Thread by @tribunaltweets

We are starting. We are continuing with Simon Jackson's examination of HW. She is being asked to speak to Professor Hindmarsh's complaint to the GMRC.

24th March 2016 is a letter from HW to Patient A's GP. But HW not sure if it's in the bundle and asking the chair. This may be returned to later.

IS (for defence) has interrupted to give important update. At 8am this morning, GMC has said it no longer wants to call Patient A or their mother - after hearing the evidence from DW yesterday. It's a surprise, says IS.

IS (Ian Stern) says it's not a matter for him/DW but a matter for the tribunal as to whether they wish to question these witnesses. Mrs A has made a number of statements going back to 2017...

(IS, ctd.): The original statement from Mrs A was obtained by the GMC and IS was due to have a meeting with lay witnesses and to say hello and familiarise them with the process. And he was due to do that this evening, at 5.30pm.

IS: Clearly during the course of the day we need a decision from the Tribunal.
Panel Chair: we have discussed calling Patient A rather than Patient A's mother. But GMC seem to be accepting the evidence.
IS: Issue of whether Patient A was actually required bc 'he's' 17 year old.

Confusion over whether GMC has accepted Patient A's evidence or not.
Panel Chair: the issue is really whether IS wants to ask Patient A questions.

IS: Mrs A has been waiting 4 years to give evidence. She is key witness re. treatment of 'her son' and IS perturbed that GMC may not want him to question her.

Panel Chair: we haven't discussed this properly so rest assured we will return to this at lunchtime and let you know what our position is by early afternoon, though it's cutting it a bit fine I recognise.

SJ: GMC has made decision they have in the light of how the case stands. We are always evaluating issues evolving and how the evidence is brought. DW gave plenty of evidence about her involvement with Patient A.

SJ ctd: IS knows that GMC re. Patient A would always be a judgment about calling Patient A and 'his' mother - it's always been a question as to whether Patient A would be needed to give evidence.

SJ: GMC have reflected what questions they would like to see Patient A being asked in light of forensic process we've gone thru to date. Have to consider the balance of what's needed now. Couldn't decide this before HW gave her evidence y'day. This is not about surprising anyone.

SJ: So that's the GRC's judgement. The consequences are for IS, that if he wants to revisit Patient A it ought to be possible but one has to bear in mind sensitivities of calling Patient A and 'his' mother.

SJ: Simple point is that the GMC doesn't seek to challenge the evidence set out in their statements and doesn't wish to put questions to them. It's a matter for the tribunal as to whether they are now called.

SJ: Tribunal must not be used to give platform to witnesses so closely involved... but he won't oppose it.
IS: Says he can't discuss this with DW until she's given all her evidence. He considers it central to the case though.

PC - Panel Chair: asks if Patient A and mother are available.
IS: Says yes.
PC: We will keep an eye on this over the course of the day depending on how much progress is made today. And you and SJ may need to discuss if you want to call them.

Now returning to SJ's examination of HW.
SJ: Starting with Patient B. As with Patient A I'll be referring to chronology and records. I'll refer briefly to the report of Dr Klink. We will start with chronology in C54, p.2, 11th July 2016 entry...

SJ: Patient B's mother contacts her doctor with message: 'I have a trans gender FtM 'son', we are on long GIDS waiting list, has name change, is living as a male, we just need testosterone'.

SJ: Reference to a CAMHS screening and possible self harm.
IS: Interrupts. We have to Q what info DW actually had, so I'm looking at the copies of the records. Rather than having them in flow of chron order they are divided b/w various medical providers..need to exercise caution.

SJ ctd: 12th July following on from that 1st contact, we see an entry set out: DW's response to Mother's letter: thanks for contacting me and telling me a bit about your son.

SJ: all the history that came from GIDs re. Patient A was helpful to her when diagnosing. So when you enter a dialogue with patient in terms of obtaining history, would one of the avenues you'd explore with patient is whether there is relevant history eg. relating to CAMHS.

DW: I like to see how the story unfolds. History taking takes place through getting to know the patient, carries on over many interactions.

SJ: Is there any sense that right at the outset, if any patient were to come into your surgery, as an NHS GP as you were, you can go straight in and find the history before even seeing the patient?

SJ: So...is the process to find the psycho-social history of the patient?
HW: I was taught to give patient full attention rather than looking at the records. If I'd asked Patient B directly 'hello I've been looking at your CAMHS reports' it would not have gone down well...

HW: Not something they'd ask Patient or mum, what is your history with CAMHS bc I want to steer away from seeing GD as a mental health problem.

SJ: Yes but when you open a dialogue with Patient, and I accept it may not be a MH issue, but there is a medical history with complex aspects and this can be addressed sensitively...

HW: There are many ways of doing this.
SJ: Now turning to the brief questionnaire given to the patient which includes past medical problems.
HW: the Questionnaire asks about medical past, physical problems, and psychological difficulties.

HW: I was interested in the questions about physiology.
SJ: Back to the chronology - the following day, there is a consent form.
[HW is trying to find the consent form.]

SJ: This is signed on 6th Sept. but in terms of the process. Going back to the chronology and staying with consent, the patient has had initial contact on July 12th with you. And almost immediately on 15th July consent is being provided. Prior to the consent being forwarded...

...what contact has there been with Patient B or B's mother about consent to prescribing?
HW: Consent form is not just intended to gain consent for the medicine, it's an information document. Just bc someone signs it it doesn't mean it'll be used.

HW: Saying consent form is part of a whole process, they don't just sign the form and the prescription arrives..
SJ: I suggest to you that a consent form being signed is typically the very end of the process and not a lever for discussion with patient about what's appropriate.

HW: I don't think there is a particular rule or order about gaining consent - it's an individualised process.
SJ: But, as I suggested to you re. Patient A, before someone formally consents to any treatment they should have had a full opp to discuss with the prescriber exactly...

...what treatment is being offered and the benefits and drawbacks.
HW: And that's the conversation I had with Patient B and mother at that appointment.
SJ: What about the assessment process though?

SJ: You describe the assessment process as 'triaging'..
HW: First contact with me and Patient B and mum included giving them information and consent form (signed two months later, in Sept.) and first prescription was in October. Dates are not my forte...

HW, ctd: And then there was my clinic appointment before treatment started. [HW is looking at bundle for the date]

HW: [Referring back to the questionnaire now.] Patient laid out history of self harm and poor mental health in their answer to the psychology part of the questionnaire.
[SJ is asking about the clinic note from DW now]

SJ: Clinic note says 'I suggest we start with 25milligram of Testostone and shared care agreement".
Where do we see record of discussion of risks and benefits?

HW: I don't have a record of that.
It's not recorded, because my routine verbal reaction is to discuss risks benefits and side effects; I don't do it in emails.
SJ: In terms of consent there is still important issue to have full dialogue that is recorded?

HW: A duty for me to ensure Patient understands, and I apologise there isn't a record of the specifics of what was discussed. Various doctors have various different types of consent forms - doctors do differ in the way they display written information and record consent.

HW ctd: I agree that dialogue is imperative.
SJ: But for someone so young (16) going on gender affirming medication, shouldn't we have the benefit of knowing whether or not issues were raised about fertility and other complex outcomes and whether it was recorded?

HW: I can't add anything.
SJ: Your role is not to challenge the patient's own statement of their own identity?
HW: No there is no need to unless something in the history?
SJ: with patient B, you didn't see the need?

HW: I had alot of info from Patient A's mother. We can't diagnose gender identity but i had a synopsis from Patient A's mum [mention of one sentence] saying he was living as a boy, typical story of wearing boys clothes, everyone thought he was a tom boy. This info was gained...

..during my discussion with Patient and mum.
SJ: Was that the only discussion you had with patient before they signed consent form?
HW: Short answer, yes.

SJ: 16th July the form was given to patient. Then consent form was signed 6th Sept. Can I take it it was signed remotely and returned?
HW: It was returned & attached to an email... on 6th Sept.
SJ: No further conversation since 13th August, 3 weeks before consent form returned.

SJ [is now looking at records to see if there was any counselling]: Was counselling discussed with patient? [line is muffled here] There is an entry about a payment to you. And a starting date for Testosterone and no further delays.

SJ: What happened with the counselling?
HW: I don't recall any specifics about counselling or what happened about that before prescribing, which started 26th October.

SJ: There is a flag on records. Clinic manager emails Patient's mother asking if there was counselling - would you have been alerted to the fact there WAS counselling?
HW: Difficult to remember. On the e-health records, there are fields that would be filled in to give summary...

HW: That field might not have been filled in. If something was needed like counselling, there would have been a specific referral so I'm just wondering if Margaret was doing tick box exercise for the records and to my memory Patient B was not in need of counselling at that time..

SJ, back to chronology. Patient B writes direct, 'I'm a 16 year old trans, who managed to get a bridging prescription from you of half sachet of testosterone gel'... Where did the reference to bridging script come from?

HW: Patients are well aware of terminology of 'bridging prescriptions'.
SJ: Patient B is raising issue of a change in dosage. Before a dosage is changed, what process wud you undergo for any patient or this one?

HW: When you are inducing a second patient of a patient at this age you can increase the dose quickly because first puberty already happened. I would see how masculinisation was going and suppression of feminine characteristics was going.

SJ: Would you see the patient to do this?
HW: Says Covid has meant virtual consults are normal.
SJ: But this was pre-Covid. Did you not think a further meeting important, to see what psychosocial aspects were, how he was feeling?
HW: Heard from Patient B's mum.

HW. He (Patient B said, and his mum) is more temperamental with mood swings. I would need to see if periods have stopped. Patient and mum sends lots of correspondence about him wanting to move to injections...

HW: I know this was pre covid but I was perhaps ahead of my time using multiple methods and telehealth services.
SJ: You identified comms from patient and patient's mum but isn't it beyond taking bloods and getting patient's own reports to do a proper exam to find out what..

...psychical changes there were?
[Sound is breaking up badly these last few mins]
SJ is really trying to get at fact HW did not meet Patient B or mum to increase dosage of testosterone.
Panel chair warning not to use patient's name. It's critical no names disclosed.

Back to SJ's question on assessment and monitoring.
SJ: Deal with the monitoring first. Leads into issue of altering prescriptions. When first prescription was written around 26th Oct 2016 what was treatment plan for monitoring and review?

HW: I do review at 3 months after first prescription.
SJ: That would be Jan Feb 2017? Would it be diarised so if patient forgot, your admin team would send reminder for review coming up?

HW. How it works is that a new prescription is needed so the fact it's running out makes patient aware it's time for a follow up.
SJ: Around Jan yr email: 'I more than happy to have chat and more than welcome to come and see me in clinic to talk about testosterone levels' ...

SJ would it be not be appropriate to meet patient?
HW: As we saw with Patient A, the follow up was with nurse. What we do with late teen already undergone female puberty has full chest and hip development and height has finished by 16 or 17..

HW: If it's a boy you can monitor testicular growth. But of course Patient B didn't have testicles so little to be done and as we see in the literature physical exam is highly sensitive in this patient group.

HW: These patients after 3 months do not benefit from exam and doctor doesn't get any info because there isn't enough features at masculinisation at stage such as adams apple or beard growth. The most important thing to know was about his periods and whether they'd stopped ...

HW ctd:...which I didn't need to see the patient for.
SJ: On 17th Feb 2017, you issued further prescription. Was that increased to 50 milligram?
HW: No. Patient B asking to go onto T injections. I use them less regularly. More imp. step was to reduce oestrogen (GRNH agonists).

SJ: So patient asked to increase T but not given.
HW: A good example of me not doing what patient asked for, but to use the blocker rather than increase T at this stage.

SJ now returning to Dr Klink as relevant to prescription on 17th Feb.
Chair says this will be last questioning before take a break.

SJ: Dr Klink said: Patient B was started on 25 milli T gel once a day. However this is considered a stepping up dosage and may not suppress his cycle so Patient B should use X or an agonist to stop menses.

HW: Giving testostone to someone producing oestrogen can be enough to suppress the menstruation. It will eventually be enough to suppress the menstrual cycle. If you give them blocker right away you put them into state of menopause right away that has bad effects like hot flushes

HW: Have to consider age and stage, and cost. Adding blocker is 120 pounds. We talked about health economics earlier. So I prefer to go gently and see the effects of T first before adding blocker to suppress femininity.

SJ: You relied on obtaining of the bloods and self description of patient and what mother said about mood but you have not seen or examined or spoken to patient.
HW: correct.

SJ And you haven't consulted with anyone else about what to do about the agonists?
DW: No, not with any other health care expert only with patient.

SJ: Dr Klink (endocrinologist) advised the best thing to do increase T but DW proposed to add analogue to stop menses but not likely to increase virilisation.
HW: That was Dr K's opinion. I am not sure which member of MDT would have helped him to make right decision about right

...medical treatment. There are many ways of doing it and I would argue that increasing to adult dose of T after only 3 months of treatment in a 16 year old (girl) is too early.
SJ: When you raised Q abt role of MDT member in treatment, where there is to be a balancing ..

SJ ctd: ...exercise, to discuss fully about rate of virulisation, how patient is doing, to fully inform the patient about his options and being supported and making judgements about , balancing continuation with menses with suppression of menses. This is what MDT should do.

DW: We know Patient B didn't have good experience at CAMHS. But in order to talk about considerations about cost I didn't need MDT. In terms of virilisation. I was happy to discuss with patient only. I value MDT expertise but we should use them when they are really valuable..

DW:...and important. We have to be careful we are not delaying care. We need to decide best way to achieve next stage. If we could get blocker then we could think about increasing T and I didn't need anyone else to help make that decision at that stage.

SJ: In terms of this history. See statement from Patient B about changes developed since T was prescribed in Oct as part of virilisation. He says I want to move onto injections, while the gel is useful, but I've been waiting since 2014 but changes are too slow as am on low dose.

DW: I would be facing questions about going too fast if I'd just given adult doses by injection every 3-4 weeks from a low dose over 3 months. One of the experts was talking about mood effects of T and anyone who brought up teen sons knows what T does...

DW. I know trans masculine patients often think gel is wishy washy but as doctor I need to give script I think best. Let's suppress menses and gel gives gentle masculinities.

DW says she wouldn't mind a break.
Panel Chair calls break during which SJ and IS will discuss issue of Patient B and his mum as witness.
[For clarity, Patient B is a 16 year old girl when first referred to DW in 2016 referred to as 'he'].
We will return at 11.35 on a new thread.