The Cover-Up and Tales From Northampton Mental Health Trust

Solution to my Messy Room

Angus Dei has decided that I should have a Tarpaulin to cover-up the horrendous amount of paperwork from my dealings with GMC Towers. I have decided to take him up on it. The picture above shows two tough guys covering up bags of paper. And there we have it, my solution to achieving a tidy room quickly. This is the sort of principle the NHS follows. If you have a problem, cover it up and no one will notice it is there :). Actually, it is a Department of Health policy and I am sure they have invested in a large tarpaulin for the vast majority of England.

I just returned from the freezing cold and I am sure if I had balls they would have frozen off. Instead, I have rushed in, got that tarpaulin around my mess in my study and sat down complete with pink fluffy socks. There is an art to carrying off pink fluffy socks. The important lesson to learn is never drive in the freezing cold with your pink fluffy socks, a dressing gown and your large doggy slippers as I once did to deliver some food to my relatives. You are likely to get stopped by the police, asked to get out [ in the freezing cold] and asked what your name is. You tell them " Dr Pal" and they look at you and howl with laughter while asking you whether you deserve a ticket for wearing the rather large doggy slippers [ complete with flapping ears] and that you see is one of the joys of winter. This incident happened a few winters ago but I have learned my lesson well - these days, the doggy slippers are packed in the boot.

To more serious things, Dr India tells me that a job at our previous Trust in Northampton is up for grabs. Yes, Dr India and I spent some memorable days there. Dr India had to climb out of his Doctors Only website view of me and I had my heckles up on most days. Nevertheless, it was a memorable time because a large parcel had landed in my cottage. That parcel was from the GMC following a Data Protection Act request. The parcel admitted that they had conducted a covert inquiry without telling me for about 2 years. Nice people aren't they. I sat there in disbelief for a while then pottered off to Budgens, purchased two Galaxy bars and watched Miss Congeniality. The next day I wrote the litigation papers against the GMC. Don't for one minute believe anyone can rely on defence unions or lawyers.

Anyhow, Northamptonshire Mental Health Trust has always been known to have a dysfunctional management. The are also known to protect the worst doctors. And the worst thing about the Trust is that the rest of the consultants collude in this protection. Actually, you have never seen a worst bunch lilly livered human beings this side of East Midlands. So is this a safe place to work and is this a safe job to apply for? The answer is " NO" it isn't. That is the shorter version. The longer version is listed below.

My warning is this, please will all junior doctors stay away from Northampton Mental Health NHS Trust. This dysfunctional Trust has caused the downfall of many junior doctors over the years. The last junior doctor was strung up at the GMC, helped by his bosses Dr Anders Skarsten, Dr Linda Hall and Dr O Neill Kerr . The tale is here. Those of us who have read the transcripts can quote it as follows

"The Chairman at the GMC questioned Dr O Neill Kerr on the issue of Dr Appulingham and asked

"Can you just advise on the thinking prior to the GMC referral, just in the context of what were the issues that led to that route? Because it is an unusual referral, in some respects, for the GMC" .

Alexander O Neill Kerr responded "

Yes. It arose as a result of the adverse event investigation that was conducted by Dr Scarsden, who was a general adult psychiatrist. His recommendation in his report was that Dr Appulingam be referred to the General Medical Council Fitness to Practise Directorate. I was new in post and I took advice from our Director of Human Resources and looked at the process that one follows when concerns were raised.

The transcript went onto quote a letter written by Appulingham as told by the GMC Chairman.

"However, Northampton NHS Trust is looking for a scapegoat to put the blame for the system failure." That may or may not be true, but I think I have to ask you, as the Medical Director, are you looking for a scapegoat? Is Dr Appulingam a convenient scapegoat locum doctor not in permanent post, ethnic minority? You can see the sort of list of factors that might lead that to be an accusation that someone would feel is valid"

The Chairman had stated

"We have an anxiety about hearing Dr O'Neil‑Kerr at this stage. The reason we have the anxiety is that we have seen, and you have drawn our attention to it just now, that the doctor draws attention to the coroner's inquest verdict of systems failing within the Trust......

This is all well and good but what of Dr Appulingham. At the start of the hearing he stated

"I do not feel I will be able to add any new evidence other than my lawyer had already submitted. My cardiologist at Harefield Hospital advised me to retire from work completely because of the seriousness of my heart condition. I spent thousands and thousands of pounds to my lawyer to respond to the allegation made against me for the unfortunate death of Mr MC to avoid any more stress to me. I cannot afford to spend any more money to a lawyer towards this case. My daughter will be starting her university education very soon. My family is struggling financially…"

In my view, the trio scapegoated this doctor then washed their pretty little hands of him. That said, there have been an inordinate number of emails to all of us from Northamptonshire Mental Health Trust complaining of bullying and victimisation.

With respect to the case - no blame was apportioned onto the people responsible for the system failure - the managers and the senior doctors. The senior doctors though continue to bicker amongst themselves while the system is falling apart.

This is the reason no doctor in their right mind should apply for the above job.

Judgment in the Appulingham Case.

Fitness to Practise Panel
18 – 22 June 2007
Regent’s Place, 350 Euston Road, London, NW1 3JN

Name of Respondent Doctor: Dr Kanthiah APPULINGAM

Registered Qualifications: MB BS 1971 Ceylon

Registration Number: 2464945

Type of Case: New case of impairment by reason of misconduct

Dr P Jefferys, Chairman (Medical)
Mr K Harrington (Lay)
Dr T Okitikpi (Lay)
Dr L McClelland (Medical)

Legal Assessor: Mr A Ostrin

Secretary to the Panel: Mr P Gray

Representation:

GMC: Miss Plaschkes, Counsel, instructed by GMC Legal, represented the GMC.

Doctor: Dr Appulingam was not present and was unrepresented.

allegation

“That being registered under the Medical Act 1983,

‘1. At the material time you worked as a Locum Staff Grade Psychiatrist with the Community Mental Health Team at Northamptonshire Healthcare NHS Trust;
Found Proved

‘2. On 13 or 14 January 2004 you had a consultation with patient A in the outpatient clinic;
Found Proved

‘3. Patient A had a medical history which included the following,

a. A 19 year history of mental illness,
Found Proved

b. A 19 year history of schizophrenia,
Found Proved as Amended

c. Episodes of psychotic symptoms brought on by non-compliance with medication,
Found Proved

d. Disengagement with psychiatric services,
Found Not Proved

e. Overdoses in 1985, July 1990 and December 1990,
Found Proved as Amended

f. That his symptoms were well controlled with Olanzapine,
Found Proved

g. That on 16 June 2003 he had been diagnosed as having schizophrenia (in remission) and a history of problem drinking;
Found Proved

‘4. On the day of the consultation,

a. You diagnosed patient A as having a depressive episode without somatic symptoms ICD Code F32.0,
Found Proved

b. You did not prescribe any medication,
Found Proved

c. You discharged him from the outpatient clinic at his request;
Found Proved

‘5. You failed to make an adequate assessment of patient A’s condition;
Found Proved as Amended

‘6. You failed to adequately check from other sources the veracity of the information given to you by patient A;
Found Proved

‘7. At that consultation,

a. You misdiagnosed patient A’s condition,
Found Proved

b. You failed to prescribe Olanzapine or other appropriate medication or arrange an early review in the outpatient department,
Found Proved

c. You should not have discharged patient A from the outpatient clinic;
Found Proved

‘8. You failed to make an adequate risk assessment of patient A;
Found Proved

‘9. You had failed to seek the advice of a Consultant Psychiatrist before discharging patient A;
Found Not Proved

‘10. You did not have authority to discharge patient A without liaising with the Mental Health Team;
Found Proved

‘11. You failed to put in place a crisis/contingency plan and/or any adequate follow up;
Found Proved

‘12. On 27 January 2004,

a. Patient A’s condition seriously deteriorated,
Found Proved

i. later that day patient A was taken to the GP surgery by his parents but refused to go in,
Found Proved

ii. Dr X, his general practitioner, prescribed Olanzapine,
Found Proved

iii. Dr X telephoned you for assistance but you indicated that you could not do anything at present and you would review him on 30 January 2004,
Found Proved

b. You failed to place yourself in a position to make an adequate assessment of patient A’s condition,
Found Proved

c. You advised patient A’s family to take him to the Accident and Emergency Department should his condition deteriorate further,
Found Proved as Amended

‘13. On 29 January 2004 patient A died from an overdose of Co-proxamol;
Found Proved

‘14. Your conduct as set out above was,

a. Inappropriate,
Found Proved

b. Irresponsible,
Found Proved

c. Not in the best interests of your patient;’
Found Proved

“And by reason of the matters set out above your fitness to practise is impaired because of your misconduct.”
Found Proved

Determination on whether to proceed in the absence of the doctor

“Miss Plaschkes,

Dr Appulingam has not attended this hearing, nor is he represented.
The Panel has carefully considered the submissions that you have made under rule 40 regarding service of notice of this hearing on Dr Appulingam. It notes the outcome of the investigations it required you to carry out and notes Dr Appulingam’s letter received by the GMC on 15 June 2007 which states “I am unable to attend the inquiry on 18 June 2007”. It has heard that notice of hearing dated 18 May 2007 was sent via courier to the doctor’s address as shown in the Medical Register.
The Panel also noted that the doctor is aware of the date of the hearing and the Panel has seen the notes of the Pre-adjudication Stage 2 Telephone Conference on 25 April 2007 recorded by the GMC solicitor. That note states “Doctor will not attend. VL confirmed that it can proceed in his absence. Dr A said he understood that and he has no objection. He will not be present and will not be sending a representative.” It further considers that it is implicit from his letter to the GMC of 25 August 2007 (received by the GMC on 31 May 2007) that the doctor accepts the hearing will go ahead in his absence.

The Panel is therefore satisfied that notice of this hearing had been properly served on Dr Appulingam in accordance with Rule 40 of the GMC (Fitness to Practice) Rules 2004.

The Panel has considered your submissions on whether to proceed in the absence of the doctor, in accordance with Rule 31 of the procedure rules. On the basis of the submissions you have made the Panel is satisfied that Dr Appulingam is aware of the date of this hearing. It notes that the doctor has given reasons on three occasions why he would be unable to attend the hearing. It considers that it is implicit in his correspondence to the GMC that he does not object to the hearing going ahead in his absence. Dr Appulingam received legal advice about his position at an earlier stage. Balancing the interests of Dr Appulingam against those of patients and the public, the Panel has decided to proceed in his absence.

The Panel therefore determined to proceed with the case in the doctor’s absence”.

Determination on the facts:
“Miss Plaschkes,
Dr Appulingam did not attend this hearing, nor was he represented;

The Panel has considered all the evidence in this case. It has considered the submissions you have made. It has taken account of the written submissions made by Dr Appulingam. It has applied the criminal standard of proof. It has considered the report of the expert witness, xxxxxx dated 1 February 2007 and his evidence to the Panel. It has taken each head and sub-head of allegation separately. The Panel has drawn no adverse inference from the doctor’s non-attendance at this hearing.

Allegation 1 is found proved

Allegation 2 is found proved

Allegation 3a is found proved

Allegation 3b is found proved as amended as follows:
“A 19 year history of schizophrenia”

Allegation 3c is found proved

Allegation 3d is found not proved
In reaching this finding the Panel accepts the evidence of xxxxxx that disengagement normally describes a patient “who wants absolutely nothing to do with the services and will fight if one attempts to persuade the patient otherwise”. There was insufficient evidence to be sure this applied to Patient A.

Allegation 3e is found proved as amended as follows:
“Overdoses in 1985, July 1990 and December 1990”

Allegation 3f is found proved
The expert confirmed that the medical records demonstrated that the higher level of Olanzapine controlled the patient’s symptoms well.

Allegation 3g is found proved

Allegation 4a is found proved

Allegation 4b is found proved

Allegation 4c is found proved

Allegation 5 is found proved as amended as follows:
“You failed to make an adequate assessment of Patient A’s condition”
In reaching this finding the Panel accepts the evidence of the expert that although some aspects of Dr Appulingam’s assessment of the patient were adequate many others were not.

Allegation 6 is found proved
In reaching this finding the Panel accepts the evidence of the expert that the medical records available to the doctor should have been checked more thoroughly for evidence of the effects of stopping or reducing medication on Patient A’s psychotic symptoms.

Allegation 7a is found proved

Allegation 7b is found proved

Allegation 7c is found proved
In reaching this finding the Panel accepts the evidence of the expert in this case.

Allegation 8 is found proved
In reaching this finding the Panel accepts the evidence of the expert that in this case the risk assessment should have included potential future risks, in particular of relapse of psychotic symptoms after cessation of medication.

Allegation 9 is found not proved
The Panel is not satisfied that there is sufficient evidence to support this charge.

Allegation 10 is found proved

Allegation 11 is found proved

Allegation 12a is found proved in its entirety
In respect of 12a iii the Panel accepts Dr X’s evidence that this is what
Dr Appulingam told her during her first telephone call. However there was a second telephone call between Dr X and Dr Appulingam in which assistance was provided by Dr Appulingam.

Allegation 12b is found not proved

Allegation 12c is found proved as amended as follows:
“You advised Patient A’s family to take him to the Accident and Emergency Department should his condition deteriorate further”

Allegation 13 is found proved

Allegation 14a is found proved in light of our findings on allegations 5, 6, 7a, 7b, 7c, 8, 11 and 12a

Allegation 14b is found proved in light of our findings on allegations 7a, 7b, 7c and 11

Allegation 14c is found proved

The Panel will now hear submissions on whether Dr Appulingam’s fitness to practise is impaired.”

Determination on Fitness to Practise:

“Miss Plaschkes,

The Panel has heard that at the material time Dr Appulingam worked as a Locum Staff Grade Psychiatrist with the Community Mental Health Team at Northamptonshire Healthcare NHS Trust.

On 13 or 14 January 2004 he had a consultation with Patient A in the outpatient clinic. Patient A had a medical history which included the following,

- A 19 year history of mental illness,
- A 19 year history of schizophrenia,
- Episodes of psychotic symptoms brought on by non-compliance with medication,
- Overdoses in 1985, July 1990 and December 1990,
- That his symptoms were well controlled with Olanzapine,
- On 16 June 2003 he had been diagnosed as having schizophrenia (in remission) and a history of problem drinking;

On the day of the consultation, Dr Appulingam diagnosed Patient A as having a depressive episode without somatic symptoms ICD Code F32.0. The Panel has found and is seriously concerned that this was a misdiagnosis of Patient A’s condition. The Panel has also made findings that although some aspects of
Dr Appulingam’s assessment of Patient A’s condition were adequate many other areas were not. In the light of the patient’s long standing mental illness it was necessary for Dr Appulingam to look in more detail into the history of the patient’s condition. Further, Dr Appulingam failed to prescribe Olanzapine or other appropriate medication or arrange a review in the outpatient department.

The Panel heard that Dr Appulingam discharged the patient from the outpatient clinic at his request. He did not have authority to do so without liaising with the Mental Health Team. The Panel is seriously concerned about Dr Appulingam’s discharge decision. Before making this decision Dr Appulingam failed to make an adequate risk assessment of Patient A and he subsequently failed to put in place a crisis/contingency plan and/or any adequate follow up. Given the risk of relapse in Patient A the Panel considers that it was necessary to make arrangements for adequate aftercare for the patient, including exploration of the nature of support available to the patient. He did not do so.

On 27 January 2004, Patient A’s condition seriously deteriorated. Later that day, Patient A was taken to the GP surgery by his parents but refused to go in.
Dr X, his general practitioner, telephoned Dr Appulingam for assistance on two occasions. On the first occasion Dr Appulingam indicated that he could not do anything at present and he would review him in three days time on 30 January 2004, the earliest available appointment. On the second occasion Dr Appulingam reported that he had spoken with Dr H. Dr X told him that she had now given Patient A a prescription of Olanzapine, and Dr Appulingam confirmed that this was appropriate.

Dr Appulingam also advised Patient A’s family to take him to the Accident and Emergency Department should his condition deteriorate further. Later that day Patient A refused to go to hospital in an ambulance called by his family and subsequently spent the night of 27 January at his parents’ home.

Patient A returned to his own home on 28 January 2004 where he took an overdose of Olanzapine, Co-Proxamol and Atenolol, and was found dead at his home on
29 January 2004.

The Panel has considered your submissions on whether Dr Appulingam’s fitness to practice is impaired. It has also considered the correspondence from Dr Appulingam in this regard. It has had regard to the GMC’s “Indicative Sanctions Guidance” and “Good Medical Practice”.

The Panel has borne in mind that the conduct being considered concerned
Dr Appulingam’s clinical involvement with a single patient on more than one date over a short period. It has had regard to his working environment at the time of the events and to the Coroner’s finding of ‘system failure’. However, Dr Appulingam’s clinical actions were a serious departure from what is expected of a competent practitioner. Dr Appulingam discharged a patient at risk of relapse of psychosis without medication and without making arrangements for adequate follow up.

The GMC publication “Good Medical Practice” (2001) states that doctors must “make the care of your patient your first concern”. It also states that “good clinical care must include,
· an adequate assessment of the patient’s conditions, based on the history and symptoms and, if necessary, an appropriate examination;
· providing or arranging investigations or treatment where necessary;
· taking suitable and prompt action when necessary.”

Dr Appulingam did not adhere to this guidance in his assessment, treatment and management of Patient A. The Panel is satisfied that Dr Appulingam’s mistakes in his assessment and management of Patient A were serious. It has already made a finding that his conduct was inappropriate, irresponsible and not in the best interests of the patient.

The Panel has taken into account relevant material from the GMC Indicative Sanctions Guidance (April 2005). Section 11 states “…..the GMC’s role in relation to fitness to practice is to consider concerns which are so serious as to raise the question whether the doctor concerned should continue to practice either with restrictions on his registration or at all. It has also taken account of paragraphs
53 – 58 of the Guidance and, in particular, section 55 under the heading Good Medical Practice – good clinical care. This states that doctors must provide good standards of clinical care, must practice within the limits of their competence and must ensure that patients are not put at unnecessary risk.

Section 58 states that a question of impaired fitness to practice is likely to arise if:
· A doctor’s performance…. has put patients at risk of harm,
· A doctor has shown… a reckless disregard of clinical responsibilities towards patients.

The Panel has taken into account the concept of proportionality, having balanced the interests of Dr Appulingam as against those of the public and patients; in particular declaring and upholding proper standards of conduct and behaviour. The Panel is therefore satisfied on the basis of the evidence and information before it that
Dr Appulingam’s fitness to practice is impaired”.

Determination on Sanction:

“Miss Plaschkes,

The Panel has previously determined and announced that Dr Appulingam’s fitness to practice is impaired by reason of his misconduct.

The Panel has considered what action to take against Dr Appulingam’s registration. It has considered your submissions, the evidence and documentation provided, and notes that the GMC considers that suspension at a minimum would be appropriate in this case. It has also considered the correspondence submitted by Dr Appulingam.

The Panel has had regard to the General Medical Council’s (GMC) Indicative Sanctions Guidance. The purpose of a sanction is not to be punitive, but to protect patients and the public interest. The public interest includes the protection of patients, maintenance of public confidence in the profession and declaring and upholding proper standards of conduct and behaviour.

The Panel has also borne in mind the principle of proportionality, weighing the public interest with the doctor’s own interests.

The Panel considered whether to conclude the case by taking no action. Given the serious findings against the doctor the Panel considers that such a course of action would be wholly inappropriate.

The Panel next considered whether it would be sufficient to impose conditions on
Dr Appulingam’s registration. It has borne in mind that any conditions must be proportionate, workable and measurable. The Panel considers that conditions would not reflect the seriousness of Dr Appulingam’s misconduct. It considers that conditions would not be workable in this case given the submissions made that
Dr Appulingam did not take up offers for remedial training made to him in the recent past. Further, you have made it aware that he does not wish to continue to practise as a doctor, having applied for voluntary erasure. The Panel therefore determines that conditions would not be appropriate in this case.

The Panel went on to consider whether it was sufficient to suspend his registration.

The allegations which the Panel has found proved against the doctor represent a serious departure from the professional conduct the public is entitled to expect from registered medical practitioners. The Panel consider that Dr Appulingam’s conduct was unacceptable for a psychiatrist of his experience. He discharged a patient at risk of relapse of psychosis without medication and without making arrangements for adequate follow up.

Any sanction made by the Panel must mark its disapproval of Dr Appulingam’s behaviour and send a message both to the profession and the public that this kind of serious departure from the relevant standards in Good Medical Practice is not acceptable. The Panel determines that a sufficient sanction in this case is a period of suspension. It then considered the period of this suspension. This misconduct involved a single patient, with no evidence of any other concern about the doctor’s clinical competence or conduct, within a context of system failure. The Panel therefore determines that a period of six months suspension is appropriate and proportionate.

The Panel went on to consider whether to review Dr Appulingam’s case before the end of his period of suspension. It took into account that it has no evidence of his current situation or health. It therefore determined to review his case before the end of the period of suspension. At that review hearing, the Panel would be assisted by the following:

a. Evidence of attempts he has taken to keep up to date with Good Medical Practice;
b. Medical Reports from his treating medical practitioners;
c. Character References.

This means that, unless Dr Appulingam exercises his right of appeal, this decision will take effect 28 days from when written notice of the determination is deemed to have been served upon him. A note explaining his right of appeal will be sent to him”.

Determination on Immediate Sanction:

“Miss Plaschkes

Having determined that Dr Appulingam’s name should be suspended from the Medical Register, the Panel has now considered, in accordance with Section 38 (1) of the Medical Act 1983 as amended, whether his registration should be suspended forthwith.

The Panel has considered your submissions on behalf of the GMC. It has balanced Dr Appulingam‘s own interests against the wider public interest. The Panel has borne in mind the serious nature of the matters that have led to his suspension.

This misconduct involved a single patient and is within a context of system failure. There is no evidence of any other concerns about the doctor’s clinical competence or conduct. The Panel has heard that the doctor is not currently working and does not intend to work as a doctor in the future and has applied for voluntary erasure.

The Panel is not satisfied that there is sufficient evidence to support the making of an order for immediate suspension.

The Panel has concluded that it is not necessary for the protection of members of the public and in the public interest that his registration be suspended with immediate effect.

That concludes this case”.


Confirmed

Date Chairman