MPTS - PUBLIC RECORD · 2020-04-08 · 11/02/2020. Medical Practitioner’s name: Dr Georgi...

Record of Determinations – Medical Practitioners Tribunal

MPT: Dr ZAFIROV 1

PUBLIC RECORD

Dates: 03/02/2020 - 11/02/2020 Medical Practitioner’s name: Dr Georgi Krasimirov ZAFIROV

GMC reference number: 7059858

Primary medical qualification: Magister (Physician) 1999 Higher Medical Institute Stara Zagora

Type of case Outcome on impairment New - Misconduct Impaired

Summary of outcome Erasure Immediate order imposed

Tribunal:

Legally Qualified Chair Mrs Julia Oakford Medical Tribunal Member: Dr Paul Diprose Medical Tribunal Member: Dr Meenakshi Verma Tribunal Clerk: Mr Sewa Singh

Attendance and Representation:

Medical Practitioner: Not present and not represented Medical Practitioner’s Representative: None

GMC Representative: Mr Peter Atherton, Counsel

Attendance of Press / Public In accordance with Rule 41 of the General Medical Council (Fitness to Practise) Rules 2004 the hearing was held in public.


MPT: Dr ZAFIROV 2

Overarching Objective Throughout the decision making process the tribunal has borne in mind the statutory overarching objective as set out in s1 Medical Act 1983 (the 1983 Act) to protect, promote and maintain the health, safety and well-being of the public, to promote and maintain public confidence in the medical profession, and to promote and maintain proper professional standards and conduct for members of that profession. Determination on Facts - 07/02/2020 Background 1. Dr Zafirov qualified as a doctor in 1999 at the Higher Medical Institute Stara Zagora, Bulgaria, and is currently registered with the GMC. 2. The first area of allegation regarding Dr Zafirov is that in October 2016, he issued two prescriptions to Patient A (‘the first prescription’) for Diazepam and Clonazepam, and (‘the second prescription’) only for Diazepam, via an online provider of medical services. It is alleged, amongst other matters, that Dr Zafirov did not take an adequate medical history of Patient A and that he failed to inform Patient A’s GP. Patient A died on 1 December 2016. Following an investigation, it was deemed that Patient A’s death was not as a direct result of Dr Zafirov’s prescribing. 3. The second area of allegation is that Dr Zafirov, in December 2016, issued a prescription (‘the third prescription’) for Clobazam for Patient B, via an online provider of medical services, and failed to take an adequate medical history of Patient B or provide appropriate safeguarding advice. 4. It is also alleged that Dr Zafirov, via these three prescriptions, facilitated the unsafe supply of potentially addictive and harmful medications. 5. Finally, it is further alleged that at the time of issuing the prescriptions, Dr Zafirov knew that he did not have licence to practise and that his actions were dishonest. 6. These matters came to the attention of the GMC following an investigation by Police Scotland into the death of Patient A, and a Care Quality Commission (CQC) inspection of the online provider of medical service which employed Dr Zafirov. The Allegation and the Doctor’s Response 7. The Allegation made against Dr Zafirov is as follows:


MPT: Dr ZAFIROV 3

That being registered under the Medical Act 1983 (as amended):

1. On 23 September 2015 you relinquished your licence to practise.

To be determined

2. On 15 October 2016 you issued a prescription for Diazepam and Clonazepam for Patient A (‘the first prescription’) via an online provider of medical services.

To be determined

3. The first prescription was inappropriate in that it was excessive to prescribe both Diazepam and Clonazepam when you did not have:

a. access to Patient A’s medical records;

To be determined

b. a face to face discussion with Patient A; To be determined

c. a discussion with Patient A’s General Practitioner (‘GP’). To be determined

4. At the time of issuing the first prescription you failed to take an adequate medical history from Patient A, in that you did not make enquiries in relation to:

a. any treating specialist;

To be determined

b. the frequency of Patient A’s hospital attendance. To be determined

5. On 28 October 2016 you issued a prescription for Diazepam for Patient A (‘the second prescription’) via an online provider of medical services.

To be determined

6. The second prescription was inappropriate in that it was excessive to issue a further prescription for Diazepam:

a. 13 days after the first prescription;

To be determined

b. without an examination. To be determined


MPT: Dr ZAFIROV 4

7. At the time of issuing the first and second prescriptions you failed to:

a. take an adequate medical history from Patient A, in that you did not make enquiries in relation to:

i. any presenting symptoms;

To be determined

ii. Patient A’s liver; To be determined

iii. Patient A’s kidneys; To be determined

iv. Patient A’s current mental state; To be determined

v. whether Patient A had a history of:

1. musculoskeletal problems; To be determined

2. sleep apnoea; To be determined

3. pulmonary insufficiency; To be determined

4. myasthenia gravis; To be determined

5. alcohol or drug addiction; To be determined

6. mental health issues;

To be determined

vi. any other medication that Patient A was taking; To be determined

b. adequately examine Patient A, in that you failed to examine the state of Patient A’s mental health; To be determined


MPT: Dr ZAFIROV 5

c. state the maximum daily dose; To be determined

d. provide adequate safeguarding advice, in that you failed to advise Patient A:

i. to avoid any other medication containing benzodiazepine or sedative;

To be determined

ii. to take the lowest dose for the shortest time to avoid dependence;

To be determined

iii. what to do in the case of:

1. an allergic reaction; To be determined

2. a worsening of their condition;

To be determined

iv. of the risks of:

1. paradoxical anxiety; To be determined

2. driving and operating machinery whilst taking the medication;

To be determined

v. in relation to the management of any current health condition;

To be determined

e. inform Patient A’s GP of the prescription; To be determined

f. have any regard to the fact that Diazepam and Clonazepam, if appropriately prescribed, could have been provided at less or no cost through the NHS. To be determined


MPT: Dr ZAFIROV 6

8. On 28 December 2016 you issued a prescription for Clobazam for Patient B (‘the third prescription’) via Medinfoservices, an online provider of medical services. To be determined

9. At the time of issuing the third prescription you failed to:

a. take an adequate medical history from Patient B, in that you did not make enquiries in relation to:


To be determined

ii. any other medication that Patient B was taking; To be determined

iii. Patient B’s current mental state;

To be determined

iv. whether Patient B’s had a history of: (Amended in accordance with Rule 17(6))

1. sleep apnoea;

To be determined

2. pulmonary insufficiency; To be determined

3. myasthenia gravis;

To be determined

4. alcohol or drug addiction; To be determined


To be determined

b. adequately examine Patient B, in that you failed to examine the state of Patient B’s mental health; To be determined

c. state:

i. the correct dosage;

To be determined


MPT: Dr ZAFIROV 7

ii. the maximum daily dose;

To be determined

d. provide adequate safeguarding advice, in that you failed to advise Patient B:

i. of the risks of:

1. stopping the medication abruptly;

To be determined

2. drowsiness; To be determined

3. paradoxical anxiety;

To be determined


To be determined


To be determined


1. an allergic reaction; To be determined


To be determined

iv. in relation to the management of any current health condition;

To be determined

e. inform Patient B’s GP of the prescription. To be determined

10. You facilitated the supply of potentially addictive and harmful medications when you should have known that it was unsafe to do so:

a. in the first and second prescriptions to Patient A;


MPT: Dr ZAFIROV 8

To be determined

b. in the third prescription to Patient B. To be determined

11. At the time of issuing the prescriptions detailed in paragraphs 2, 5 and 8 above (the Prescriptions) you did not hold a licence to practise. To be determined

12. You knew at the time of issuing the Prescriptions that you did not hold a licence to practise. To be determined

13. Your actions as described at paragraph 11 above were dishonest by reason of paragraph 12. To be determined

And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct.

To be determined The Outcome of Applications Made during the Facts Stage 8. The Tribunal granted an application made by Mr Peter Atherton, Counsel for the GMC, pursuant to Rule 31 of the GMC (Fitness to Practise Rules) 2004 as amended (‘the Rules’), to proceed with Dr Zafirov’s hearing in his absence. The Tribunal’s full decision on the application is included at Annex A. 9. The Tribunal granted Mr Atherton’s application, made pursuant to Rule 17(6) to amend paragraph 9a(iv) of the Allegation. The Tribunal concluded that the amendment could be made without any injustice to Dr Zafirov. The Tribunal’s full decision on the application is included at Annex B. The Admitted Facts 10. No facts were admitted. The Facts to be Determined 11. The Tribunal was required to determine whether the facts alleged, as set out in the Allegation, occurred; and, if so, whether Dr Zafirov’s fitness to practise is impaired by reason of misconduct.


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Factual and Documentary Evidence 12. The GMC provided to the Tribunal documents which included:

(i) a witness statement and exhibits from Mr D, Investigation Officer at the GMC, dated 28 August 2019;

(ii) three reports from the GMC expert, Dr E:

• 15 November 2018 and 1 October 2019 in relation to Patient A • 5 July 2018 in relation to Patient B

(iii) a sample copy (blank) of the online questionnaire which patients would be

required to complete when placing an order for medication online; (iv) standard operating procedure (SOP) for the pharmacy and prescribers;

(v) Pharmacy provider agreement dated 24 May 2016;

(vi) a letter from the Care Quality Commission (CQC) Medinfoservices, dated

15 November 2017, refusing Medinfoservices application to register as a service provider in respect of a regulated activity

(vii) National Institute for Clinical Excellence (NICE) guideline on ‘Controlled

drugs: safe use and management’ (NG46). Witness 13. Dr E gave oral evidence. 14. The Tribunal found Dr E to be an experienced clinician who has many years of experience working as a GP, and also has experience in the field of controlled drugs, and of remote prescribing, albeit not online prescribing. She told the Tribunal that she had kept abreast about updates in the use and management of controlled drugs and online prescribing as these were evolving areas. Her evidence was clear and credible. She appeared to personally have concerns about the safety and veracity of online prescribing and the Tribunal considered this led her, on occasion, to be inflexible and unwilling to make concessions. The Tribunal’s Approach 15. In reaching its decision on facts, the Tribunal has borne in mind that the burden of proof rests on the GMC and it is for the GMC to prove the Allegation. Dr Zafirov does not need to prove anything. The standard of proof is that applicable to


MPT: Dr ZAFIROV 10

civil proceedings, namely the balance of probabilities, i.e. whether it is more likely than not that the events occurred. 16. It is alleged that Dr Zafirov’s actions in relation to paragraphs 2, 5 and 8 of the Allegation were dishonest by reason of his actions in paragraph 12 of the Allegation. The Tribunal adopted the test for determining dishonesty which is set out in the case of Ivey (Appellant) v Genting Casinos (UK) Ltd t/ a Crockfords (Respondent) [2017] UKSC 67, which states:

‘1. First ascertain (subjectively) the actual state of the individual’s knowledge or belief as to the facts. The reasonableness or otherwise of his belief is a matter of evidence (often in practice determinative) going to whether he held the belief, but it is not an additional requirement that his belief must be reasonable; the question is whether it is genuinely held.

2. When once his actual state of mind as to knowledge or belief as to

facts is established, the question whether his conduct was honest or dishonest is to be determined by the fact-finder by applying the (objective) standards of ordinary decent people. There is no requirement that the defendant must appreciate that what he has done is, by those standards, dishonest.’

17. The Tribunal noted that there was no evidence before it that Dr Zafirov was of previous bad character, and therefore, determined that it should take into account his good character as a doctor when considering his propensity to act in the way suggested by the Allegation. It acknowledged that this may be of particular significance in relation to weighing up the probability of whether a doctor of good character would act dishonestly. 18. In considering each paragraph of the Allegation, where appropriate, the Tribunal had regard to the following documents referenced in Dr E’s evidence, namely:

• GMC Ethical guidance on Remote Consultations, which suggests that before prescribing, a doctor first considers:

‘1. What do I know about the patient’s needs and wishes? 2. What are the limitations and risks of communicating with the patient by phone/video link/online? 3. Will I need to carry out a physical examination or other assessment? 4. Do I have access to the patient’s medical records, and do I need them? 5. Will the patient need follow up or ongoing assessment? and


MPT: Dr ZAFIROV 11

Where you cannot satisfy all of these conditions, you should not use remote means to prescribe for a patient.’

• GMC Good Practice in Prescribing and managing medicines and devices

• NICE – Guideline on Controlled drugs: safe use and management (C4)

• Good Medical Practice (GMP) (March 2013 version) – Paragraph 16, which states: ‘16 In providing clinical care you must: a. prescribe drugs or treatment, including repeat prescriptions,

only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs

b. provide effective treatments based on the best available

evidence c. take all possible steps to alleviate pain and distress whether

or not a cure may be possible d. consult colleagues where appropriate e. respect the patient’s right to seek a second opinion f. check that the care or treatment you provide for each patient

is compatible with any other treatments the patient is receiving, including (where possible) self-prescribed over-the-counter medications

g. wherever possible, avoid providing medical care to yourself

or anyone with whom you have a close personal relationship.’ 19. Finally, the Tribunal noted the case of Kuzmin, R (On the Application Of) v General Medical Council [2019] EWHC 2129 (Admin) (05 August 2019) because Mr Peter Atherton, Counsel for the GMC, referred the Tribunal to it and said that the Tribunal was able, generally, to draw adverse inferences, although he acknowledged that the circumstances in this case are different to those in the case of Kuzmin. The Tribunal had particular regard to paragraphs 60 and 61 where Lord Justice Hinkinbottom stated: ‘60. For those reasons, I do not consider that Ms O'Rourke's core submission has

been made good. In my view, it is open to an MPT to draw adverse inferences


MPT: Dr ZAFIROV 12

from the failure of a charged registered medical practitioner to give evidence, including, in an appropriate case, the inference that he has no innocent explanation for the prima facie case against him, subject to such an inference not being procedurally unfair.

61. However, whilst emphasising that whether an adverse inference is drawn will

be highly dependent upon the facts of the particular case, it seems to me that, generally, no inference will be drawn unless:

i) a prima facie case to answer has been established; ii) the individual has been given appropriate notice and an appropriate

warning that, if he does not give evidence, then such an inference may be drawn; and an opportunity to explain why it would not be reasonable for him to give evidence and, if it is found that he has no reasonable explanation, an opportunity to give evidence;

iii) there is no reasonable explanation for his not giving evidence; and

iv) there are no other circumstances in the particular case which would make it unfair to draw such an inference.’

20. The Tribunal had regard to the Notice of Hearing (NOH) issued to Dr Zafirov which included the arrangements for his hearing and informed him that the Tribunal may proceed in his absence. However, the NOH does not inform Dr Zafirov that the Tribunal may draw adverse inferences in relation to the evidence placed before it at the findings of facts stage. Dr Zafirov was not present nor represented at the hearing. The Tribunal decided the principle established in the case of Kuzmin v GMC did not apply in this case as notice had not been given to Dr Zafirov as ‘generally’ required. The Tribunal’s Findings 21. The Tribunal considered each disputed paragraph of the Allegation separately and has evaluated the evidence to make the findings on the facts. Paragraph 1

1. On 23 September 2015 you relinquished your licence to practise. Found Proved

22. The Tribunal had regard to the statement of Mr D, dated 28 August 2019. In paragraph 4, he stated: ‘I can confirm that Dr Zafirov’s license to practice was removed from 23 September 2015, meaning that since that date he has not been permitted


MPT: Dr ZAFIROV 13

to undertake any form of medical practice within the United Kingdom for which a licence to practise with the GMC is required. I can confirm that, despite removal of his license to practice, Dr Zafirov remained registered with the GMC.’ 23. The Tribunal was provided with a screenshot of the GMC Siebel record for Dr Zafirov which showed his registered email address since 22 May 2015. It was also provided with a screenshot of the Siebel record for an email sent to Dr Zafirov’s registered email address on 23 September 2015. The email stated: ‘Your GMC reference number: 7059858 Dear Dr Zafirov Your licence to practise will be removed from 23/09/2015. From 23/09/2015 your updated entry will be visible on our online register. You can view and print proof of your entry on the register from your GMC Online account. Removal of your licence to practise means that with effect from 23/09/2015 you are not permitted to undertake any form of medical practice within the United Kingdom for which a licence to practise with the GMC is required. If you need any information or advice about this please contact us. …... By remaining registered, you will maintain your professional connection with us and you can ask us to confirm your good standing to other regulators or employers. You will also keep your entry on the medical register (and GP and Specialist registers if applicable) but it will show you do not have a licence to practise. If you would like us to restore your licence to practise in the future please refer to our website or telephone us quoting your GMC reference number.’ 24. Based on the evidence before it, the Tribunal was satisfied that Dr Zafirov relinquished his licence to practise on 23 September 2015 and it found paragraph 1 of the Allegation proved.


MPT: Dr ZAFIROV 14

Paragraph 2

2. On 15 October 2016 you issued a prescription for Diazepam and Clonazepam for Patient A (‘the first prescription’) via an online provider of medical services. Found Proved

25. The Tribunal was provided with a copy of a Medical Prescription dated 15 October 2016 and stamped by Tweens Pharmacy, the issuing Pharmacy. The prescription stated: ‘1x Diazepam ………. 1 tab a day Diazepam 10mg 28 tabs 1x Clonazepam ………. 1 tab a day at night Clonazepam 2.0mg 100 tabs’ 26. The prescription was signed electronically ‘Georgi Zafirov’ together with Dr Zafirov’s license number ‘7059858’ which was in fact his GMC registration number. 27. In view of the evidence before it, the Tribunal was satisfied that Dr Zafirov issued the prescription as set out in the particulars and it therefore found paragraph 2 of the Allegation proved. Paragraph 3



Found Proved 28. The Tribunal had regard to the GMC entitled ‘Good practice in prescribing and managing medicines and devices’ - Ethical Guidance document, in which it states: ‘You are responsible for the prescriptions that you sign. You must only prescribe drugs when you have adequate knowledge of your patient's health. And you must be satisfied that the drugs serve your patient's need.’ 29. At paragraphs 60 and 61, in the section headed ‘Remote prescribing via telephone, video-link or online’, it states: ‘Before you prescribe for a patient via telephone, video-link or online, you must satisfy yourself that you can make an adequate assessment, establish a


MPT: Dr ZAFIROV 15

dialogue and obtain the patient’s consent in accordance with the guidance at paragraphs 20 - 29. and

You may prescribe only when you have adequate knowledge of the patient’s health, and are satisfied that the medicines serve the patient’s needs. You must consider: a. the limitations of the medium through which you are communicating with the patient b. the need for physical examination or other assessments

c. whether you have access to the patient’s medical records.’ 30. In her report, Dr E stated ‘There is no evidence in Patient A’s medical notes to suggest that Dr Zafirov requested access to see them, …’ She went on to highlight the five points in the GMC Ethical guidance on Remote Consultations, set out above in the ‘Tribunal’s Approach’. In her evidence, Dr E explained that the two drugs are controlled drugs, are long acting and can lead to addiction. She said that it was a failure on Dr Zafirov’s part not to have requested access to Patient A’s medical records before prescribing, because matters such as a patient’s gender and age, presenting complaint, mental health history, and addiction history, are important factors in determining the appropriateness of prescribing, given the nature of the drugs. 31. Dr E also stated 'On the 15/10/16, in my opinion, it was not appropriate to prescribe 2 benzodiazepines in an acute situation, without Dr Zafirov having access to Patient A's GP records, face to face discussion with Patient A and a possible discussion with Patient A's GP. From my own addiction experience, there are very few clinical indications for 2 benzodiazepines to be prescribed. Both Diazepam and Clonazepam are long acting benzodiazepines and, without the ability to assess Patient A, the drugs should not, in my opinion have been prescribed together.' 32. The Tribunal noted that Dr Zafirov only had the online medical questionnaire to inform him about Patient A’s medical history. It was of the view that this was insufficient to inform his decision to prescribe. The Tribunal determined, based on the evidence before it, that Dr Zafirov did not have access to Patient A’s medical records prior to prescribing the two drugs for Patient A. The Tribunal accepted Dr E’s opinion in relation to this paragraph. It therefore found paragraph 3a of the Allegation proved.

b. a face to face discussion with Patient A; Found Not Proved


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33. In her report, Dr E commented that because Diazepam and Clonazepam are controlled drugs, Dr Zafirov should have attempted to contact Patient A to get a full history, for example, current medication, current and past medical history, mental health and addiction history. She went on to say that Dr Zafirov should have 'examined Patient A's mental health either by telephone or face to face assessment'. In her evidence to the Tribunal, Dr E was very clear that the responsibility lay with Dr Zafirov to do this. 34. The Tribunal had regard to the GMC - Guidance on Prescribing and managing medicines and devices (2013) and Ethical guidance on Remote Consultations. 35. The Tribunal took into account that, at the time of prescribing, Dr Zafirov only had access to Patient A's online medical questionnaire. The patient should have given all the information he was required to do so in the questionnaire. Therefore, the Tribunal considered that further discussion, face to face, would not necessarily have assisted Dr Zafirov beyond making further inquiries regards to Patient A’s medical records and possible discussion with Patient A’s GP. It did not accept Dr E’s assertion of the necessity of face to face discussion as the medical questionnaire should have been completed, as far as the Tribunal was concerned, to the best of Patient A’s knowledge. 36. Accordingly, it found paragraph 3b of the Allegation not proved.

c. a discussion with Patient A’s General Practitioner (‘GP’). Found Proved 37. The Tribunal had regard to and accepted Dr E's evidence that Dr Zafirov should have had a discussion with Patient A's GP prior to prescribing these particular types of drugs for Patient A. If Patient A had refused consent for discussion with their GP, then the Tribunal accepted Dr E’s assertion that Dr Zafirov should have declined to prescribe. It therefore found paragraph 3c of the Allegation proved. Paragraph 4



Found Not Proved

b. the frequency of Patient A’s hospital attendance. Found Not Proved


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38. The Tribunal considered paragraphs 4a and 4b together. 39. The Tribunal was not provided with a full copy of the online questionnaire which Patient A would have filled in. 40. In her report, Dr E stated 'In my opinion an adequate history would therefore need to include details about Patient A's epilepsy, the specialist they see and frequency of hospital attendance. Patient A's GP, in my opinion, would need to know the frequency of any seizures, …..' 41. There is no evidence before the Tribunal that Patient A suffered from epilepsy or that he had had such seizures. The online questionnaire had a specific box to inquire if the patient had a diagnosis of epilepsy. The Tribunal noted that in Patient A's medical records, there is no mention that he suffered from epilepsy, albeit Dr Zafirov would not be aware of this. 42. The Tribunal considered that Dr Zafirov, in prescribing for Patient A was being asked to prescribe a continuation of medication which Patient A would have declared on the questionnaire to being previously prescribed. It was of the view that this would not have necessitated the taking of further medical history with respect to any treating specialists or the frequency of hospital attendances. The Tribunal inferred that Dr Zafirov was in possession of a medical questionnaire which provided him with an adequate medical history in this respect. 43. The Tribunal found paragraphs 4a and 4b of the Allegation not proved. Paragraph 5

5. On 28 October 2016 you issued a prescription for Diazepam for Patient A (‘the second prescription’) via an online provider of medical services. Found Proved

44. The Tribunal was provided with a copy of a ‘Medical Prescription’ dated 28 October 2016 and stamped by Tweens Pharmacy, the issuing Pharmacy. The prescription stated: ‘1x Diazepam ………. 3 tabs a day’ Diazepam 10mg 28 tabs 45. The prescription was signed electronically ‘Georgi Zafirov’ together with Dr Zafirov’s license number ‘7059858’ which was his GMC registration number. 46. In view of the evidence before it, the Tribunal was satisfied that Dr Zafirov issued the prescription as set out in the particular, and it therefore found paragraph 5 of the Allegation proved.


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Paragraph 6



Found Proved 47. The Tribunal had regard to the document entitled 'Standard Operating Procedure (SOP) for the Pharmacy and the Prescribers. Under the section headed 'Client Protection', it stated: '8. Clients are not allowed to have more than one order per month of the same product.' 48. The date of the second prescription was 28 October 2016, thirteen days after the date of the first prescription (15 October 2016). This was contrary to the SOP and had the potential to be a safety issue for Patient A. 49. The Tribunal therefore found paragraph 6a of the Allegation proved.

b. without an examination. Found Proved 50. The Tribunal noted that Patient A had already been prescribed a 28 day supply of Diazepam in the first prescription. The Tribunal accepted Dr E’s evidence that Dr Zafirov should not have prescribed a further dose of the medication, within a one month period, without having examined Patient A. 51. The Tribunal therefore found paragraph 6b of the Allegation proved. Paragraph 7



52. In relation to paragraph 7a of the Allegation, Mr Atherton, in his submissions, invited the Tribunal to take a holistic approach when considering this paragraph. The Tribunal therefore considered the entirety of the particulars alleged in paragraph 7a together.



MPT: Dr ZAFIROV 19

Found Not Proved

ii. Patient A’s liver; Found Not Proved

iii. Patient A’s kidneys; Found Not Proved

iv. Patient A’s current mental state; Found Proved


1. musculoskeletal problems; Found Not Proved

2. sleep apnoea; Found Not Proved

3. pulmonary insufficiency; Found Not Proved

4. myasthenia gravis; Found Not Proved

5. alcohol or drug addiction; Found Not Proved


Found Not Proved

vi. any other medication that Patient A was taking; Found Not Proved

53. Dr E, in her written and oral evidence, told the Tribunal that Dr Zafirov failed to take an adequate medical history from Patient A, in that he did not make enquiries in relation to the matters set out in (i) to (vi) above. She said that because of the nature of Diazepam and Clonazepam, it is essential that the prescriber has information beyond that which is provided by the patient in the questionnaire, before prescribing them. 54. The Tribunal accepted Dr E’s evidence that Diazepam and Clonazepam are potentially harmful drugs, and that it is important for any prescriber to have a full or adequate medical history of the patient before prescribing. It also accepted that in accordance with paragraph 16 of GMP, as set out above, Dr Zafirov had a duty to


MPT: Dr ZAFIROV 20

‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.’ 55. The Tribunal does not have before it a copy of the actual questionnaire completed by Patient A, and therefore it is unable to know what information Patient A provided. The Tribunal, however, had no evidence before it that Patient A had not completed the questionnaire fully and accurately. This is based on the ‘Confirmations’ in the questionnaire which state: ‘I declare that the information I have given is complete and without reserve

and I agree to read the patient information leaflet provided before this medication. :

I declare that I agree with the Customer Responsibility Statement. : I declare that I agree with the Informed Consent Agreement. : I have read the Conditions of Use and I agree to them. :’ 56. The Tribunal had regard to SOP and noted that this places no requirement upon the prescriber to inquire further if the medical questionnaire is completed appropriately and the relevant information has been provided by the patient. The Tribunal was of the view that the questionnaire was adequate for the purpose of obtaining a patient’s medical history, if completed fully. The Tribunal could not determine, in the absence of the actual medical questionnaire completed by Patient A, whether Dr Zafirov had failed to discharge his duty. 57. Having considered all of the evidence available, the Tribunal determined that, on the balance of probabilities, Dr Zafirov did discharge his duty, in relation to paragraph 7a (i), (ii), (iii), (v) and (vi) of the Allegation. Accordingly it found these paragraphs not proved. 58. In relation to paragraph 7a(iv) of the Allegation, the Tribunal determined that the questionnaire did not provide for the necessary information for a prescriber to be able to make an assessment of a patient’s current mental state. This was a particularly important aspect to assess because of the nature of the drugs that were being prescribed. Accordingly, the Tribunal found paragraph 7a(iv) of the Allegation proved.

b. adequately examine Patient A, in that you failed to examine the state of Patient A’s mental health; Found Proved

59. The Tribunal has already found that the questionnaire is not adequate for the purpose of enabling a prescriber to make an assessment of a patient’s mental state. It had regard to Patient A’s medical records in which there is reference to mental health issues. The Tribunal took into account that these were potentially harmful


MPT: Dr ZAFIROV 21

drugs. The Tribunal determined, that in view of the nature of the drugs, an adequate examination of Patient A’s mental health could not be made on the information in the questionnaire alone. 60. Accordingly, it found paragraph 7b of the Allegation proved.

c. state the maximum daily dose; Found Not Proved

61. The Tribunal had regard to the NICE Guidelines (NG46). At paragraph 1.5.3 it states:

‘When prescribing ‘when required’ controlled drugs:

• document clear instructions for when and how to take or use the drug in the person’s care record

• include dosage instructions on the prescription (with the maximum daily amount or frequency of doses) so that this can be included on the label when dispensed

• ask about and take into account any existing supplies the person has of ‘when required’ controlled drugs.’

62. The Tribunal also had regard to the prescriptions dated 15 October 2016 and 28 October 2016. It accepted that the description in relation to the daily dose(s) was poorly worded. However, it was of the view that a description for a dose of one tablet a day and for a dose of three tablets a day is sufficiently clear in terms of the maximum daily dose. In addition, the Tribunal noted this was not prescribed as a ‘When required’ controlled drug as set out in paragraph 1.5.3 of the NICE Guidelines on controlled drugs. Therefore, the Tribunal did not accept Dr E’s opinion that Dr Zafirov failed in his duty to state the maximum daily dose. 63. The Tribunal, therefore, found paragraph 7c of the Allegation not proved.



Found Not Proved


Found Not Proved



MPT: Dr ZAFIROV 22

1. an allergic reaction;

Found Not Proved

2. a worsening of their condition; Found Not Proved



Found Not Proved


Found Not Proved


Found Not Proved 64. The Tribunal considered the alleged particulars in paragraph 7d together. 65. It had regard to photographic evidence of a bottle of medication, which had apparently been dispensed to Patient A. The description on the label, although feint, appears to state words to the effect: ‘To be taken …. sleepy do not drive ….. avoid alcohol ….’ 66. The Tribunal has already found that it is unable to establish what information Patient A provided to Dr Zafirov. It noted that Patient A would have signed the declaration in the questionnaire form: ‘I declare that the information I have given is complete and without reserve

and I agree to read the patient information leaflet provided before this medication.’

67. The Tribunal determined, on the balance of probabilities, that Patient A should already have been aware of the particulars mentioned in paragraph 7d above. 68. The Tribunal had before it evidence to suggest that an information leaflet for Dihydrocodeine (DHC) was provided to Patient A, by the same Pharmacy. This leaflet appeared to the Tribunal to cover necessary safeguarding information.


MPT: Dr ZAFIROV 23

69. On the balance of probabilities, the Tribunal determined that the medication would have been labelled and the leaflet would have been provided to Patient A. Also, this was a repeat prescription for medication about which Patient A had agreed to read any information provided. The Tribunal does not accept that sufficient evidence has been adduced for it to conclude that Dr Zafirov failed to provide adequate safeguarding advice to Patient A. 70. It therefore found paragraph 7d (i) – (v) of the Allegation not proved.

e. inform Patient A’s GP of the prescription; Found Proved

71. The Tribunal was provided with Patient A’s medical records. It noted that there is no mention of the drugs being prescribed for Patient A by Dr Zafirov, during the period of October 2016. 72. The Tribunal did not know whether Patient A had given consent for his GP to be informed of his online purchase. However, it considered that, in view of the nature of the drugs and safeguarding matters, Dr Zafirov should have informed Patient A’s GP. If Patient A had said ‘No’ to informing his GP, then Dr Zafirov should not have prescribed the medication. 73. The tribunal took into account Section 31 and 32 of Good Practice in prescribing medicines and devices, which provide that all doctors involved in a patient’s care should be aware of what drugs had been prescribed to the patient. The Tribunal accepted Dr E’s opinion that special care must be taken when prescribing controlled drugs such as benzodiazepines as GPs must be aware of abuse potential. 74. Accordingly, the Tribunal found paragraph 7e of the Allegation proved.

f. have any regard to the fact that Diazepam and Clonazepam, if appropriately prescribed, could have been provided at less or no cost through the NHS. Found Not Proved

75. In her report and during her oral evidence, Dr E stated: ‘Prescriptions became free of charge in Scotland in April 2011. Therefore, in my opinion, any prescriber should be questioning i.e. it should be a

Red Flag, why a patient is wishing to pay for medication. From the medical records, Patient A saw his GP fairly regularly and therefore had the opportunity to request or discuss medication. Indeed, the records show that Patient A was already on a prescription for Diazepam 10mg. ……’


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76. The Tribunal had regard to paragraph 25 of the GMC Good Practice in Prescribing and managing medicines and devices, which states: ’25 The amount of information you give to each patient will vary according to the nature of their condition, the potential risks and side effects and the patient’s needs and wishes. …..’ 77. The Tribunal took into account that Patient A would have completed the online questionnaire, and then signed the declarations, meaning that he consented to entering into a contract for the purchase of the drugs prescribed. The Tribunal noted that there is no specific duty upon a doctor, in a private setting, to make Patient A aware that the drugs he wished to purchase could be obtained through the NHS, indeed, Patient A had willingly agreed to pay for the drugs and the Tribunal had no evidence as to why he was choosing to pay for them rather than obtain them through the NHS. 78. The Tribunal acknowledged that all doctors registered with the GMC would be aware of relevant prescription charges. The Tribunal accepted that Patient A’s request for the drugs could have raised a ‘red flag’ for prescribing. However, there is no information before the Tribunal as to what information Patient A provided to Dr Zafirov. 79. In light of the above, the Tribunal found paragraph 7f of the Allegation not proved. Paragraph 8

8. On 28 December 2016 you issued a prescription for Clobazam for Patient B (‘the third prescription’) via Medinfoservices, an online provider of medical services. Found Proved

80. The Tribunal was provided with a copy of a Medical Prescription dated 28 December 2016. The prescription stated: ‘2x Clobazam ………. 3 tabs a day’ Clobazam 10mg 60 tabs 81. The prescription was signed electronically ‘Georgi Zafirov’ together with Dr Zafirov’s license number ‘7059858’ which is also his GMC registration number. 82. In view of the evidence before it, the Tribunal was satisfied that Dr Zafirov issued the prescription as set out in the particulars. It therefore found paragraph 8 of the Allegation proved.


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Paragraph 9




Found Not Proved

ii. any other medication that Patient B was taking; Found Not Proved


Found Not Proved


1. sleep apnoea;

Found Not Proved



Found Not Proved



Found Not Proved 83. As with paragraph 7a, the Tribunal considered the entirety of the particulars alleged in paragraph 9a of the Allegation, together. 84. The Tribunal had regard to Dr E’s written and oral evidence that Dr Zafirov failed to take an adequate medical history from Patient B, in that he did not make enquiries in relation to the matters set out in (i) to (vi) above. Dr E said that because of the nature of Clobazam, it is essential that the prescriber has information beyond that which is provided by the patient in the questionnaire, before prescribing it. 85. The Tribunal accepted Dr E’s evidence that Clobazam is a potentially harmful drug, and that it is important for any prescriber to take a full or adequate medical


MPT: Dr ZAFIROV 26

history of the patient before prescribing. It also accepted that in accordance with paragraph 16 of GMP, as set out above, Dr Zafirov had a duty to ‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.’ 86. The Tribunal has not been provided with a copy of the actual questionnaire completed by Patient B, and therefore it is unable to know what information Patient B provided. The Tribunal, however, considered that that Patient B should have completed the questionnaire fully accurately. This is based on the ‘Confirmations’ in the questionnaire which state: ‘I declare that the information I have given is complete and without reserve

and I agree to read the patient information leaflet provided before this medication. :

I declare that I agree with the Customer Responsibility Statement. : I declare that I agree with the Informed Consent Agreement. : I have read the Conditions of Use and I agree to them. :’ 87. The Tribunal had regard to SOP and noted that this places no requirement upon the prescriber to inquire further if the questionnaire is completed appropriately and relevant information has been provided by the patient. It noted also, that the questionnaire does not seek to inquire about information, for example, whether the patient had sleep apnoea. The Tribunal was of the view that the questionnaire was adequate for the purpose of obtaining a patient’s medical history, if completed fully and completely. The Tribunal could not determine, in the absence of the actual questionnaire completed by Patient B, whether Dr Zafirov had failed to discharge his duty. 88. Having considered all of the evidence available, the Tribunal determined that, on the balance of probabilities, Dr Zafirov did discharge his duty, in relation to paragraph 9a (i), (ii), (iii) and (v) of the Allegation. Accordingly it found these paragraphs not proved.

b. adequately examine Patient B, in that you failed to examine the state of Patient B’s mental health; Found Not Proved

89. Dr E, in her evidence, stated: ‘In my opinion an adequate history would therefore need to include details about ’s epilepsy, if they had such a diagnosis, the specialist they see and frequency of hospital attendance. A GP, in my opinion, would need to know the frequency of any seizures, driving and work history and other epilepsy medication currently taken. Due its effect on the body, Dr Zafirov would need


MPT: Dr ZAFIROV 27

to establish if had any hepatic or renal issues. Any over the counter medication or illicit medication would also need to be discussed. A GP would also need to know ’s current mental state and any psychiatric, sedative or night sedation medication that he was taking.’ 90. The Tribunal accepted that where there are multiple indications, it is important that a practitioner take an adequate medical history of the patient before prescribing. However, the Tribunal has not been provided with Patient B’s medical records, in contrast to Patient A where his medical records were available. Further, the Tribunal does not have a copy of the actual questionnaire completed by Patient B. 91. In the circumstances, the Tribunal cannot draw inferences in the absence of any relevant information. It therefore found paragraph 9b of the Allegation not proved.

c. state:

i. the correct dosage; Found Proved

92. The Tribunal interpreted this as relating to the total amount of medication prescribed. In her report, Dr E stated ‘in my opinion, the quantity of 120 tablets is wrong and should not have been prescribed, 28 days being the norm, i.e. 84 tablets’. The Tribunal accepted Dr E’s evidence. 93. accordingly, found paragraph 9c(i) of the Allegation proved.

ii. the maximum daily dose; Found Not Proved

94. The Tribunal had regard to the NICE Guidelines (NG46). At paragraph 1.5.3 it states:

‘When prescribing ‘when required’ controlled drugs:

• document clear instructions for when and how to take or use the drug in the person’s care record

• include dosage instructions on the prescription (with the maximum daily amount or frequency of doses) so that this can be included on the label when dispensed

• ask about and take into account any existing supplies the person has of ‘when required’ controlled drugs.’


MPT: Dr ZAFIROV 28

95. The Tribunal also had regard to the prescriptions dated 28 December 2016. It accepted that the description in relation to the daily dose was poorly worded. However, it was of the view that a description for a dose of three tablets a day is sufficiently clear with respect to the maximum dose. In addition, the Tribunal noted this was not prescribed as a ‘When required’ controlled drug as set out in paragraph 1.5.3 of the NICE Guidelines on controlled drugs. Therefore, the Tribunal did not accept Dr E’s opinion that Dr Zafirov has failed in his duty to prescribe by not specifically stating the maximum daily dose. 96. It therefore found paragraph 9c(ii) of the Allegation not proved.


i. of the risks of:


Found Not Proved

2. drowsiness; Found Not Proved


Found Not Proved


Found Not Proved


Found Not Proved


1. an allergic reaction; Found Not Proved


Found Not Proved

iv. in relation to the management of any current health condition;

Found Not Proved


MPT: Dr ZAFIROV 29

97. The Tribunal considered the alleged particulars in paragraph 9d together. 98. The Tribunal has already determined that it is unable to establish what information Patient B provided to Dr Zafirov, because it does not have before it a copy of Patient B’s completed form. It has also already determined that Patient A would have signed the declaration in the questionnaire form: ‘I declare that the information I have given is complete and without reserve

and I agree to read the patient information leaflet provided before this medication.’ and that would also apply to Patient B.

99. The Tribunal determined, on the balance of probabilities, that Patient B would already have been aware of the particulars mentioned in paragraph 9d above, for the same reasons as above in relation to Patient A at paragraph 7d of the Allegation. Therefore, the Tribunal has concluded that insufficient evidence has been adduced for it to conclude that Dr Zafirov failed to provide adequate safeguarding advice. 100. It therefore found paragraph 9d (i) – (vi) of the Allegation not proved.

e. inform Patient B’s GP of the prescription. Found Not Proved

101. In contrast to Patient A, the Tribunal has no information before it, for example, Patient B’s medical records, to be able to determine whether Dr Zafirov informed Patient B’s GP. Further, in the absence of Patient B’s completed questionnaire, the Tribunal cannot know whether Patient B consented to his GP being informed about his purchase of the drug. It did, however accept the expert’s evidence that had Patient B not consented to his GP being informed, then the prescription should have been declined. 102. The Tribunal therefore found paragraph 9e of the Allegation not proved. Paragraph 10



Found Proved 103. The Tribunal had regard to the prescriptions which Dr Zafirov issued for Patient A. It took into account its finding in relation to paragraph 6a and 6b and 7a(iv) and 7b of the Allegation. The Tribunal has already accepted Dr E’s evidence that, due to the nature of the drugs, they were ‘potentially dangerous’ for Patient A. The Tribunal, therefore, determined that Dr Zafirov facilitated the supply of


MPT: Dr ZAFIROV 30

potentially addictive and harmful medications when he should have known that it was unsafe to do so. 104. It therefore found paragraph 10a of the Allegation proved.

b. in the third prescription to Patient B. Found Proved

105. The Tribunal had regard to the prescription which Dr Zafirov issued for Patient B. The Tribunal accepted Dr E’s evidence that, given the nature of the drug, the correct dose should have been a maximum supply of 84 tablets for 28 days and there was a risk of overdose or becoming addicted. 106. It therefore found paragraph 10b of the Allegation proved. Paragraph 11

11. At the time of issuing the prescriptions detailed in paragraphs 2, 5 and 8 above (the Prescriptions) you did not hold a licence to practise. Found Proved

107. The Tribunal has already found that Dr Zafirov relinquished his licence to practise in September 2015 and that, therefore, at the time of prescribing, he did not hold a licence to practise. It therefore follows that paragraph 11 in relation to paragraphs 2, 5 and 8 are found proved. Paragraph 12

12. You knew at the time of issuing the Prescriptions that you did not hold a licence to practise. Found Proved

108. The Tribunal had regard to the email sent to Dr Zafirov from the GMC on 23 September 2015 advising him that his licence to practise had been relinquished. It also had regard to Dr Zafirov’s Work Details Form, dated 14 September 2017. In section 12.3 of the form, in response to the question ‘Reason(s) for your registration (e.g. recent work completed in a non-UK country, specialism that requires dual registration, etc), Dr Zafirov stated: ‘It is mandatory to be a member in order to have a licence to practice in Bulgaria’ 109. Based on the evidence before it, the Tribunal determined that Dr Zafirov knew that he did not hold a licence to practise at the time of issuing the prescriptions. Accordingly, it found paragraph 12 of the Allegation proved.


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Paragraph 13

13. Your actions as described at paragraph 11 above were dishonest by reason of paragraph 12. Found Proved

110. The Tribunal has already found that Dr Zafirov knew he did not hold a licence to practise. The Tribunal took into account that on the prescriptions which Dr Zafirov issued, he stated his licence number ‘7059858’ which was in fact his GMC registration number. The Tribunal took the view that a doctor registered with the GMC would be aware that he needed a licence to undertake any form of medical practise. This would include the issuing of prescriptions which is one of the core functions of practising as a doctor. 111. The Tribunal was of the view that a reasonably informed member of the public would consider Dr Zafirov’s actions dishonest. 112. The Tribunal took into account that Dr Zafirov was of good character but concluded that having regard to the cogent evidence of his dishonesty, that it would give no weight to it. 113. It determined that Dr Zafirov’s actions as described at paragraph 11 were dishonest. Accordingly, it found paragraph 12 in relation to paragraph 11 of the Allegation proved. The Tribunal’s Overall Determination on the Facts 114. The Tribunal has determined the facts as follows:

1. On 23 September 2015 you relinquished your licence to practise. Found Proved

2. On 15 October 2016 you issued a prescription for Diazepam and Clonazepam for Patient A (‘the first prescription’) via an online provider of medical services. Found Proved



Found Proved

b. a face to face discussion with Patient A;


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Found Not Proved

c. a discussion with Patient A’s General Practitioner (‘GP’). Found Proved



Found Not Proved

b. the frequency of Patient A’s hospital attendance. Found Not Proved

5. On 28 October 2016 you issued a prescription for Diazepam for Patient A (‘the second prescription’) via an online provider of medical services.

Found Proved



Found Proved

b. without an examination. Found Proved




Found Not Proved

ii. Patient A’s liver; Found Not Proved

iii. Patient A’s kidneys; Found Not Proved

iv. Patient A’s current mental state; Found Proved


MPT: Dr ZAFIROV 33


1. musculoskeletal problems; Found Not Proved

2. sleep apnoea; Found Not Proved


4. myasthenia gravis; Found Not Proved


6. mental health issues; Found Not Proved

vi. any other medication that Patient A was taking;

Found Not Proved

b. adequately examine Patient A, in that you failed to examine the state of Patient A’s mental health; Found Proved

c. state the maximum daily dose; Found Not Proved



Found Not Proved


Found Not Proved


1. an allergic reaction; Found Not Proved


MPT: Dr ZAFIROV 34




Found Not Proved


Found Not Proved


Found Not Proved

e. inform Patient A’s GP of the prescription; Found Proved

f. have any regard to the fact that Diazepam and Clonazepam, if appropriately prescribed, could have been provided at less or no cost through the NHS. Found Not Proved

8. On 28 December 2016 you issued a prescription for Clobazam for Patient B (‘the third prescription’) via Medinfoservices, an online provider of medical services. Found Proved




Found Not Proved

ii. any other medication that Patient B was taking; Found Not Proved


Found Not Proved



MPT: Dr ZAFIROV 35

1. sleep apnoea;

Found Not Proved



Found Not Proved



Found Not Proved

b. adequately examine Patient B, in that you failed to examine the state of Patient B’s mental health; Found Not Proved

c. state:

i. the correct dosage;

Found Proved

ii. the maximum daily dose; Found Not Proved


i. of the risks of:


Found Not Proved

2. drowsiness; Found Not Proved


Found Not Proved


Found Not Proved


MPT: Dr ZAFIROV 36

ii. to take the lowest dose for the shortest time to avoid

dependence; Found Not Proved


1. an allergic reaction;

Found Not Proved


iv. in relation to the management of any current health

condition; Found Not Proved

e. inform Patient B’s GP of the prescription.

Found Not Proved



Found Proved

b. in the third prescription to Patient B. Found Proved

11. At the time of issuing the prescriptions detailed in paragraphs 2, 5 and 8 above (the Prescriptions) you did not hold a licence to practise. Found Proved

12. You knew at the time of issuing the Prescriptions that you did not hold a licence to practise. Found Proved

13. Your actions as described at paragraph 11 above were dishonest by reason of paragraph 12. Found Proved

And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct.

To be determined


MPT: Dr ZAFIROV 37

Determination on Impairment - 10/02/2020 1. The Tribunal now has to decide in accordance with Rule 17(2)(l) of the Rules whether, on the basis of the facts which it has found proved, Dr Zafirov’s fitness to practise is impaired by reason of misconduct. The Evidence 2. The Tribunal has taken into account all of the oral and documentary evidence received during the facts stage of the hearing. Submissions 3. On behalf of the GMC, Mr Atherton referred the Tribunal to its determination on the facts and highlighted some of the matters found proved, including that Dr Zafirov prescribed potentially addictive and harmful drugs to Patient A and Patient B; that he prescribed without a licence to practise; and that he had acted dishonestly. Mr Atherton submitted that these matters represented significant departures from Good Medical Practice (GMP). He said that paragraphs 15, 16, 60, 61 and 64 of GMP were engaged in this case. Mr Atherton referred the Tribunal to the GMC guidance documents entitled ‘Good practice in prescribing and managing medicines and devices (2013)’ and ‘Ethical guidance on Remote Consultations’. He reminded the Tribunal of Dr E’s opinion that Dr Zafirov’s actions fell seriously below the standard expected of a doctor. 4. Mr Atherton referred the Tribunal to relevant authority and reminded it that impairment is a two stage process. He submitted that the facts found proved constituted serious misconduct and, as a consequence, the Tribunal should find Dr Zafirov’s fitness to practise to be impaired. 5. In relation to remediation and insight, Mr Atherton referred the Tribunal to Dame Janet Smith’s fifth report into the Shipman inquiry and said that there is no evidence before the Tribunal of Dr Zafirov’s insight or of any steps he has taken to remediate his conduct. In relation to dishonesty, Mr Atherton referred the Tribunal to paragraph 120 of the Sanctions Guidance (SG) (September 2019). He submitted that Dr Zafirov’s actions represented serious misconduct and his actions were a dangerous and persistent misuse of technology intended to facilitate the provision of inappropriate treatment and advice to patients. Mr Atherton further stated that, as Dr Zafirov had no licence to practise having relinquished it, there is no evidence that at the time of the events, he had kept his medical knowledge and skills up to date because he would not have undergone any revalidation process. 6. Mr Atherton invited the Tribunal to find Dr Zafirov’s fitness to practise currently impaired.


MPT: Dr ZAFIROV 38

The Tribunal’s Approach 7. The Tribunal reminded itself that at this stage of the proceedings there is no burden or standard of proof and the decision on impairment is a matter for the Tribunal’s judgement alone. 8. In approaching the decision, the Tribunal was mindful of the two-stage process to be adopted. First whether the facts as found proved amounted to misconduct which was serious professional misconduct, and then second whether that misconduct led to a finding of current impairment. 9. The Tribunal has already given a detailed determination in relation to the facts of Dr Zafirov’s case. It has taken those matters into account in its deliberations. It has also taken into account the submissions made by Mr Atherton. 10. The Tribunal must determine whether Dr Zafirov’s fitness to practise is impaired today, taking into account his conduct at the time of the events and any relevant factors since then such as insight, whether the matters are remediable, have been remedied and any likelihood of repetition. 11. Throughout its deliberations, the Tribunal has been mindful of its responsibility to uphold the overarching objective as set out in the Medical Act 1983 (as amended). That objective is the protection of the public and involves the pursuit of the following: a. to protect, promote and maintain the health, safety and wellbeing of the public b. to maintain public confidence in the profession c. to promote and maintain proper professional standards and conduct for members of the profession The Tribunal’s Decision Misconduct 12. The Tribunal first considered whether the facts found proved are a sufficiently serious departure from the standards of conduct reasonably expected of Dr Zafirov as a registered medical practitioner to amount to misconduct. In its deliberations, the Tribunal had regard to the current version of GMP (March 2013). It also noted that Misconduct is not defined by statute but it has been said to be serious professional misconduct or conduct which a fellow professional would regard as deplorable. 13. In its deliberations, the Tribunal had regard to paragraphs 1, 6, 11, 12, 15(a), 16 (a, b, d and f), 65, 66, 71(a) and 77 of GMP. These state:


MPT: Dr ZAFIROV 39

‘1. Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues,1 are honest and trustworthy, and act with integrity and within the law.

6 To maintain your licence to practise, you must demonstrate, through

the revalidation process, that you work in line with the principles and values set out in this guidance. Serious or persistent failure to follow this guidance will put your registration at risk.

11 You must be familiar with guidelines and developments that affect your work. 12 You must keep up to date with, and follow, the law, our guidance and other regulations relevant to your work. 15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient 16 In providing clinical care you must: a. prescribe drugs or treatment, including repeat prescriptions,

only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs

b. provide effective treatments based on the best available

evidence c. …. d. consult colleagues where appropriate e. …. f. check that the care or treatment you provide for each patient is

compatible with any other treatments the patient is receiving, including (where possible) self-prescribed over-the-counter medications


MPT: Dr ZAFIROV 40

65. You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession. 66 You must always be honest about your experience, qualifications and current role. 71 You must be honest and trustworthy when writing reports, and when

completing or signing forms, reports and other documents. You must make sure that any documents you write or sign are not false or misleading.

a. You must take reasonable steps to check the information is correct. 77 You must be honest in financial and commercial dealings with patients, employers, insurers and other organisations or individuals.’ 14. The Tribunal also had regard to:

• GMC Ethical guidance on Remote Consultations • GMC Good Practice in Prescribing and managing medicines and devices

Patient A 15. The Tribunal found that Dr Zafirov prescribed Diazepam and Clonazepam (the first prescription) to Patient A on 15 October 2016. He then prescribed Diazepam (the second prescription) to Patient A on 28 October 2016. The Tribunal found that Dr Zafirov did not have access to Patient A’s medical records, other than the information provided to him by Patient A in the medical questionnaire. Further, he did not have any discussion with Patient A’s GP prior to prescribing. 16. The Tribunal noted that Patient A had already been prescribed Diazepam by his GP and it considered, therefore, that the prescription for Diazepam was, in effect, a repeat prescription for continuation of medication. However, Patient A had not been prescribed Clonazepam previously. 17. The Tribunal had regard to the document entitled 'Standard Operating Procedure (SOP) for the Pharmacy and the Prescribers. Under the section headed 'Client Protection', it states: '8. Clients are not allowed to have more than one order per month of the same product.' 18. The date of the second prescription was 28 October 2016, thirteen days after the date of the first prescription (15 October 2016). This was contrary to the SOP. Given the nature of the drugs, and the fact that Dr Zafirov prescribed two of these


MPT: Dr ZAFIROV 41

types of drugs in the first prescription and then a further dose of one of these types of drugs in the second prescription, without an examination of Patient A. The issuing of the second prescription was excessive and could have had potential safety issues for Patient A. Patient B 19. The Tribunal found that Dr Zafirov prescribed Clobazam to Patient B on 28 December 2016. Dr Zafirov did not have access to Patient B’s medical records, other than the information provided to him by Patient B in the medical questionnaire. The dose in the prescription stated: ‘2x Clobazam ………. 3 tabs a day’ Clobazam 10mg 60 tabs 20. The Tribunal accepted Dr E’s evidence that as Clobazam is a potentially harmful drug, it is important for any prescriber to take a full or adequate medical history of the patient before prescribing. It also accepted that in accordance with paragraph 16 of GMP, as set out above, Dr Zafirov had a duty to ‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.’ It also accepted her evidence that the correct dosage should have been the equivalent to a one month supply, 28 days being the norm, i.e. 84 tablets. 21. Dr Zafirov prescribed 120 tablets to Patient B. The Tribunal concluded that prescribing a drug such as Clobazam (120 tablets), without necessarily having the benefit of all the medical information beyond that which is provided in an online medical questionnaire, Dr Zafirov should have exercised a degree caution. It was of the view that this type of drug could have had potential safety issues for Patient B. Practising without a licence and dishonesty 22. The Tribunal found that Dr Zafirov relinquished his licence on 23 September 2015 and that he was advised of this in an email from the GMC, of the same date. In the email, the GMC set out the restrictions upon Dr Zafirov, following his licence being relinquished, in particular: ‘Removal of your licence to practise means that with effect from 23/09/2015 you are not permitted to undertake any form of medical practice within the United Kingdom for which a licence to practise with the GMC is required. If you need any information or advice about this please contact us.’ 23. The Tribunal considered, from the above paragraph, that Dr Zafirov could have contacted the GMC if he was unsure about any restrictions upon his practice


MPT: Dr ZAFIROV 42

following his licence being relinquished. However, there is no evidence before the Tribunal that Dr Zafirov did so. 24. The tribunal found that Dr Zafirov’s actions in issuing the prescriptions were dishonest. At the time of issuing the prescriptions, Dr Zafirov provided his licence number ‘7059858’ which is in fact his GMC registration number. Patient A and Patient B would not know that Dr Zafirov had no licence to practise. 25. The Tribunal determined that, in all the circumstances of this case, Dr Zafirov’s actions amounted to serious misconduct. Impairment 26. The Tribunal, having found that the facts found proved amounted to serious misconduct, went on to consider whether Dr Zafirov’s fitness to practise is currently impaired by reason of his misconduct. 27. The Tribunal had regard to paragraph 76 of the judgment in the case of CHRE v NMC & Paula Grant [2011] EWHC 927 (Admin), in which Mrs Justice Cox provided a helpful approach to the determination of impairment: ‘Do our findings of fact in respect of the doctor’s misconduct…show that his/her fitness to practise is impaired in the sense that s/he: a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or… d. has in the past acted dishonestly and/or is liable to act dishonestly in the future.’ 28. The Tribunal considered whether Dr Zafirov’s misconduct was capable of being remediated, has been remediated, and whether the misconduct was highly unlikely to be repeated. In so doing, it considered whether there was evidence of Dr Zafirov’s insight into his misconduct and any steps taken by him to remediate it. 29. The Tribunal has been provided no evidence at all that Dr Zafirov has reflected on his misconduct or that such behaviour has been remediated and would not be repeated in the future. He has provided no evidence that he fully understands that he should not have prescribed without a licence. There is also no evidence that he understands his actions had the potential to harm patients, adversely affect the reputation of the profession, or damage public confidence. Dr Zafirov has provided


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no evidence of insight into his misconduct. The Tribunal could not exclude a risk of repetition of his behaviour. 30. The Tribunal took into account that Dr Zafirov occupied a position of privilege and trust. Doctors are expected to act in a manner which maintains public confidence in them and in the medical profession and to uphold proper standards of conduct. Dr Zafirov prescribed controlled medication to two patients when he did not have a licence to practise. The Tribunal concluded that his misconduct has brought the profession into disrepute and has breached a fundamental tenet of the medical profession, as having a licence to practise is a prerequisite of practising as a doctor. 31. The Tribunal determined that Dr Zafirov’s misconduct would be considered unacceptable and unprofessional by other members of the profession and the public alike. It considered that his behaviour had brought the medical profession into disrepute and had breached a fundamental tenet of the medical profession. 32. In all the circumstances, the Tribunal concluded that a finding of impaired fitness to practise was required in order to protect the public, maintain public confidence in the profession and to promote and maintain proper professional standards and conduct for members of the profession. The Tribunal has therefore determined that Dr Zafirov’s fitness to practise is impaired by reason of his misconduct. Determination on Sanction - 11/02/2020 1. Having determined that Dr Zafirov’s fitness to practise is impaired by reason of misconduct, the Tribunal now has to decide in accordance with Rule 17(2) (n) of the Rules on the appropriate sanction, if any, to impose. Submissions 2. On behalf of the GMC, Mr Atherton submitted that the appropriate sanction was one of erasure. He reminded the Tribunal that in exercising its judgment on the appropriate sanction it must start with the least restrictive. 3. He referred the Tribunal to its determinations on the facts and impairment and highlighted those sections which he said indicated why it was not appropriate to take no action, or impose conditions or suspension. He referred the Tribunal to paragraphs 108 and 109 of the Sanctions Guidance (SG) relating to erasure and said that sub-paragraphs 109 (a), (b), (c), (d) and (h) were engaged in this case. He said that Dr Zafirov’s misconduct was a serious departure from the principles of GMP; his misconduct was repeated; it was an abuse of position and trust. Further, his persistent lack of insight into what he did and the impact of his actions was reflected throughout the fact that he has offered no apology for or any reflection upon his actions; has not provided any evidence to demonstrate why he acted or behaved in the way he did; has provided


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no evidence of insight, and has not substantively engaged with the GMC investigation. Mr Atherton added that Dr Zafirov presented a risk of repeating his misconduct by continuing to write prescriptions without a licence to practise. 4. Mr Atherton submitted Dr Zafirov’s misconduct was fundamentally incompatible with his continued registration on the Medical Register and invited the Tribunal to impose an order of erasure. The Tribunal’s Approach 5. The decision as to the appropriate sanction, if any, to impose is a matter for the Tribunal alone, exercising its own judgement. In so doing, it has given consideration to its findings of fact, its findings of misconduct and impaired fitness to practise and the submissions made by Mr Atherton. 6. Throughout its deliberations the Tribunal bore in mind that the purpose of sanctions is not to be punitive, but to protect the public interest. The public interest includes protecting the health, safety and wellbeing of the public, maintaining public confidence in the profession, and declaring and upholding proper standards of conduct and behaviour. In making its decision, the Tribunal also had regard to the principle of proportionality, and it considered Dr Zafirov’s interests as well as those of the public. It also considered and balanced the mitigating and aggravating factors in this case. 7. The Tribunal identified the following aggravating factors: Aggravating

• Dr Zafirov’s actions are a serious departure from GMP; • His misconduct was persistent insofar as he wrote three prescriptions for

addictive and harmful drugs, without a licence to practise; • He failed to corroborate with a professional colleague, i.e. Patient A’s GP; • He prescribed potentially addictive and harmful to two patients who were

potentially vulnerable; • He abused his position of trust; • His actions brought the medical profession into disrepute; • There is no evidence, at all, of any insight or remediation, for example, a

personal statement detailing why he acted in the way he did, or any response to the Allegation against him (in the absence of such, the Tribunal can infer that he has little or no insight into his misconduct);

• The Tribunal’s finding that Dr Zafirov presented a risk of repeating his misconduct.

The Tribunal gave considerable weight to these factors.


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Mitigating 8. The only mitigating feature identified in this case is that Dr Zafirov acknowledged receipt of the hearing bundle and advised that he would not attend these proceedings. The Tribunal gave no weight to this. No action 9. In coming to its decision as to the appropriate sanction, if any, to impose in Dr Zafirov’s case, the Tribunal first considered whether to take no action. The Tribunal considered, amongst others, paragraphs 68-70 of the SG which highlights that taking no action following a finding of impaired fitness to practise would only be appropriate in exceptional circumstances. 10. The Tribunal has determined that, given the gravity of the facts found proved, and in the absence of any exceptional circumstances in this case, taking no action would be neither appropriate, proportionate nor in the public interest. Conditions 11. The Tribunal next considered whether it would be sufficient to impose conditions on Dr Zafirov’s registration. The Tribunal took account of the SG, in particular paragraphs 79, 81 and 82. It also had regard to paragraph 85, which states: ‘85 Conditions should be appropriate, proportionate, workable and

measurable.’ 12. The Tribunal acknowledged that there were elements Dr Zafirov’s conduct which had the potential to be remediated, for example, if Dr Zafirov’s misconduct were as a result of his lack of understanding that what he did was wrong in prescribing the drugs online, then he may have been able to address this by means of training and other mechanisms. However, in the light of the Tribunal’s findings, that Dr Zafirov’s actions had occurred whilst he had not held a licence to practise and were dishonest, the Tribunal determined that it would not be possible to formulate a set of appropriate or workable conditions which could adequately address Dr Zafirov’s misconduct. The Tribunal concluded that a period of conditional registration would not be a sufficient, workable, or proportionate sanction to satisfy the requirements of the overarching objective. Suspension 13. The Tribunal then went on to consider whether a period of suspension would be an appropriate and proportionate sanction to impose on Dr Zafirov’s registration.


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The Tribunal took into account paragraphs 91, 92, 93, and 97(a), (e) and (g), which state: ‘91 Suspension has a deterrent effect and can be used to send out a signal

to the doctor, the profession and public about what is regarded as behaviour unbefitting a registered doctor. Suspension from the medical register also has a punitive effect, in that it prevents the doctor from practising (and therefore from earning a living as a doctor) during the suspension, although this is not its intention.

92 Suspension will be an appropriate response to misconduct that is so

serious that action must be taken to protect members of the public and maintain public confidence in the profession. A period of suspension will be appropriate for conduct that is serious but falls short of being fundamentally incompatible with continued registration (ie for which erasure is more likely to be the appropriate sanction because the tribunal considers that the doctor should not practise again either for public safety reasons or to protect the reputation of the profession).

93. Suspension may be appropriate, for example, where there may have

been acknowledgement of fault and where the tribunal is satisfied that the behaviour or incident is unlikely to be repeated. The tribunal may wish to see evidence that the doctor has taken steps to mitigate their actions.

97. Some or all of the following factors being present (this list is not exhaustive) would indicate suspension may be appropriate. a. A serious breach of Good medical practice, but where the

doctor’s misconduct is not fundamentally incompatible with their continued registration, therefore complete removal from the medical register would not be in the public interest. However, the breach is serious enough that any sanction lower than a suspension would not be sufficient to protect the public or maintain confidence in doctors.”

e No evidence that demonstrates remediation is unlikely to be successful, eg because of previous unsuccessful attempts or a doctor’s unwillingness to engage. g The tribunal is satisfied the doctor has insight and does not pose a significant risk of repeating behaviour.’ 14. The Tribunal had regard to paragraph 1 of GMP, which states: ‘Patients need good doctors. Good doctors make the care of their patients

their first concern; they are competent, keep their knowledge and skills up to


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date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law.’

15. Dr Zafirov relinquished his licence to practise in September 2015. There is no evidence before the Tribunal that he kept his knowledge and skills up to date. Further, having a licence to practise is a prerequisite for a doctor before undertaking medical practice. By stating his GMC number as his licence number on the prescriptions when he had no licence to practise, Dr Zafirov failed to fulfil the requirements of paragraph 1 of GMP. Further, Dr Zafirov prescribed potentially addictive and harmful drugs on three separate occasions. 16. There is no evidence before the Tribunal that Dr Zafirov has reflected on his misconduct, has apologised for his actions, or accepted any wrongdoing. Dr Zafirov has provided no evidence, at all, that he recognises the impact his actions could have had on Patient A and Patient B. Further, Dr Zafirov has not provided any evidence that he understands how his actions had the potential to harm patients; adversely affect the reputation of the profession; or to damage public confidence. The Tribunal was therefore not satisfied that remediation is likely to be successful. Dr Zafirov has not acknowledged any fault or wrongdoing for his actions. The Tribunal could not be satisfied that he would not repeat his misconduct. 17. Dr Zafirov failed to uphold the proper standards of behaviour expected of doctors by the public, and his conduct breached a fundamental tenet of the profession. His failure to comply with the relevant professional standards was serious and his conduct brought the profession into disrepute. 18. The Tribunal was mindful that a period of suspension is a temporary measure designed to remove a doctor from medical practice in anticipation that the doctor will return having addressed the concerns. In light of the information before it, the Tribunal was not satisfied that a period of suspension would have that effect. In any event, taking all the circumstances into account, the Tribunal does not consider that a period of suspension is sufficient to address the seriousness with which it views Dr Zafirov’s misconduct. Suspension would not be enough in this case to protect the public, uphold proper professional standards and maintain public confidence in the profession. Erasure 19. Having determined that imposing conditions or suspending Dr Zafirov’s registration would be an insufficient sanction, the Tribunal determined to erase his name from the Medical Register. It had regard to paragraphs 108 and 109 of the SG, which state: ‘108. Erasure may be appropriate even where the doctor does not present a

risk to patient safety, but where this action is necessary to maintain public


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confidence in the profession. For example, if a doctor has shown a blatant disregard for the safeguards designed to protect members of the public and maintain high standards within the profession that is incompatible with continued registration as a doctor.

109. Any of the following factors being present may indicate erasure is appropriate (this list is not exhaustive). a. A particularly serious departure from the principles set out in Good medical practice where the behaviour is fundamentally incompatible with being a doctor. b. A deliberate or reckless disregard for the principles set out in Good medical practice and/or patient safety c. Doing serious harm to others (patients or otherwise), either deliberately or through incompetence and particularly where there is a continuing risk to patients …. d. Abuse of position/trust (see Good medical practice, …. e. [….] f. [….] g. [….] h. Dishonest, especially where persistent and/or covered up

i. [….] j. Persistent lack of insight into the seriousness of their actions or the consequences.’ 20. The Tribunal also had regard to paragraphs 120, 121, 126 and 129 of the SG, in particular, paragraph 129, which states: ‘cases in this category are those where a doctor has not acted in a patient’s

best interests and has failed to provide an adequate level of care, falling well below expected professional standards (set out in domains one and four of Good medical practice on knowledge , skills and performance, maintaining trust). Particularly where there is a reckless disregard for patient safety or breach of the fundamental duty of doctors to ‘Make the care of [your] patients [your] first concern’ ….’


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21. The Tribunal has already determined that Dr Zafirov presents a continuing risk to patient safety. His actions were a serious departure from the principles set out in GMP, a deliberate or reckless disregard for the principles set out in GMP. It bore in mind that Dr Zafirov’s actions amounted to serious misconduct which could undermine public trust in the medical profession, and also undermines the upholding of proper professional standards and conduct. 22. The Tribunal determined that, for the reasons stated above, Dr Zafirov’s misconduct was fundamentally incompatible with his continued registration on the Medical Register. Therefore, the Tribunal concluded that erasing Dr Zafirov’s name from the Medical Register would be the only proportionate sanction to impose in order to protect the public, maintain public confidence in the medical profession and declare and uphold the proper standards of conduct and behaviour. 23. Accordingly the Tribunal determined that Dr Zafirov’s name should be erased from the Medical Register. Determination on Immediate Order - 11/02/2020 1. Having determined that Dr Zafirov’ registration should be erased, the Tribunal has now considered, in accordance with Section 38 of the Medical Act 1983 as amended, whether to impose an immediate order to suspend his registration. 2. The Tribunal has borne in mind the test to be applied with regard to imposing an immediate order; it may impose an immediate order if it determines that it is necessary to protect members of the public, or is otherwise in the public interest, or is in the best interests of the doctor. Submissions on behalf of the GMC 3. Mr Atherton submitted that, in view of the seriousness of Dr Zafirov’s misconduct, and the Tribunal’s findings on sanction, an immediate order was appropriate, for the protection of the public, to uphold and maintain professional standards, and in the public interest. Tribunal’s decision 4. The Tribunal has taken account of the relevant paragraphs of the SG in relation to when it is appropriate to impose an immediate order. Paragraph 172 of the SG states:

“The tribunal may impose an immediate order if it determines that it is necessary to protect members of the public, or is otherwise in the public interest, or is in the best interests of the doctor…”


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5. The Tribunal has determined that, given the seriousness with which it viewed Dr Zafirov’s misconduct, and given its findings on impairment and sanction, it is necessary, for the protection of members of the public, to uphold and maintain professional standards, and in the public interest, to make an order suspending Dr Zafirov’s registration immediately. 6. The substantive decision of erasure, as already announced, will take effect 28 days from when notice is deemed to have been served upon Dr Zafirov, unless he lodges an appeal in the interim. If Dr Zafirov lodges an appeal, the immediate order for suspension will remain in force until such time as the outcome of any appeal is determined. 7. The current interim order of suspension is revoked. 8. That concludes the case. Confirmed Date 11 February 2020 Mrs Julia Oakford, Chair


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ANNEX A – 03/02/2020 Service and Proceeding in Absence Service 1. Dr Zafirov is neither present nor represented at these proceedings. The Tribunal has considered whether notice of this hearing has been properly served upon Dr Zafirov in accordance with Rules 15 and 40 of the General Medical Council (Fitness to Practise) Rules 2004 (the Rules) and Schedule 4, Paragraph 8 of the Medical Act 1983 (as amended). In so doing, the Tribunal has taken into account all the information placed before it, together with submissions made by Mr Peter Atherton, Counsel, on behalf of the GMC. 2. Mr Atherton drew the Tribunal’s attention to:

(i) a screenshot of the GMC record where Dr Zafirov had registered his address;

(ii) an email from the GMC to Dr Zafirov dated 4 December 2019 enclosing a copy of the Allegation against him;

(iii) the GMC Notice of Hearing (NOH) dated 4 December 2019 to Dr Zafirov, with a further copy of the Allegation

(iv) an email from Dr Zafirov to the GMC dated 6 December 2019 in which he stated ‘I write to confirm that I received the email – will read the information included and if any concern rise will inform you on time.’

(v) An email from the MPTS to Dr Zafirov dated 9 December 2019 to which was attached the NOH with details of the arrangements for the MPT Hearing – this was also sent to Dr Zafirov at the email address provided by him;

(vi) An email from Dr Zafirov dated 12 December 2019 in which he stated ‘I have received the documents send to my home address.’

(vii) An email from the GMC to Dr Zafirov dated 2 January 2020 attaching a revised version of the Allegation and Dr Zafirov’s email response on 3 January 2020 in which he acknowledged receipt of the GMC email;

(viii) An email from Dr Zafirov to the GMC dated 13 January 2020 in which he stated ‘Thank you for the email. I would like to inform you that I will not attend the meeting or be legally represented.’

3. Mr Atherton submitted that this evidence demonstrates that the NOH has been served upon Dr Zafirov. 4. Having considered all the evidence, the Tribunal is satisfied that the Notice was drafted in proper form and that delivery was attempted no later than 28 days before today’s date. The Tribunal also took into account Dr Zafirov’s email correspondence to the GMC and the MPTS, in particular, his email of 13 January


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2020. Accordingly the Tribunal is satisfied that Notice of this hearing has been properly served upon Dr Zafirov, in accordance with Rules 15 and 40 of the Rules. Proceeding in Absence 5. The Tribunal went on to consider whether to proceed in Dr Zafirov’s absence in accordance with Rule 31. It bore in mind that the Tribunal’s discretion to proceed in the practitioner’s absence must be exercised with the upmost care and caution and with regard to the overall fairness of the proceedings. The Tribunal has balanced the interests of the practitioner, including fairness to him, against the public interest, including the need to protect patients. 6. Mr Atherton referred the Tribunal to the Notice of Hearing sent to Dr Zafirov in which it makes clear that the Tribunal has the power to proceed in his absence. He reminded the Tribunal that Dr Zafirov, in his correspondence with the GMC, made it clear that he would not attend the proceedings or be represented. Mr Atherton submitted that Dr Zafirov has not requested an adjournment and is aware that the Tribunal can proceed in his absence. He submitted that it is in the wider public interest that the hearing should proceed in Dr Zafirov’s absence. 7. The Tribunal took account of the email from Dr Zafirov to the GMC dated 13 January 2020 in which he stated ‘Thank you for the email. I would like to inform you that I will not attend the meeting or be legally represented.’ 8. The Tribunal noted that Dr Zafirov has not requested an adjournment. On the basis of the information provided, the Tribunal is satisfied that Dr Zafirov has voluntarily waived his right to be present and represented at this hearing and that he is aware that the hearing can proceed in his absence. The Tribunal considers that were it to adjourn today, it is very unlikely that Dr Zafirov would attend a future hearing. The Tribunal considered that there is a public interest that the hearing takes place within a reasonable time of the event to which it relates. The Tribunal has therefore determined that it is in the public interest and in Dr Zafirov’s own interests to exercise its discretion and proceed with the case in his absence.


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ANNEX B – 03/02/2020 Application to Amend Allegation 1. On 3 February 2020, Mr Atherton made an application to amend the Allegation by the deletion of ‘’s’ in paragraph 9a(iv) which stated: ‘9. At the time of issuing the third prescription you failed to:


iv. whether Patient B’s had a history of: (Amended in

accordance with Rule 17(6)) Tribunal’s decision 2. The Tribunal had regard to Rule 17(6) which states: “17(6) Where, at any time, it appears to the Medical Practitioners Tribunal that— (a) the allegation or the facts upon which it is based and of which the practitioner has been notified under rule 15, should be amended; and (b) the amendment can be made without injustice, it may, after hearing the parties, amend the allegation in appropriate terms.” 3. The Tribunal noted that Dr Zafirov was made aware of the amendment to the Allegation in the email from the GMC to Dr Zafirov dated 2 January 2020. The Tribunal was satisfied that the amendment could be made without injustice. It therefore decided to grant the application.

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