Thread by @tribunaltweets

Afternoon session about to start.
Simon Jackson (SJ), QC for the GMC, will continue to examine Dr. Helen Webberley's (DW) decision-making from 2016 re. Patient C, a 10 year old living as a boy. Jackson will pick up the issue of consent to medical treatment.
[Thread 3].

Opening remarks: Panel Chair says they would like to hear from Patient A and Patient A's mother tomorrow.

SJ: Dr Webberley can I take you back to Patient C, to deal with issue of consent. 9th Feb 2016. Looking at the records, around the timing of the patient's consent signature, what was the dialogue b/w you, Patient C and patient C's mother?

SJ, ctd: This is the signed consent for puberty blockers. You had a consultation with Dr Pasterski present back on 8th Dec 2016. Was there a meeting with patient and patient's meeting subsequently, before signing consent?
DW: No.

SJ: So looking at entry for Dec 8th. 'We fully discussed role of blockers which would prevent further female puberty developing and give a chance to decide which puberty would be best around age of 14. We did not talk about fertility...'

ctd: We forgot to talk about fertility but would return to it'. [DW's own record].
DW: Age 14 is a good age to decide which puberty is right.
SJ: So you felt putting this child on blockers for about 4 years was a safe and best course of action?

SJ: Starting gender affirming meds so soon after blockers, was your concern that it was too soon?
DW: As soon as puberty was started it was blocked so it's not length of time without blocker that's an issue it's the amount of time without sex steroids.

DW: We were talking about different groups with delayed puberty. Puberty can happen at broad set of ages so age is not only factor to consider when to start puberty but the issue is really when to start sex steroids.

SJ: When was fertility discussed before Patient C signed the consent form in Feb?
DW: I have put all this into my witness statements.
SJ: But in terms of dialogue did it involve patient directly?

DW: It involved me talking to his mother.
SJ: Why not the patient too?
DW: I thought it was appropriate to talk to the mother not the patient.

SJ: But Patient C signed consent didn't he?
DW: In this situation both parent and parent consented.
The Mum discussed with the patient not having children, and he was adamant he didn't want them, tho note at age 11 it's difficult.
SJ: You relied only on what the mother told you?

SJ: This is highly unusual isn't it, for the patient not to have talked to you?
DW: No I don't think so.
SJ then reads out the consent form which says 'my doctor has talked to me...' and mentions discussion of alternative treatment and fertility having been discussed w/ patient.

DW: There is lots to discuss at this point and that's only one thing. You have to consider what the child will understand. There is no long term impact on fertility of taking PBs. It's just a long term pause. I was happy I'd given Mum the broad overview & answered her questions.

SJ: Isn't there an area where some aren't accepting of identity, so the decision taken may reflect the desire of the parents depending on their attitude? Ensuring the child had been directly involved in the process, seeing the child with the mum in the meeting...

...that had happened before with Dr Pasterski, you'd met together, there was no bar to having a meeting with the child.
DW: I have never been presented with a situation with the parent leading the child, it's always the child telling the parent - in my experience of gender care.

DW: Fertility was discussed in several email exchanges with the mother...I answered her questions
SJ: You did not think it necessary to have a consultation with the child before February?
DW: I did have a meeting with child in Dec but did not think necessary to discuss fertility.

SJ: "He's adamant he doesn't want children but I'm not sure that's something a child of 11 can be definite about?...but I know PBs don't interfere with fertility, do they" - said the mother in her email to DW. There is still a question in the mum's mind yes?

DW: Yes, I said to the Mum that infertility should return if puberty stops being blocked and I also discussed egg retrieval whilst on blockers. The mum had had personal experience of this (egg harvesting) and I explained more about it.

SJ: One might think that a child of that age might not understand implications of this course of action. Is it appropriate to factor in what Dr Pastersksi was saying about this boy and his psychiatric history? [refers to bit read out before - ADHD possibility]...

SJ ctd: Dr P said, "Thought processes and speech appears normal and appears to have loving and engaged family" - this isn't giving confidence that this patient had capacity to consent?

DW: Again the process of understanding must be taken in an age appropriate way and Patient C had problems with dyslexia and we saw that when he was filling in his questionnaire and his mum scribed for him. We need to be sure their ability to consent is damaged by labels.

[Sorry this meant, from DW: "We need to be sure their ability to consent is not damaged by putting labels on them like dyslexia".]

SJ: Am I right that no physical examination was carried out on Patient C?
DW: No, not an in-person 'get on bed and undress' affair.

SJ: Re. Dr Klink, transgender health care also depends on psycho social factors not just physiological and recommended to make these decisions in an MDT meeting.

DW: The use of progesterone sometimes by GPS for F2Ms when they are distressed. The guidance that's helpful is UCSF (?) guidelines: Trans masc youth are not appropriate for hormones but want to stop development of female development....

DW ctd: such as inducing stopping of periods and further breast development. So though progesterone can be used to stop periods they don't stop breast development and blockers are better to stop breast development in such a young patient.

SJ: You didn't discuss this line of treatment?
DW: The first line of treatment is blockers. Progesterone would only suppress menses not further female development which was crucial for this patient who had issues with chest development.

SJ: Two issues of appropriateness of PBs. One was cost and this was expensive because no GP was involved. The other needles.
DW: Not an issue because patient could afford to pay.
And needles - not patient's favourite thing and fear of needles was contributory factor for stopping.

SJ is now moving on to other aspects of her evidence. Asks DW to have her witness statement to hand as this is the context for all her answers to him.

SJ: Let's move to Charge 7, re. the "Doctor Matt" private company and the prescribing.
[Lots of mic feedback problems so we are waiting for it to be resolved. Everyone is on their computers ].

SJ: Your second witness statement is relevant exhibit. p.447 of bundle as an example. Prescription 11th June 2016 medication listed and signature. Are we to understand the last stage of process is when you apply an e-signature as we there and this activates the prescription?

DW: The 'print prescription' button is not a button I'd use as this is done by pharmacy.
SJ: But is the last step where you apply your signature to the prescription?
DW: Yes, there is an authorise button and then the order is accepted and I have to put a code for my e-signature.

SJ: Am I right in understanding that for each prescription prior to that stage, there is a questionnaire that is created pursuant to a patient request? There are 4 options, patient profile, consent, etc. I assume the Doc can scroll down and deal with all the issues that present?

...And that patient has previously supplied. You populate the questionnaire and this includes health profile, same process.
DW: Yes.
SJ: Please list all health care problems you have, is the last question. This is listed (underactive thyroid/diabetes)...

SJ: We can see the dosage of 500 metformin. Am I right in saying this prescription was sent out but your evidence on paper can only be explained by something not being present? If we look at what we have here (and we spent a lot of time on what was missing), we can see that...

...this order, of Metformin, there are two or 3, two lots of metformin of 500 and one of 850 within months - but you said increases are incremental?
DW: The newer way of dealing with Type 2 diabetes, metformin is best done in incremental increases. Give patient a box of 500...

DW ctd...then they can add more over time. You tell the patient to maximise the medication according to their body tolerance (it causes tummy ache). That's the modern approach to handling metformin.

SJ: I put to you that from the material here in summary there is no explanation as to why the increase has gone after 2 prescriptions of 500 straight to 850. There is nothing in the questionnaires where the patient says they can tolerate more/want a bigger dose.

SJ: It seems the patient is back from Cyprus and just wants a supply. Either mistakenly bc of your assessment or it was incorrectly put in as 850, it was a system error or you erroneously increased the dose without being an established basis? Can you explain what's missing?

DW: Online pharmacies work where patients requests medicine from pharmacy - the patient themselves 'chooses' the medicine. Like a repeat prescription. The patient would have chosen metformin 850 and put it in their basket (I didn't decide it). It's not error in system nor by me.

SJ: Is it an assumption that in her (sic) online basket she (sic) will have herself (sic) decided to put in 850?
DW: Yes, she (sic) did it.
SJ: So we can't know how patient is using the prescription, all we know is there is a leap from 500 to 850?

SJ: During this process do you have a chance to discuss with patient? So you could have seen on the system that it was only 500 before? So are we again in the Rumsfeldt known unknowns?
DW: I don't think we know. I wish we could get all the records and what have you.

DW: I do know that metformin is increased gradually due to tolerability.
SJ: 5th Aug and 26th Aug for 500, then less than a month for a 850 is a large jump. Is that time to acclimatise?
DW: We don't know what happened in Cyprus. Sorry.

SJ is moving on to Patient E [I may have misheard]. See Dr Harker's report.
SJ: Dr Harker says against background of diagnosis of a STD there should have been referral to a genital-urinary clinic.

DW: The GU Clinics will thank us for not referring all patients to these clinics and it's not always necessary.
SJ: Harker refers to needing proper investigation for the symptoms. Not necessary?
DW: It may well have been that patient E had telephone diagnosis and ordered online.

DW ctd: for privacy or convenience, for example.
SJ will next turn to Charge 9, the CQC safeguarding Inspection of "DR. Matt", the online pharmacy.
But first a break for 15 minutes, return at 3.30pm.
Will continue on this thread.
[Confirm this last bit was patient E].

SJ: Ahead of Charge 9, on 10th Jan 2017 there was a CQC Inspection focusing on DR Matt's safeguarding policies. The witness says in the course of the inspection and discussion that involved you, you and others said you were unaware of the safeguarding policy & had never seen it.

DW: The Inspectors were in London, bc it was the registered address of DR Matt in London, and Head of IT was in India, I was in Wales. I don't know which safeguarding policy of DMC it was, it was a huge org. To my knowledge there wasn't a safeguarding policy referring to Matt.

DW: Our (safeguarding) policy was that people would ask me if there was an issue. Nothing on paper.
SJ: Are you saying there didn't need to be a safeguarding policy? Mr Stratton (from CQC, our witness) gave evidence there should be one.

SJ: You are giving out prescriptions, so this policy is essential yes?
DW: We were small org and if there was a problem it comes to me and the CQC report said the clinician had received safeguarding training relevant to their role. I am not sure there was a piece of paper.

DW: I was the manager for DR Matt, but this was a very small new organisation part of the larger one (DMC). I hold my hand up that I had never seen a copy of the safeguarding policy. I am sure DMC had a SG policy for the whole organisation.

SJ: But in any organisation, however small, when dealing with health care, you'd expect a SG policy?
DW: There were only 4 of us. Two doctors and a tech support person and one other.
SJ: So an oral policy and if there is a problem, ask me.

SJ: Now moving to charge related to your membership of Royal College of General Practitioners. 10a alleges you signed a witness statement that you had been a member, passed the membership exams since 1996. It's admitted and found proved. Issue is statement you were a member.

[ Some dispute about DW's witness statements - they are looking for something.] SJ is saying passing the exam is not same as membership.
Her statement said:
"In response to the allegation I do have adequate training, I have been a member of RCGP since 1996".

SJ: Do you accept you have never been formally a member paying membership?
DW: Dr X [couldn't hear] said that I had been a member but it had lapsed. I recall taking up membership and letting it lapse probably when having children.

SJ: objecting to an interruption by IS, QC for DW, as it's interrupting his rhythm.
SJ: Email in the bundle from Royal College membership services to GMC said DW is "not and has never been a member of the RCGP". This gives us the necessary clarity.

SJ: Dr Webberley had sat the Royal College Exam on the date given but never become a member and therefore was not entitled to use the post nominal.
DW: I was a paid member and have always used expression member of the RCGP when I passed my exam. Very proud to be member.

SJ: You said earlier that you 'didn't know about the benefits of being a member'.

[DW saying that she thinks passing exams = membership].
SJ: Letter from Mr Moonie of RCGP to GMC, 2017, about use of nominal: 'It's come to our attention that DR Matt website lists DW's name as member, but passing exams does not entitle her to display herself as member of RCGP'.

DW: The allegation sounds like I was intentionally trying to deceive, which I wasn't. But I accept it wasn't correct to do what I did.
SJ: But you knew you submitted information after the letter we've just referred to, and made statement you knew to be untrue. Dishonest.

SJ: Move to next charge. Suspension from Medical Practitioner List (?). You failed to notify pharmacy because you said it wasn't necessary. Your case is you didn't think you had a duty to notify them?

DW: Decision Letter sent to me. Para in bold says "During period of the suspension you should refrain from providing primary medical services in Wales in any capacity." I then stopped my locum work.

DW: I recognise there is a duty to tell other organisations but my world had turned upside down and though didn't do any work after that I didn't inform Mr Gale of the suspension.

SJ: Under Charge 18, you accept you had duty to tell the pharmacy of yr suspension.
DW: My reaction to the suspension and the IOT (?) was not to work in any capacity at all.
SJ: There is evidence you were still providing online med services to Frost pharmacy up to May 2017, yes?

SJ: Good Medical Practice says you must without delay inform any organisations you carry out work inc with patients. Are you contending that didn't cover Mr Gale or Frosts Pharmacy bc you were subcontracting (this now references matters no longer before this tribunal)?

DW: Had I been logging in and doing patient work, it would have been different. I'd stopped seeing his (Dr Gale's?) patients by then.
SJ: Good Med Practice refers to not carrying out medical services/work after suspension. Were you carrying out work after X of May?
DW: No.

DW wants to look at the documents; they are all scrutinising various spreadsheets.
DW: I want to explain. Can we go to line 12,001?

DW: This shows a pattern. U can see every day over Xmas up til early Jan there are distinct periods where I log in and do 50-70 activities every day. Carries on thru Jan. It was around 27th Jan when my husband took over. It starts dwindling off in Feb. Days I log in tail off.

DW: So on the 13th April it shows it was the last significant day that I worked. I want to show this to emphasise that when those catastrophic things were happening in my life I was not able to work, did not work.

SJ refers to Mr Gale and what he said, and that he didn't realise she was logging in all thru March and half of April when in her statement she said he stopped in Jan. He needs to go back to what Gale said. Wasn't expecting her to go into the spreadsheet.

SJ: Are you saying to me you actually stopped working and dealing with patients on the date given by GMC re. your suspension or was it 'dwindling', which is different?
DW talks about ambiguity about who was putting in the entries in spreadsheet and her head not in right place.

SJ: Yes there was an instance of it not being clear which of you or your husband had entered something on the spreadsheet.
DW: I totally accept that I should not have practiced from receiving the suspension and I did not work after that time. [Perhaps not clear in my statement].

SJ: Moving to charge re Bevin Health Board tribunal. You were deemed to have persistently challenged the review & the investigators when they came to yr house.
DW: As much as I would love to finish this today, I'm feeling bit tired, I wonder if could start afresh in the morning.

Panel Chair agrees to retire.
Resume tomorrow morning 9.30am.
SJ will finish his examination re Bevin (said: 'no doubt DW will want to criticise their approach').
Patient A and Patient A's mum around 11.30am and Dr Schumer (witness) in the afternoon.

End of today.