Thread by @tribunaltweets2

Good afternoon & welcome back to the misconduct tribunal of Dr Michael Webberley (co-founder of GenderGP). GMC counsel (SJ) will continue to question expert, Dr Richard Quinton (RQ), after which the Tribunal will question RQ.
1.45pm start

Catch up here:
threadreaderapp.com/thread/1509086…

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 and has no counsel.

Abbrevs:
GGP: Gender GP
GMC: General Medical Council
MW: Dr Michael Webberley
RQ: Dr Richard Quinton
AK: Dr Alanna Keirans
MPTS: Medical Practitioners
Trib: Tribunal
VE: Voluntary Erasure
Chair: Leader of Trib members
GD: Gender Dysphoria
TG: Transgender
PB: Puberty Blockers

Further abbrevs:

HG: Hypogonadism
T: Testosterone
MH: Mental Health
TRT: Testosterone Replacement Therapy

We're back.
SJ: we're starting with patient S. I want to go some of your conclusions of care by MW. This is appropriate and adequate assessment and this is the role of a person competent...on what basis does a consultant physician and Endo, what evidence have you seen?

RQ: I've seen the assessments and remember having done them myself as a medical student. It's not something I've done myself since then. I know what it entails and a decent assessment looks like for GD

SJ: you've looked a counsellors report haven't you?
RQ: yes
SJ: is it your conclusion the failure to adequately and appropriately feel seriously below standard.
RQ: I'm not totally sure if someone else did it but but AK will opine on that.

RQ: Even if counsellor and therapist had done adequate mental state, they're not statutory regulated professionals and I'm not even sure that'd been enough and absolved MW.

SJ: can you deal with prescribing here?
RQ: in terms of assessment, I can't see evidence of anything there really. He seems to cut and pate info by the patient plus info from counsellor. Doesn't seem to be any due diligence.

RQ: He's faced with evidence that's weak, hasn't been verified, hasn't drilled down, it's worrying. It's like the patient has almost said 'I have gender dysphoria' and MW just agrees

SJ: there's nothing in his training to prescribe this
RQ: no, in hypogonadal cis girls we don't put them on things straightaway. Gender prescribing for TG females, start low, build up gradually rather than mega dose straight off.

RQ: There's a predetermined direction of travel that nothing will divert him.
SJ: what's your view of adequate follow up care?
RQ: well its not follow up care the way I would understand it.

RQ: there was an appearance of follow up but not the reality. I can't see that in terms of ppl other than MW. There were counsellor and admin ppl who said that's right. For me, it created the appearance but there wasn't any any clinically meaningful follow up

SJ: anything more you wish to say
RQ: it encapsulates it all. It's still disturbing to read it now.

SJ: does consent need ro be revisited by Dr who was going to prescribe after diagnosis?
RQ: I dont believe so necessarily. We physicians don't do much consenting but person consenting for surgery may not be doing the op, but have to understand what op entails

SJ: This is Patient V and your report from 2019. There's a summary of patients notes. This is a patient who was 9 years old. The summary prepared in GGP notes, identified as male from 3, Socially transitioned highly intelligent...

SJ: presented via his mother, parents concerned, referred to GIDS with waiting list 18 months, has Skype, onset of puberty, and prescription that day of blockers. No concerns raised by MDT, observes this is best treatment and straightforward

SJ: in terms of cisgender children and proceeding with treatment is it your view it's straightforward
RQ: not straightforward. In this case, they would not delay puberty but may go on parents perceptions of early puberty. The paediatricians would probably reassure parents and...

RQ: and there's no reason to be concerned...but that's not straightforward, [something about breastbinders], somethings in this clearly shoe MW doesn't understand the field.

RQ: He says the girl had transitioned from age 3... but the majority stay in their birth sex...that's pretty irrelevent...he says there's been suicide attempts and I think that's overstating it. He trying to justify something already agreed.

RQ: the evidence doesn't support that patients commit suicide. How can you be dysphoric with something that hasn't happened (puberty). They at least need puberty to commence. The idea you have to go on PB before puberty starts goes against what guidance says.

RQ: The evidence for PBs has only arisen for children 13 and over. There's no research for a child aged 9, the fact he calls it straightforward is hugely concerning to me in terms of his insight, or lack of.

SJ: you're asked whether MW was appropriately qualified, would you rely on what you said previously in regards to patient S?
RQ: yes
SJ: do you have a summary view about info sent to patients and parents about TG info?

RQ: there was a mass of info, verging on a data dump, none had been written for a highly intelligent 9 year old. The illustration who was in MDT was very misleading in the sense these were not ppl I'd recognise as appropriate MDT

SJ: they're listed here, any ref to paediatric or Endo?
RQ: no. Also Dr A still on list

SJ: This is a sssement by one of the counsellors on the list, we see some background and then presentation, 'Patient V is very boy like, short hair etc' then psychological factors reffed

SJ: do you seen any mental/psychological assesment
RQ: no. Its all happy clappy talk, nothing I recognise as a mental state examination
SJ: MW says parents need support
RQ: the patient needed support

SJ: you're asked to comment on the competence of MW to prescribe to V..your view?

RQ: this is extraordinary. There's almost no indication of prescribing PBs to a child of 9. This is exceptional for special paediatric endocrinology. It would be exceptional for a gender service and initiated by a doctor without TG knowledge or paediatrics...I'm speechless

Chair: do you say it's extraordinary for GD or extraordinary that the child was 9?
RQ: in one case it would be the youth of the child and the other that child was too old that was extraordinary

SJ: (missed)
RQ: my understanding is before puberty is properly developed, the confidence one has in a diagnosis of GD in a child is hugely less than an adolescent. If you leave them alone they end up reasonably happy with assigned sex at birth

RQ: this idea if you let a little bit of puberty happen, the child will suffer greatly, isn't true. There's a difference between I feel like the opposite sex rather than 'I don't want that to happen to me'. They are enormously different

RQ: the idea you could have same worded consent form for 8-16 years old is simply not tenable. You would need to have info sheet in different formats for clarity and undertsanding

SJ: let's look at the form
RQ: for a 9 year old? This is not fit for purpose.. it makes no attempt to put the info in a suitable way, however intelligent. One minor thing, it's partly a data dump, whether relevant or not.

Rq: I would say as well his data sheet contradicts itself, he says risk of diabetes is low on one form and high on the other. I'd not spotted that til now.
SJ: What's your exp. As to how long the process should take to go through consenting with young children

RQ: the children are never that young. Normal puberty 13 for girl, 13 for boy, you don't know puberty in delayed until its delayed. Aound 9, 9 is normal to have early puberty but normal not to so noone would change anything.

RQ: You should be doing nothing.
SJ: do you have oversight from colleagues of how process of delaying puberty might take place in Tavistock or your dept?

RQ: only the Tavistock that does that and my understanding is that there's no way they'd start a blocker at that age and assessment would be far more rigourous.

SJ: so do you defer to Tavistock judgement as to whether to intervene?
RQ: I'm certain it's not appropriate to intervene at that age

Chair: this may be a rare situation but what about a 9 year old reaching puberty at early stage but was exhibiting GD symptoms. In those circumstances would PB not be considered?
RQ: my understanding, along with WPATH, there is no evidence basis before aged 12

SJ: I have no more questions
Chair: if we can resume at 3pm please.

(This should say 12 for a girl)

We are back.
Chair: We have questions for Dr Q . My colleague will ask.
Panel: a reminder I am a lay member so the Qs I ask it may be you've covered them so I apologise in advance...but it's this and trying to understand you assert MW wasn't qualified in this area of medicine..

Panel: We know MW asserts he was. This bundle runs short of 4000 pages. This is 2527 and you'll see it's a letter from GGP. You'll see it's a undated, 3 page doc and starts with MW experience and CV we see elsewhere...

Panel: he moves into chairing the feelings of discrimination if LGBTQ community and he says he's worked with 1000s of TG patients. In this developing field in lay terms why his assertion is resisted by yourself

RQ: there are two aspects, one you have experience in care and trained in the care. He may have delat with 1000s of TG patients but he hasn't trained. There's nothing there to say he's trained in gender medicine, or under supervision, or gained experience and that's absent

Panel: We know that Doctor A was of course the registered GGP at a time MW worked there and we seefrom papers MW has taken over care from some of the patients. I go back to your point, is it possible MW could have been exposed to exp. from Doctor A

RQ: Doctor A does not havea ny recognised qualifications/training in that too.
Panel: so specialisms are in a completely different area that allows you to resist his training assertion
RQ: getting training is simple, you work under a master of mistress, recognised in the field

RQ: when a supervisor deemed you qualified you were signed off.
Panel: this doc, you may not know answer, it's written in third person, were not certain who commissioned the doc and for what purpose.

Panel: Revisiting your clear answer there's nothing in this doc that changed your view on MW experience?
RQ: no. If you flip back to MW CV he appears as superman, he can do everything....

Panel: in terms of his specialisms and consultant status but there's nothing here to his local, national, TG experience
RQ: not at all.
This is someone who has an interest. I can't quite work out on GMC register he's registered as gastroenterologist and not duel registered. Odd

RQ: his qualifications are narrower than most physicians - without the broader medicine - even though he's said he's worked in it I can't work it out

Panel: in re to MDT, here we see a list of ppl that work in MW practice. You pointed out there's no endocrinologist in that list. As an Endo is your criticism that this is NOT a suitable MDT?
RQ: there's noone qualified to prescribe hormones.

RQ: it says there's a specialist nurse but doesn't say what the specialism is. There's no peadiatric nurse Specialised in gender. Noone qualified to diagnose GD or prescribe hormones. Dr A, not qualified to make gender assessments or trained adequately

RQ: MW not qualified to make assessment, or prescribe to children, major concerns whether he's properly qualified to prescribe hormones to adults. You have to ask what if MW said he was a diabetes specialist

Panel: We see how the world's changed re zoom and online, how would MDT work (missed)
RQ: there are only three ppl equipped to provide diagnosis and they don't include MW or Dr A,

Panel: you don't see an adequate MDT process?
RA: the problem is the MDT membership they can talk to each other as much they want but if they can't prescribe there's no point.

Panel: I was never asked to review Dr A's curriculum ...Dr A has never trained with a recognised centre in gender to get that experience
Panel: we're not concerned with Dr A
RQ: yes but just to make the point MW couldn't have got exp from Dr A

Chair: when you say noone is qualified, do you mean they don't have exp necessary and out of area competence?
RQ: yes whereas by contrast if there had been a qualified prescriber in MDT and Dr A had been the GP then as part of shared care agreement

Chair: and if MW had the relent exp he would be qualified?
RQ: I can no evidence that he's had no experience. There is evidence of practice.

Chair: it's making the distinction between qualification than experience
RQ: he described himself as a physician whereas he's registered a gastroenterologist

RQ: a GP can prescribe to minor, A & E can prescribe, but physicians have never done that.

Chair: can we move onto more specific Qs to patients who are receiving androgen treatments. Pls look at your BMH report in 2019. You say Testosterone Deficiency Syndrome is newly coined and not recognised in UK. Are you aware of any body of Medical opinion recognises such as TDS?

RQ: yes there are Doctors who offer those services but none are endocrinologist or had training in hormones
Chair: are you aware of any research to support the existence of something called TDS?
RQ: no. These ppl tend not to be researchers

Chair: I want to establish there were any respected body that supported such a syndrome
RQ: if you open any endo book, none would refer to TSD

Chair: MW is criticised for failing to do any examinations for HG. You told us why physical exams form part of the process but, how important is it to conduct a physical exam and does that apply to all cases.

Chair: My understanding is that what you've said the physician should be looking a 3 areas, history, blood tests, having physical exam is it always necessary for physical exam
RQ: never 100% but I'll give a few examples, like cancer treatment affects testes.

RQ: there's no other possible cause, then there's no need to examine. Another example, a man referred with low T and LH and FSH levels but he walks in and built like a body builder.. now in that situ this man has is abusing or has abused anabolic steroids.

RQ: the fact the guy is huge gives the diagnoses. I'm not saying everyone should be stripped naked and have their balls felt but you want to get a good view of appearance. It's safest to do examination but may not always be essential.

Chair: in some circumstances, examining would be best
RQ: I would not underestimate what you can pick up physically from someone's appearance. Some think it superficial but so many cues to pick up.

Chair: What's about the position of a MH examination? There must be one?
RQ: no, one of the things our guidelines say if you have a diagnosis of HG, that should not be a contra indication to having treatment

RQ: even a physical doctor, who is not MH speciality, would say there's something wrong. Any reasonable medical practitioner seeing those features would say there's something not right.

Chair: so you wouldn't say as a matter of course a MH examination is needed unless it arose.
RQ: yes what the patient was saying, this was someone looking for T to improve self worth or physical perf. or maybe driven themselves so hard with exercise that they made themselves HG

Chair: can I ask about one aspect if the consent forms that were signed in the case if the androgen patients. You comment MW had not countersigned any of them, and there's an allegation there was failure to obtain informed consent

Chair: what is your opinion as having the countersignature in order to have informed consent
RQ: You can have informed consent without a firm. You've created the form, why haven't you signed it.

RQ: There's info on there that's wrong
If you decide as a clinician to use a consent form and you don't use, what was the purpose?

RQ: it's just sloppy practice
Chair: I understand the criticism

Chair: in relation to a no. of patients you say combined treatment has not occurred for many years...can you assist us what led to a change between a situ years ago part of mainstream medicine for HG but now different?

RQ: they've not been prescribed in my professional lifetime. They'd have prescribed in 70s. There was a panel sat in 80s and published a paper from all biv experts, some still active. They stated ONLY treatment for HG should be native T

Chair: one observation you make to describe the prescription of T as TRT is inaccurate or misleading as you say by providing T in excessive quantities to ppl who have normal T, that's not replacement that's supplementing
RQ: yes that's right

Chair: what else would you call it?
RQ: current flavour of the month is we simply call it Testosterone Treatment.

RQ: what was failed to make clear was the aim of the treatment.. the consent forms said to raise T to normal range but it was to a higher range.

Chair: were there other patients who'd received androgen therapy from BHM not in you're report.
RQ: they're all in my report
Chair: next Qs confined to patients

Chair: considering all the cases did you identify any occasion MW failed to either make diagnosis of HG or prescribe T
RQ: I can't identify a single case of HG yet were all prescribed T

Chair: can you see any instances MW made any differential diagnoses?
RQ: not once

Chair: wwre there instances within notes that there had been any attempt by MW identify the cause of T deficiency
RQ: I couldn't see he'd ever made an attempt to do that. On some occasions tests were done but wasn't something he systematically looked at nor the results

RQ: let's say one did have low-level T, they might have had a pituitary tumour!

Chair: in relation to TG patients of GGP. Can I just put some propositions to you and see if you agree. I understand your evidence, there is plainly a place for and a need for children/adolescence in some circumstances if experiencing GD, should be provided PBs?

RQ: that is now standard practice in UK under certain circumstances when conditions are Mey
Chair: it's a form of treatment the NHS provides
RQ: absolutely
Chair: but we've certainly read a great deal in thr papers to suggest this service results in long delay

RQ: I can't commentate of waiting lists of delays. Where we are now is the darkest of Days.. there is a long wait in adult services but can't vomment on GIDS.
Chair: if we proceed on basis that there is a demand that's not being met and resulting in children/ado waiting...

Chair:... that could bring about a situ where they're not receiving PBs/hormones until its too late or a sub optimum time as puberty will have advanced
RQ: it's a theoretical possibility but it's also with the passage of time the diagnosis becomes clearer

RQ: the passage of time the patient hasn't come to harm and it can work either way
Chair: on the basis there is that theoretical disadvantage...
RQ: (interupts) puberty HAS to be on its way. Its a misconception by MW to stop puberty starting at all

Chair: it might be said those peopsotions that given PB effects are reversible
RQ: partly

Chair: what is the harm or difficulty in prescribing via bridging basis, that is to say to provide necessary hormones to arrest or delay puberty until such time until they can be properly assessed (missed)
RQ: this is where you'd benefit from a children's endocrinoligist

RQ: to stop a chds puberty is a major step, it's not a neutral action and for bone density purposes, we hope it'd recover but we'd need to see.

RQ: Children with delayed puberty have got vertabrea that's narrower and that's an irreversible thing that's not gonna change. When you stop growing that's it.

RQ: it's not easy but the key thing is you have to be in a position to make a well informed diagnosis and to prescribe appropriately.
Chair: trying to look at it as a lesser of two evils.. you want to have an MDT and full assessment if it's GD

Chair: that's the ideal but you may have a situ because of waiting lists, the child is not going to get the diagnosis they seek. It's not going to happen and so if it were to be said, it's not ideal, it is less bad if you prescribe PB until such time they can be diagnosed,why not

Chair: what are the other downsides to prescribing PBs to someone who in fact doesn't have GD?
RQ: it was within MW remit to have his patients seen by some1 qualified to make diagnosis because there were 3 clinical psychologists, but he didn't. In V's case, 9 year old wasn't seen

Chair: point is if MW didn't do what he did and we have some positive feedback, it might be said if he didn't do this for them , they wouldn't have got help?

RQ: children with GD tend to revert to birth sex, adolescents seem to not revert. It's not a neutral step and I would reiterate if you have a difficult case, for goodness sake make sure it goes by the most experienced ppl on your team. Use them!

Chair: my colleague has some questions
Panel: I'm the Medical member of the Trib and a lot of the Qs have been asked by my colleagues. I'll ask a few more Qs on MW experience.
RQ: sure

Panel: you were taken to this letter earlier, it says he moved to gastro from Endo
RQ: that may have been (missed) stage? We don't know what he was doing. There's not enough detail there and a he'll if a long time ago

Panel: you're aware MW isn't here
RQ: that's his choice.

Panel: he goes on to say I am widely read in the field
RQ: oh good. Its almost inconceivable
Panel: why?
RQ: when you consider how challenging it is to train in your own speciality, them to be able to keep track of a very different speciality...I've never heard of any1 doing it

RQ is listing his experience and his pathways to where he is now.
RQ: what he's describing is the diametrically opposite to the universal career course as they get older. They shed more stuff and concentrate on what they're best at.

Chair: there may be exceptions
RQ: he may be an exceptional man, but I've never seen it ever

Panel enquires about RQ MDT experience
RQ: what would happen in responsible private sector, the patient would self refer, they'd have an assessment with ppl with a psychology/psychiatry background, then would refer onto endo specialist. I would see that Patient

RQ: if no problems I'd ask GP to prescribe...wereall on a App called Flock, if you're a transman on T but continue to have vaginal intercourse and a risk of pregnancy, are we happy with condoms or something more robust in order to be safe? These are the kind of convos we have

RQ: we benefit from talking to each other all the time, at the point there's a queen or king bee that it stops being an MDT
Panel: can you see if MW did that
RQ: No nor from what's in front of me. It seemed an MDT in name rather than functionality. It didn't need to be.

RQ: with recruitment of other key members, it could have been a properly functioning MDT.
Panel: he contends he's filling a gap, it was bridge between patients waiting. If that were the case would there be more reason to have robust MDT?

RQ: MW was a brilliant organiser, he could have recruited the right people and then gap in the service could have been filled. I imagine he'd be able to run a tight ship with right ppl I place but the original set up wasn't his.

RQ: Which is why it's called Gender Gp and not Gender Gastroenterologist

Panel: my question was would you be happy to prescribe remotely without ever seeing someone face to face?
RQ: but none of the patients sent to me had HG.
Panel: Would you do that without seeing patients?
RQ: Why would we NOT see them? The GPs are great in this country

RQ: guidance would say do T test first but if you thought it was low and considering treatment you need to determine lightbulb broken or light switched off

Chair: finally going back to a comment when you said 'indefensible' when prescribing without informing GP
RQ: that's my opinion, if thr patient gets unwell and can have all kinds of unnecessary tests, all for something of an obvious reason that the GP doesn't know about

RQ: if you don't let GPs know what's going on you're exposing patient to unnecessary things. It's in the GMC guidance, were not Catholic priests in the confessional box

Panel: Would you not inform a GP if a patient asked?
RQ: I would say your GP is such a crucial part of your care I'm not sure this is viable without their knowledge. We need to talk about this and find out what reasons are.

RQ: I've never encountered anyone who said'dont tell my gp', different from sexual clinic, but these aren't long term treatments.
If I couldn't persuade a patient, I'd decline.

Panel: do you think MW should have done that?
RQ: the criticism is he's even put the box there, he asked the choice! I've never heard that being asked other than this document!
Panel: I have no more questions

Chair and panel, RQ and SJ are discussing availability for RQ to come back for 30 minutes another day.
SJ has another matter about a disclosure he needs to make and needs instructions. SJ will do that on Friday and we will start at 1pm, with RQ returning at 2pm.
Chair adjourns.

@threadreaderapp please unroll