Thread by @tribunaltweets

Good morning. This is @katie_sok at day 30 of the Helen Webberley tribunal. We are expecting to start at 10.30am with continued evidence from Dr Dean.

As previously: HW is Helen Webberley, SJ is Simon Jackson QC Counsel for the GMC, IS is Ian Stern QC Counsel for Dr Webberley, P stands for the Tribunal Panel and Dr D or JD for Dr Dean.

Tweets may be added in batches during the day rather than real time.

Internet connectivity issues means our tweets are not loading properly. Morning session has now finished. I will load tweets from this morning as soon as possible. Hearing resumes at 1.30pm.

Discussion over camera technicalities. Chair: Good morning Dr D, thank you for making yourself available. Plan is 1.5 hrs this morning and 1hr this pm.

[Internet issue sorted!]

SJ: Good morning Dr D. Carrying on with qu’ns from last week. One issue asked by IS related to one of the docs which showed an extract from a reflective learning log. Related to your visit to Callen Lorde (CL) in the US. Remember those qu’ns?

Dr D: I do

SJ: nature of medical team available to deal with cohort of TG (transgender) patients, you said existence of MDT team included endocrinologists. Can you expand on nature of way care delivered at CL?

Dr D: I attended consults w. patients (follow up consults and new patients) delivered by medical practitioners (GPs primarily) and nurse specialists. Met with psychologists and other members of the team, where patients had special requirement for add’l expertise then other

disciplines were available such as surgery and endo – I didn’t observe that but was told so

SJ : If MDT they don’t need to be under one roof? Can you expand on availability?

D: if patient needed input from psychologist because of concerns of neurodiversity they wanted to explore then appointments in a couple weeks to meet with psych. All of this is documented in medical electronic records.

This is very similar to MDT in UK where we have access to surgeons either through [Microsoft] Teams or telephone if need to discuss an issue. Can also meet as wider team if multiple opinions at same time needed. Never saw this at CL but told it is in place

SJ: GNRH and GA (gender affirming) hormones. How were decisions made when to commence and what dosage?

Dr D: my observation exclusively in management of adults. Poss. one 16+yrs but don’t recall. No one under age 16.

Dr D: Policy at CL was initial screening by health professional (could be nurse) then consult by person who would prescribe endocrine treatment. In that case seen by GP as I observed

Dr D: Decision to prescribe and endorse by one practitioner usually, except in the circa 15% of complex cases.

SJ: did you get an insight re the 15%?

Dr D: No, short visit. One patient did have medical complexities but it was something the GP could deal with. This is similar to the UK where around 15% of cases are complex and need further assessment.

[Some discussion regarding that pre-screening of referrals. Practitioners do obtain reports from prior encounters with medical professionals]

SJ: We’ll move on now. IS produced a document with a list of issues raised with you. Do you have it?

Dr D: Yes

SJ: Turn to para 19. What IS is putting is that HW had lots of material from the Tavi. She had sufficient info to go on to rely on prev. assessments.

SJ: On 15/7/2015 there was GIDs assessment for Patient A – in records 144 to 150…. [think there was an issue between A and Prof B in July / Aug 2015 but couldn’t quite hear] …

SJ: Sep 2015 Patient A signed consent form for blockers with Professor Butler at the Tavi. ++5 months to Feb 2016, Patient A contacts HW.

SJ: then in March 2016 a review by Prof B, then in April 2016 HW gives GA hormones. In terms of material available, what’s your view re. the need to reassess the patient sent 5 months previously before giving GA hormones?

Dr D: Im not an expert in assess and management for under 17 yrs. If apply same standards, guidelines advise accept prev. assess from experts and should avoid reassess. because its distressing to reassess with same qu’ns.

They may infer there is some distrust in testimony. E.g. for endorsement for surgery an assess from prev. 12 months would be considered ok if no substantial change in gender identity (GI). However, assess of capacity to consent is for each intervention (informally).

Patient must understand, retain, weigh and communicate decisions. Eg for blockers it's not adequate for a different intervention such as GA hormones. Does not need to be lengthy but practitioner must be assured that patient understands

Blockers generally considered reversible although that is subject to some qu’n, not the case for GA hormones so additional assessment for that is required.

[IS interjects] IS: I did not mean to say that no assessment is required. Look at number 19… not just a question of history from the Tavi

SJ: In terms of the issue of assessment… Patient A records 178 to 179 then go to 115 to 116. In summary, on 3 March, Patient A has undergone consult with Professor Butler, emotionally labile… a form was completed.

Circa one week later, Prof B says: A is depressed [on blockers], things are much more settled on decapatel(?) Bloods taken today.

Against that background, should a further detailed assessment be taken before GA hormones?

Dr D: I think so if on blockers for some time. But I take issue with Prof B’s assessment.

A has been on blockers for several months before that letter was written. It is true that in a minority of patients there can be an increase in […] testosterone release but usually settled in a week or two and should not reoccur

My experience is that people waiting for hormone therapy, with long period on blocker find it very frustrating. Rage, anxiety, frustration – I don’t think to do with endocrine state – emotional response to delays

SJ: Is the guidance not a stable state before starting GA hormones?

Dr D: Often see distressed patients. Important that bio-psycho-social state should be assessed but that does not mean every patient must be calm and tranquil – matter of clinical judgement whether feelings are clinically relevant and suggest pause or whether rational response.

SJ: Lets return to no. 25 on IS’s list. Mother did not consent to communicate with UCLH, shared care plan sent to GP, [missed a bit] Lets go to C6 or part 6 of bundle GMC good practice guidance 2013, page 84

I will read it to you. The stem para “you must continue safe transfer of patients between providers, a) share all relevant information within and outside the team”

So, where does the duty lie for a clinician to liaise and collab & to what extent is that duty restricted by patient saying I don’t want you to tell anybody what you are doing?

Dr D: Yes that is v. challenging situation – conflict between patient confidentiality and consent. No right answer. Largely depends on making a judgement of what is in patient’s best interests. Where there is significant doubt then go to MDT and speak with peers

Where patient reveals info and says I do not want you to tell Dr X then there are circumstances where this supercedes statute e.g.

safeguarding issues. But other situations are more finely balanced. Personally, my approach is engage with patient (not mother) explain the risks that might be incurred from another practitioner providing care w/o info e.g. might cause misdiagnosis or possibly harm.

In my exp. I’ve not found a patient unwilling to have that info shared but if they did and I was concerned about the risk to them I would tell them I would not provide the intervention.

SJ: I don’t think this is in dispute but when HW started prescribing in April 2016, Patient A had been on blockers since Sept. By reference to NHS spec, patient A would remain on blocker until it was appropriate for him to start GA hormones at circa 16 yrs.

His state would have been reviewed regularly. But HW prescribed testosterone in April… unless Tavi told …

[IS interjects with objection] IS: this is not a question, a speech..

SJ: trying to establish when HW had all the info where the duty lies to communicate & whether or not the criteria militated the Tavi being told about HW prescription

Chair: can you articulate your question before giving the background?

SJ: Knowing that A was on blockers and likely to stay on them & that if patient chooses to depart from GIDS regime care would be stopped…

would the risk of interruption to that care…. where does the duty lie for GA hormones… to first advise the patient of risks and the duty to alert the then primary carer?

Dr D: Communication duty would lay with prescriber, HW. Inappropriate for treatment to be stopped by 1st provider just because sought alternative advice in private sector. Risks e.g. presumption of menstruation causing distress, psycho impact, risk of self-harm

There are circs (see endo society guidelines 2009?) where delay of x-sex hormone is not always right. If patient left on blocker for more than 2 years there are implications for their health. Bone development and other risks from prolonged use of GNRH

[Note to reader: Do ask if any abbreviations used are not clear]

SJ: the issue is whether or not there is a duty to advise of consequences of prescribing in these circs?

D: I think this is a very complex issue with no right/wrong answer. My decision personally would be not prescribe w/o communicating with UCLH. I would have engaged with patient to persuade why its in their best interests. If still refused, I would not have prescribed.

SJ: Return to correspondence bundle. D44, Page 8 [Note we don’t have access to the bundle] Should be letter dated 24/10/2016

Dr D: Yes letter… info for Will H… then second one from me.

SJ: Name is blanked out “good to see in you Cardiff….” was that sent to HW or someone else do you know?

Dr D: I suspect from me to HW

SJ: “accommodate patient’s best interest… suspect we might be able to change landscape, think it might help if we explore roles of specialists for initial assessment (ax) for transition …. and for the rest of lives. Be happy to start a dialogue. Let me know” [some paraphrasing]

Dr D: I cannot be certain that letter was to HW, seems likely, but could be a commissioner from Welsh healthcare. I might be able to find email and confirm.

SJ: How long will that take?
IS: we could come back after lunch
Dr D: Might take be a while to find [Looking now] No can’t find now.

SJ: go to page 11 (electronic pages) … email dated Dec 16 to a Mr James Palmer.. “Meeting re initiation of hormone treatments for young patients….” Do you know if this from you?

Dr D: Not from me.
SJ: 14 Dec email from HW to NHS England, you are cc’d. “Dear all… not sure why I am receiving no reply re minutes… Best Wishes, HW”

SJ: What was that meeting?

Dr D: Um, remember concern at NHS England that the approach…. no I can’t remember meeting took place. HW was providing care in a different way than NHS England so might have been about that. But I don’t recall it going ahead.

SJ: I don’t think I have more questions bar confirming re that letter. Thank you

Chair: Need to discuss if panel has questions for you Dr D. Can you find email in 20 mins? [This is letter of 24/10/2016 referred] Come back before 12pm at say 11.55am. Now 11.35am. That ok?

D: Yes, if I can’t find in 20 mins prob. lost in cyber space.
BREAK

Resumed at 12pm. Dr D has found the email. It was not addressed to HW. Panel to put questions to Dr D. Will take 30 mins, then go to advocates for further qu’ns.
Discussing timings for this with Dr D. Chair: Shall we start again at 1.30pm? He agrees. Adjourned until 1.30pm.