's initial assessment. If Dr Pasterski was not checking for this then who would? Dr Agnew concerned about rationalisation given for lack of thorough assessment and commented that

a highly socially motivated child will present differently.We are starting again now so I'll have to return to this section later.

Ian Stern now starts to cross examine Dr Agnew. Mentions some good things about Dr Webberley and Dr Pasterski in the reports he has given. Outlines he's going to try and attack Dr Agnew's qualifications to give these opinions.

Three pages of Dr Agnew's CV. 2001/2004 first degree in Psychology p 237 of C3 attached to the report. Dr Agnew has to log on to GMC Connect. Problems getting to the same document....private session briefly ..... we are off line again

Just jumping back briefly while the Panel are in private session - Dr Agnew stating that the absence of a proper evaluation of the patient's ADHD meant that Dr Webberley was without a full assessment to determine the patient's capacity or competence to consent to treatment.

Dr Pasterski had suggested that a private assessment be undertaken but Dr Agnew pointing out this wholly inadequate.

We are back Dr Agnew 2001/2004 graduated with degree in Psychology. 2005/2008 degree in Clinical Psychology. Then UCL as Trainee Psychologist then 2008- 2015 - 17 different positions - all quite short. One year is the longest period ? Yes. March 09- 10 Churchill Hospital ? Yes.

Locum psychologist - yes often then made permanent and a few times the hospital has shut down. Tower Project was a project on autism. IS is probably going to try to undermine Dr Agnew's credentials. A lot of jobs? yes agreed. Dr A does expert witness work ? Yes.

Dr Agnew describes his work. Vast experience across a broad range of mental health and related services. IS trying to understand the nature of Dr Agnew's expertise. Research papers arising from your doctorate studies? Yes. 2012 some modules from a Masters - two out of nine ? Yes

Never worked in a GIDS Clinic , or as a GP in Gender Identity, never treated a patient or been part of a team dealing with G.I. issues. I have assessed GD in other work with autism. Any experience in other countries? No. Locum advantages ? Places can close and you have to move?

How do you carry out a long term assessment when you move around? Some posts were quite long. I have long experience with my patients in private practice. How do you learn from others? We have a core model of supervision in psychology so we are continuously learning.

I have identified gender dysphoria in my practice. My knowledge about what should happen at an MDT is from the Guidelines. You are giving us your interpretation of the guideline documents but without you having done any of the work yourself i.e. diagnosis and treatment of GD.

My opinion is based on what they should have done in relation to the guidance. What they've done to individual patients would be a clinical decision. IS says you are looking at documents without knowing what happens in practice. I had not read WPATH before this case, no.

Discussion about whether Dr Agnew knows enough to give expert evidence in this area? I am giving the evidence not about GD or the clinical interventions for it but about standards to which Webberly and Pasterski were working.

Dr A has accepted what he does not know but his opinion is not a clinical opinion but about standards. I had heard of Dr W's services - this is not all completely new to me. We don't treat GD - it is explored not treated. Role of psychologist? Giving assistance to a child - NHS

NHS spec and WPATH would require the psychologist to carry out those diagnostic test which were appropriate. A number of schools of thought about treatment - criticism of the GIDS clinics- protocols over patients? Yes that is said. WPATH and NHS guidelines are quite clear what is

to be looked at. Nottingham 17 plus service does not have an MDT ? No. Different for adults. Waiting times mean that a child of 16 may be waiting until he/she is 18 for treatment. In Patient C the ADHD would not have been a bar to treatment? Agreed. Suppose Patient C had been ref

referred to CAMHS - he might not have been seem for 18 months? Correct. What about within the MDT what if one of the specialists was not available? MDT has all participants available at the same time. IS - an expensive model? Yes. Gold standard? It is what the WPATH states.

Is there research about the gold standard? Distribution of accountability ? No, that's not how it works. Accountability and responsibility remains personal to that professional.

Do something ? Do nothing ? Whose decision? it varies in the NHS - what should happen, referral, screening, assessment, MDT in concert. GPs take important decisions every day without the help of the MDT.

Looks at Operational Research Document - cut and pasted from NHS document? Yes. Dr A has summarised his reading of the guideline documents. Some interpretation may be needed re GIDS services. Chairman thinks evidence will continue until Monday =. Short break now until 3.30 pm

We're back. IS in the middle of asking about a document which he has not described while online. Asking about which services are not deliverable by a GP - another doc I can't see this of course. IS trying to limit the force of Dr Agnew's evidence and asking about when MDTs are

needed. When the treatment is outside the skillset of the treating GP for example? Yes. Does Dr A know about bridging prescriptions? Dr A has not reviewed the guidance on this for this report. Patient A records... 30th July 2015 referral report from Tavistock ..discussion points

fertility, yes, September 2015, current issues.. fully consented, discuss fertility... Any reference to capacity or competency assessment ? No. Consent form signed? Yes. Let's assume there was a full conversation about all these matters. Is that acceptable? I was not asked to rev

review the process at Tavistock - there seem to be signatures - mother, Professor and patient. Applying the standards to this - what should they do by way of process and documentation. Gillick competence is looser than Mental Capacity Act. We follow MCA.

Many, many services don't do capacity properly. There is still a duty to assess Gillick competence even if you still had consent from a child. For something like this a full competency would be needed - because you need to track competency as the child grows/is treated. No this

is not written down - just good best practice. Talking about how to create an MDT even across hospitals. Suggestion of linking to Mermaids even? Patient A's mother says UCLH indicated the service would terminate if Patient A continued on testosterone. Stopping medication is an

intervention. Discussion which was hard to follow without the factual nexus concerning Patient A, UCLH , the Tavistock and Dr Webberley.

Objection from SJ who is saying that IS is cherrypicking certain documents from UCLH and Tavistock - unfair to do this and not provide all the history of the treatment of A. Chairman thinks it is still a legitimate line of enquiry. SJ - as Chairman says - is this all there is?

IS did ask whether these are all the records? If there are others let's see them. Dr A can remember a letter saying medication was being stopped. SJ is going to check over the weekend and see what has been said about the existence of the records. SJ I'll need to check that Prof

Butler - thinks he may have described another class of documents too. SJ will check this and deal with this in re-examination. Presumption of consent for capacity purposes at 16 - yes. Patient had seen CAMHS but they did not attend. Dr A thinks he was referred for an autism

assessment. Not sure which document IS is challenging Dr Agnew about now - appears to be slightly repetitive of matters covered this morning. Not detecting any major new points. Summarises an essential issue set out in Dr A's conclusion namely that there are many who suffer

because of the long waiting lists. Not fair that trans people have to choose between two systems. Chairman is now talking about running order etc now Dr A agrees he can come back on Monday. Adjourned to Monday at 9.30 a.m. 23.08.21.