Thread by @MPTS_Hearing

The hearing is due to start shortly. Today we are expecting to hear from Dr Roger Walters, Consultant Child and Adolescent Psychiatrist at Chesterfield Royal Hospital. He will be discussing Pt B.

The Chair is welcoming Dr Roger Walters (Dr RW) to the hearing and introducing him to the panel and counsel.

SJ is referring to Dr RW's witness statement, SJ seeks confirmation that the statement and accompanying evidence from Dr RW are true to the best of his knowledge. Dr RW confirms.

IS asks Dr RW to look at the letter of referral to Pt B in relation to his possible need for anti-depressants. Pt B, 17yo had been pursuing gender-affirming care.

IS asks had Pt B been referred to the adult service. Dr RW says he had been seen by the adolescent service in Leeds and that he was waiting to be referred to the adult service. Dr RW said he thinks there had been a delay in the referral to the adult GIDS.

Dr RW said he had struggled at school because of his mental health difficulties and didn't perform as well. IS says that Pt B has been discharged from CAMHs in June 2016. Dr RW says he thinks that is correct.

IS asks is it correct that on the 24th Aug 2017 Dr RW sent a letter to Dr W. He says he didn't receive a response.

Dr RW says he saw Pt B earlier in August (prior to the letter to Dr W) and he says he knew the GP who was Pt B's Dr. Dr RW asked Pt B's GP if he was asked to do any blood tests or monitoring.

Dr RW asked Pt B's Dr to provide him with all the records relating to Pt B. Dr RW went to the practice to go through Pt B's notes. He says he found 1 letter from Dr W where she refers to a shared care agreement but no other corrospondence from Dr W

Dr RW was seeking information about who was providing the prescription of testosterone to Pt B. (Dr RW removing his cat as it was meowing at him, Dr W having a chuckle at the cat noises.)

IS asks Dr RW was he aware that Dr W had requested a shared care arrangement from Pt B's Dr, Dr RW says he was.

IS asks Dr RW to look at a doc from a pharmacist that states that Pt B has started on a treatment and needs puberty blockers as well, asks what he should do, Dr RW says he has never seen that letter before.

In response to a q by IS, Dr Rw says gender dysphoria is outside his area of expertise.

IS refers to email from Prof Carmichael: following 1 meeting with GIDS and 1 did not attend, Pt B asked for a referral to GIDs after going to GGP they are looking for a referral to GIDS to minimise costs.

Email cont: We need to do what we can to mitigate risk, will refer to endo and agree a plan with Pt B. Queries consent process, asks GP to continue the prescription until the endo appt can be arranged. Not sure if the Leeds team will agree to continue prescribing.

Correspondence from Dr RW to Prof Carmichael: says mum of Pt B says they don't have much T left, discusses a bridging prescription for Pt B.

Prf C correspondence says: I spoke to the endocrinologist in Leeds, they will be able to offer an appt, we will wait for the family to contact us.

Correspondence from Dr RW says: I spoke to the GP and they are happy to provide a bridging prescription, asks will it be PGB or someone in Leeds.

Dr RW says he and Prof Carmicheal had agreed on continuing the T gel prescription and that he requested blood test from the GP, which he thinks came as a result of a "helpful conversation" with PGB.

IS asks Dr RW about the testogel and the dose, Dr RW says that was the prescription they had been using from Dr Webberley. IS asks did he discuss the fact that he was going to prescribe testogel with PGB or Prof C?

Dr RW says that he thinks he did discuss the testogel with PGB/P C, and prescribed him with half a sachet of T gel

Dr RW adds that it was chosen as he was already on testogel (comes as a sachet). IS refers to a letter from a psychologist from GIDS Oct 2017 , letter states that Pt B had not seen an endo or had a psych assessment.

Dr RW's correspondence says he had understood Pt B would have an expedited apt with endo and asked for an update from the NHS, he asks if endo will contact Pt B or should he contact the endo. He says he prescribed a bridging prescription for T.

Dr RW says he issued a bridging prescription as Pt B's GP wouldn't prescribe without the endocrine appointment.

Email from Dr RW Nov 2017: Dr RW emailed GP saying Pt B has been seen by Leeds GIDS and is waiting for endo and asks has a decision been made about the dose?

IS reads a letter from DR RW to a different GP - updating the GP about whats happened and about Pt B's mental health. Says that Pt B is in the process of transferring to adult services but the waiting list is long.

Dr RW set out a management plan for Pt B and planned to see him again in July 2018 for a final appt. Dr RW says that at this final appt he discharged Pt B from a mental health pov and referred him back to his GP.

Chair suggests a break, SJ requests a longer break to pass on more information to Dr Walters.

Chair adjourns until 11.10.

Chair is apologising for the tech difficulties, confirms IS has finished his cross-examination, invites SJ to continue.

SJ: Dr RW is it correct that it's outside your competence to diagnose GD? Dr RW said since the case of Pt B he has undertaken more training but that he would be "hesitant to make a definitive diagnosis"

SJ asks about the training he went on and how did he access it as a consultant psychiatrist, Dr RW says it was a 1 day course open to CAMHS professionals.

The additional training post dates the time we are concerned with, is that correct asks SJ, Dr RW confirms.

Dr RW says he would not want to make the definitive diagnosis, I would identify that GD was a part of the case and think about what's the most appropriate course for that patient.

SJ asks would patients present with GD along with other presentations of issues. Dr RW says that is correct, he says autistic spectrum disorders present frequently with GD and some adult BPD patients.

SJ: Pt B presented in your clinic and it was apparent to you that there were concerns about whether this patient had GD, so who would you have referred to find out if he had GD? Dr RW: Leeds GIDS.

Dr RW says that it is typical for CAHMS to refer to GIDS

Dr RW is being asked by SJ to look at the Good Medical Practice specs re bridging prescriptions and reduction of harm policies.

SJ reads from the guidelines regarding bridging prescriptions, asks Dr RW if he familiarised himself with these guidelines before providing a bridging prescription. Dr RW confirms that he did.

SJ says Pt B prior to the prescribing had not seen a psychologist or an endocrinologist. Dr RW corrects him and says Pt B had previously seen a psychologist but not an endo but had disengaged from the psychologist due to being unhappy with the process.

Dr RW says Pt B did not want to engage with GIDS as they were frustrated with the service and process they had experienced.

SJ is reading from the correspondence between Dr RW and Prof C, as raised earlier today. SJ refers to an email from the following day, Dr RW writing to prof C, saying he is seeing Pt B and mother next week, Mum had said there wasn't much T left, supply was low.

SJ asks if the low supply was a key factor in his prescribing a bridging prescription of T, Dr RW confirms

SJ reads an email from Dr RW, asks what steps had Dr RW taken to establish what would be the appropriate does and what to prescribe. Dr RW says he had Pt B's own account and had spoken to PGB, he was told it wasn't an abnormal dosage of medication.

SJ asks if he had input from an endo as to the bridging prescription. Dr RW says he spoke to PGB.

SJ draws attention to the two existing diagnoses for Pt B, asks were they a factor in the decision to provide a bridging prescription. Dr RW says yes, Pt B's GD was affecting his mental health and Pt B was frustrated with his care.

Dr RW says that Pt B's depression was clearly linked to his dysphoria and their frustration with the process and that feeling "things were uncertain and they were at risk of not being able to continue their prescription".

Pt B had previous suicidal ideation which Dr RW says was not all due to GD. This is another reason why Dr RW says he felt a bridging prescription was important for harm reduction.

SJ asks where he sourced information about the dosage of T he prescribed? Dr RW says he was trying not to make any changes until Pt B was able to get back under NHS care. Dr RW said the dosage wasn't abnormal and that he cannot recall for sure if he discussed the dosage with PGB.

"I was hoping we could overcome his degree of reluctance to get back involved with GIDS" says Dr RW

Is it correct to say Pt B previously refused to engage with GIDS prior to going to Dr W? asks SJ. Dr RW says that Pt B started on the process of assessment but declined further engagement with GIDS by not attending an appointment.

Chair is requesting a break, returning at 12.

Chair asks Dr RW about the guidelines for bridging prescriptions, Dr RW says he followed them.

Chair asks if Dr RW can confirm that Pt B said he had felt unheard by previous professionals? Dr RW says that is correct and that in part it was in relation to his own service.

Dr RW says that Pt B felt he wasn't being listened to and that professionals weren't responding in a way he felt was appropriate. He says Pt B had a feeling of frustration regarding his GD and the delay in being able to access gender-affirming treatment.

Chair asks was your service was approached because of the GPs concern that Pt B was prescribed T by an external source, Dr RW says that is not correct, he was referred due to "Low mood and risk"

Dr RW says the reason for referral of Pt B to CAMHS was an urgent risk to self-harm and suicidal ideation.

Chair wants further details on the "not being listened to" point. Dr RW's reads from his notes Aug 2017, "triggers gender clinic messing up, CAMHS, if I feel like I'm being listened to"

Dr RW has left. SJ says he has no other witnesses for today.

SJ says Monday 2nd August Pt A's GP, Dr Young is due to attend. SJ says they need evidence from Dr Hindmarsh and that they will update when they get it. There seems to be confusion about the future schedule of the hearing.

The GMC has no witness listed for the 5th August, Chair asks do they anticipate having one on that date?

SJ says he will discuss with IS and look at rearranging to fill any gaps. There are 2 non-sitting days but he is not sure who has requested them.

SJ says that it's not always possible to have witnesses come when you want them. Chair said he understands that but there is a need to avoid having isolated days with no witnesses.

Chair says that the list of evidence now includes the statement from Pt a's mother and Pt A and that everyone should receive that if they haven't already. The reasoning behind disclosure and amendment has been completed and will be emailed as well.

Chair thanks everyone, hearing adjourned until Monday morning at 9.30am.

SJ raises the issue of Prof Hindmarch asking if the panel will have questions for the Prof. IS says Prof Hindmarch did not see the patient and is not being called as an expert. He says the question arises as to how the hearing will deal with him as a witness.

IS refers to evidence showing too-ing and fro-ing between Dr W and Prof Hindmarsh, he says it is set out there the various views of the two. Also Prof H admits to having no experience with GD but does have experience with sex hormones.

IS says there are two alternatives: either I can ask about his opinion as though he is an expert or take his opinion as fact and go from there.

SJ says the difficulty with Prof Hindmarsh is that he is not a witness of fact, but his opinion will stand as fact unless it is cross-examined and that he sent a complaint to the GMC.

IS says Prof H had no interaction with Dr W and that no factual issue can arise between PH and Dr W as they have never interacted. Prof H complained about Dr W due to his interaction with PGB posits IS.

SJ says that Prof H is in the same position as PGB, he is not being called as an expert witness. He says his statement has been shorn of opinion.

Chair suggests IS and SJ have a discussion and says that they will reflect on the issues.

Chair thanks everyone, adjourns until Monday at 9.30am