Thread by @tribunaltweets2

Welcome back to the afternoon session of Michael Webberley's misconduct tribunal.

Catch up with this morning here:
threadreaderapp.com/thread/1508359…

The GMC counsel are Simon Jackson QC (SJ) and his junior Ryan Donohue (RD).

(RD was the GMC counsel in Dr Adrian Harrop’s case which we reported last Oct)

The counsel are attending online and the 3 tribunal members are in person.

MW is not present.

Abbrevs:
GGP: Gender GP
GMC: General Medical Council
MW: Dr Michael Webberley
MPTS: Medical Practitioners
Trib: Tribunal Service Tribunal
VE: Voluntary Erasure
Chair: Leader of Trib members
DQ: Doctor Quintin
GD: Gender Dysphoria
TG: Transgender
PB: Puberty Blockers

We are back. The clerk checks connections.
Chair: before we recommence can I just mention, we have received an email from an interested member of the public. Sent at 11.27 and copied to your solicitor. Have you seen that?
SJ: I'm happy to deal with it

Chair: our view is it wouldn't be appropriate for Trib to enter into correspondence and don't propose to provide a response to the email. Of course that doesn't preclude the GMC from responding if they see fit

SJ: what I would say is as counsel for GMC its important that subs and resprentations I make to Trib are accurate and do not give rise to the risk of things being misreporting. Not raising misreporting. If I've said something inaccurate I will put it right.

SJ: in paragraph 11 I say 'Dr Q also found literature given to patients regarding meds, what he considers dishonest' that is factually inaccurate and I'll set out why. That paragraph should have continued 'which the GMC considers dishonest'

SJ: The relevant paragraph begins 'the participation and informed consent is characterised by obscure language.. ' (too fast)
Dr Quinton says the term 'replacement' is clearly untrue as MW is increasing testosterone over normal levels.

SJ: if one goes to notice of allegation, paragraph 3, 'you knew the info in consent form was untrue...' and then importantly paragraph 4 'your conduct as set out in para 3 was dishonest'.

SJ: I should have more accurately stated this and apologise to Trib that I said something inaccurate but doesn't deviate in any way in the alleged dishonesty of MW.

Chair: thank you and we'll proceed.
SJ: under the heading 'what defines a specialist in TG medicine'. A status as such is defined by entry onto the register. The practice of TG medicine is fundamentally experimental.

SJ: DQ said speciality of TG services lacks formal entry and exit points. MW has been a member of WPATH. DQ considers a specialist should be clinically competent, making diagnosis, taken adequate quality clinical training under reputable consultant.

SJ: Should show evidence of CPD, appraisal portfolio and peer interactions as part of MDT.

DQ 'NHS England expects ppl to cooperate'.

Where MW is writing to GPs, the GP is entitled to ask the background of MW

SJ: that's the issue being addressed. Continuing into the heading of 'expertise' I think we've covered MW and turn to DQ. In order to comment on the competence, DQ is a consultant endocrinologist at Newcastle, (reads more qualifications)

SJ: DQ sits in advisory committees and has developed specialism in reproductory endocrinology. That said he says his experience in adults, gives guidance to MDTs and oversees hormone treatment.

SJ: He acknowledged he's not acted as a lead clinician however he's recently participated in discussions about children with gender issues and cisgender children as well.

SJ: I've already addressed how gender treatment has evolved. DQ observes there's no accreditation scheme that would permit MW to transfer his skills.

SJ: Dq confirmed he's unaware of any mainstream positions on TG medicine who would be prepared to initiate hormone to children. Very few paediatric encrinologists would feel able to do so.

SJ: DQ says MW has not followed any discernable pathway to offer this service. In DQs opinion MW was not a credible specialist within TG medicine.

(Missed)

SJ: (talks of Dr Keirans experience and qualifications)

SJ: there will always be concerns, especially regarding hormones in adolescents. We will look at the child age 9 who remains on hormones until 16.

SJ: Giving hormones to child with 'time to think'...one thing with GGP, the consent form for PB and hormones is all in the same document. The primary healthcare provider, MW was taking on the role of MDT himself.

SJ: The GMC submit there is a risk patients would get a lesser standard of care rather than refer them on to specialists.

The prescription of hormones without a careful assessment and their needs, is fraught with difficulties, commonly known as 'bridging prescriptions'

SJ: The key Q to prescribe or not to prescribe, the Q why is the prescription to be written, is it for gender variance or for anxiety of the gender variance?

SJ: WPATH speaks of the dangers of not identifying other difficulties when diagnosing. We then come to bringing prescriptions. Those involved in the care of TG patients may have to deal with patients who have dropped out of NHS care.

SJ: The Q is whether service by MW was provided as an alternative to the standard. Eg. Patient T, Dr Patel received call from MW where MW explained situ and correspondence and Dr A isn't involved any longer.

SJ: He said he's not Dr A's supervisor and goes on to the issue to prescribing after a breakdown with the Tavistock.

SJ: Opinions are required at crucial stages, the following applies to all persistent GD, it may be distressing but unless documented, which Dr Keirans will take us through...

SJ: rather than just the pressure of a person saying 'my child is severely distressed and suicidal' and that puts docs under pressure to concede.

SJ: where Dr Webberley may be asked to prescribe bridging prescriptions of testosterone, that's not for a pause before they go into a Gender Identity clinic (GIC) because they've fallen away from the GIC.

SJ: (reads GMC guidance) 'The risk of self harm and suicide is much greater than the normal population'

'Some trans ppl after facing depression waiting for intervention may turn to self medication drugs online...

SJ: ...If your patient is self medicating you should speak to them about consent'

MW steps out of the guidance and aays he doesn't need ro refer as he is the Gender specialist

SJ: in the context of this case, children are asked to sign forms so important to their future, the focus is very much the child consenting.

SJ: There is significant law, Gillick, and the House of Lords said Drs could lawfully give Contraception if she had 'intelligence' and certain conditions satisfied.

SJ: (reads quote about children consenting and capability of their understanding consent) 'a minor under 16, can sue or be sued'

SJ: two distinctions arise out of that, eg, giving consent for treatment for broken arm/injury, but when one is looking at giving advice about treatment that will change child's development and completely alter it, more parallel to Gillick.

SJ: The judgement in the of 1993 (16 year old with anorexia, W, Local authority applied to give treatment without her consent) a feature of anorexia is it is capable of destroying competence.

SJ: The advanced the illness the more compelling it becomes. In the minors best interest has much reduced significance. I'm not saying that gender variance is anorexia.

SJ: The prescribing of agonists was because of the extreme anxiety and may have been displaying suicidal ideation, rather than the underlying GD.

SJ: The GMC submits that the situ may have presented itself to MW, it remains the duty of Dr and the Dr must be satisfied the patient has capacity and given informed consent, and that the benefits and burdens have been raised.

SJ: The whole premise of prescribing online reduces the Dr to have a meaningful dialogue and make sure the patient understands.

SJ: not every child under 16 can achieve Gillick competence, however much important discussion is undertaken.

SJ: It is necessary to have regard about the future though the child might not be concerned about them now, particularly about fertility and sexual function. A child may be making decisions which will impact on lifelong fertility.

SJ: The case of Quincy Bell, at the heart if the decision, Tavistock departed from Gillick. (Reads judges ruling, too fast)

SJ: Great care is needed as Gillick itself made clear. Of course although this judgement post dates the events we're concerned with, it's important when looking at Gillick, nothing has changed since Gillick.

SJ: important to note already strong guidance from 2016. If we can move to TG patients and start with S.
Chair: we would like a break if 15 mins
SJ: I'm in your hands. I think this is public hearing, it's a Q whether the Trib are helped by going through this in detail?

Chair: Thus far it has been very helpful although of course we appreciate when coming onto patients and allegations there are matters of detail we may not have to go through at this stage as we can cross refer with the experts. This is helpful though.

SJ: if the Trib don't need it, you'll have the factual matrix anyway, but what I don't want to do is to fill time with opening if they can spend time looking at other things.
Chair: We will let you know our view and reconvene just after 3pm

We are back.
Chair: yes you were coming onto specific allegations of patient S. We've had an opportunity to review that content and we think at this stage we don't need you to go through or recite.

SJ: We're mindful that amongst the patients, the allegations follow a theme, a generic nature, that MW was providing care out of his competence. If there were features relating to specific patients that would be useful to highlight, then we would encourage you to deal with that.

SJ: There are 7 self-selecting TG patients and I'd like to select 2 of them as examples from the 7 and deal with those. The first is Patient V. I referenced V in my opening

SJ: in July 2018, its worth noting its a year on from MW in essence becoming the Dr behind the prescribing of GGP b/c Dr A had ceased involved 2017, a Dr Joanne Dangerfield saw Patient V, a 9 year old child, born female that now lived as a boy

SJ: Dr JD was assessing headaches of Patient V and was concerned V was starting hormones. V was on a waiting list to be seen by Tavistock and was aware Dr A had been involved in Patients V's care. It was then DJD alerted GMC.

SJ: V was then being seen by MW. Mw said he was good to Skype with V and prescibe. It should be noted V's parents were supportive of GGP involvement and MW throughout GMC investigation.

SJ: Medical records were obtained. Questionnaires, Patient V had a 2 hour meeting with a counsellor in June, in July Vs parent had a Skype with MW for 20 minutes with V present for 10 minutes.

SJ: Following that MW prescribed GNHA and the injection administered by family friend who was a nurse.

SJ: The link there is back to the letter in relation to Patient V where MW was writing on behalf of GGP. When approached in that way the GP declined. Patient V changed GP under auspices of MW

SJ: DQ had serious concerns of age appropriateness sent to V by MW. The leaflet was 'seriously misleading and inappropriate' and MW wasn't qualified, MW had presented inaccurate picture of GIDS, leading patients to GGP

SJ: The MDT described by MW and GGP, DQ opined there was no genuine MDT in the care of Patient V and his care fell seriously below standard. MW did not do any psychological assess V and no notes, no bone density scan carried out either.

SJ: MW didn't assess V's stage of puberty by blood test which falls below standard, as did his failure to perform physical exam. His treatment plan failed to meet standards.

SJ: MW didn't follow guidance, lack of MDT, his practice giving PB without evidence and lack of robust review while V on PBs.
DQ also had concerns about consenting process which was a single document.

SJ: The testosterone treatment was not appropriate and not reversible. Dq saw no counter signature. DQ opines MW wasn't qualified to assess V's treatment.

SJ: turning to Dr Keirans assessment of V, she notes V was only 9 when in first contact. There are records of passing communications but no notes/letters about MDT and all the people involved.

SJ: Dr Keirans notes MW liases with GP after the treatment has begun. The standard was below that of a respected physician according to Dr. Keirans as well.

SJ: Dr Keirans indicates PBs might have been appropriate but lack of documents and no trail to the background of treatment plans. Dr Keirans said its not clear the capacity of patient was assessed and no attempt to review impact of treatment

Patient W was 18 when he died. MW did not provide primary documentation. According to MW statement to coroner, said he'd been on GIDS waiting list but patient W was keen start hormones.

SJ: MW had a consultation with W via Skype and it was said W 'always had a knowledge he was male but didn't know what it was called and wanted testosterone since 4 years old'.

SJ: This allegarion mainly relates to record keeping. We do not know what was supplied to W or dosage. There was talk of a monthly payment plan for hormones. Father of W, said packages started to arrive in the months before he died.

SJ: in September the GP prescribed Testosterone gel, requested by MW, and Patient W would need monitoring with blood tests. DQ notes patient W was under MW from June to Sept and on basis of a Skype and two emails, MW had diagnosed GD

SJ: MW failed to undertake assessments and didn't document his prescriptions, failed to enter shared care agreement and when it was in place, MW hadn't informed W's GP of his prescribing testosterone.

SJ: MW was unaware if W's mental health history. This is a contradiction as medical records on this date back to patient being a very small child.

SJ: I'll move on to GGP regulatory concerns. The GMC observed MW along with a fellow Dr controlled GGp, a vehicle that Drs could offer services to TG patients. Dr A was listed on company's house and MW joined as a director in Jan 2017

SJ: In May 2019, GGP gave following statement (reads about 'transphobia' and all Drs are regulated in their own country'). A new article was published on GGP about Dr A and MW about restrictions treating TG patients and a working hub outside the UK and states the suspension of MW

SJ: (reads full 'institutional transphobia' doc on GGP) in period leading up to 3019, the structure of GGP had changed and started operating as Spectrum Services and became registered office of GGP.

SJ: The GMC submit that removing GGP in UK by complex use of other companies, GMC submit that MW was jointly responsible for reconstructing GGP and prescribing testosterone was moved outside UK. GGP has moved overseas to avoid UK regulations.

SJ: Use of name GGP with effect from 2018, Dr A was suspended, prior to that, Dr A had been sole practitioner. By reason of that suspension GGP was operating without a GP. It lead patients to believe there was a UK GP involved.

SJ: MW has not provided a response to allegations although GMC have received various documents. It's right to say throughout these proceedings MW has always denied the GMCs allegations.

Chair: A few questions.

(The chair is SJ are going through a few details the Chair would like clarified, namely when Dr A ceased involvement)

SJ: in May 3017, Dr A was subject of interim order which put conditions on registration, particularly to identify a supervisor to Dr A's work. The outcome was it wasn't possible to identify a supervisor so was tantamount to suspension and it was then MW took on role of treatment.

Chair: Other question is about Dr Keiran's response but I don't think we have a copy and I'm wondering why we don't. If this is a doc DQ relies on it might be something we ought to see. I'll leave that for your consideration.
SJ: If you would yes

SJ: We can provide that and send that through later today or address briefly on Wednesday
Chair: I'd like it today or tomorrow.
SJ: I'll try and resolve that today.

Chair: The Final matter is just a general observation when you call Dr Quinton, something appears evident from the papers and his report, is that the evidence they have seen regarding various witnesses, comes essentially from 2 sources.

Chair: There are medical records provided by MW from GGP or BHM in respect to patients. We have them for some but not all. We have witness statements from patients themselves or their families or GPs but that's only in relation to some.in some cases we have both.

Chair: It's clear on occasions the experts don't have evidence and they draw inferences or they say theu can't reach a conclusion. One thing I anticipate to consider is inferences experts make are well founded.

Chair: I raise that because it will be helpful as to WHY they infer this, that and the other. Eg. DR Q deals with the fact that you can't get formal qualifications in TG medicine & much of a practitioner skill and experience of that will be experiential not formal qualifications

Chair: Dr. Q expresses MW did not have that and he will have to say why and how he viewed it like that. That's the sort of example. An absence of evidence is not necessarily evidence of absence. Unless any other matters I suggest we adjourn until Wednesday morning.

Chair: I'll just check with colleagues, no nothing to flag
SJ: Lastly then, the issue we touched on before. The Trib may wish to hear from one of the cohort of BYH or TG witnesses, so we can enquire about them being called. We have Dr Quinton on Wed & Dr Keiran the week after.

SJ: Lastly then, the issue we touched on before the Trib may wish to hear from one of the cohort of BYH or TG witnesses, so we can enquire about them to be called. We have Dr Quinton on Wed and Dr Keiran the week after.

Chair: we had put that decision about witnesses to one side b/c we intended to hear the opening, which we have now. It is sometimes better to hear witnesses before an expert but its not an inflexible rule.

Chair: It would be better we hear from Dr Quinton in any event and consider between now and Wed morning about questions we ask of other witnesses and if we do, we can indicate on Wednesday. Is that satisfactory?
SJ: That's absolutely fine.

Chair: We will adjourn until 9.30 promptly on Wednesday and conscious of the fact we have a lot to cover.

@threadreaderapp please unroll