PUBLIC RECORD - MPTS › ... › dr-natasha-waters-14-feb-20.pdf · 2020-04-08 · Record of...

Record of Determinations –

Medical Practitioners Tribunal

MPT: Dr WATERS 1

PUBLIC RECORD

Dates: 03/02/2020 - 14/02/2020

Medical Practitioner’s name: Dr Natasha WATERS

GMC reference number: 6116264

Primary medical qualification: Vrach 1996 Kemerovskij Medicinskij Institute

Type of case Outcome on impairment New - Misconduct Impaired

Summary of outcome

Conditions, 12 months. Review hearing directed

Tribunal:

Legally Qualified Chair Mr David McLean

Lay Tribunal Member: Mr John Ennis

Medical Tribunal Member: Dr Candida Borsada

Tribunal Clerk: Mr Stuart Peachey

Attendance and Representation:

Medical Practitioner: Present and represented

Medical Practitioner’s Representative: Dr Waters was present and represented by Ms Sarah Clarke QC, Counsel, instructed by Ms Rosie Jewers of Clyde and Co.

GMC Representative: Mr Peter Warne, Counsel, instructed by GMC Legal, represented the General Medical Council.



MPT: Dr WATERS 2

Attendance of Press / Public In accordance with Rule 41 of the General Medical Council (Fitness to Practise) Rules 2004 the hearing was held partly in public and partly in private. 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 and Impairment - 10/02/2020 Rule 41 1. This determination will be read in private. However, as this case concerns Dr Waters’ alleged misconduct, a redacted version will be published at the close of the hearing. (1) THE FACTS 2. At the outset of these proceedings, Ms Sarah Clarke, QC, on Dr Waters’ behalf, admitted the entirety of the Allegation. The Tribunal therefore announced the Allegation as admitted and found proved. 3. The admitted facts of Dr Waters’ case are as follows:

1. On or around 27 January 2017 you retrospectively altered Patient A’s:

a. pre-operative consent form (‘Consent Form’) in that you added the following:

i. haemorrhage; Admitted and found proved ii. return to theatre; Admitted and found proved iii. repair of injury; Admitted and found proved

b. clinical notes (‘Clinical Notes’), dated 13 January 2017, in that

you added the following:

i. pre op; Admitted and found proved



MPT: Dr WATERS 3

ii. previous 5x did not relief pain at all; Admitted and found proved iii. aware of risks of haemorrhage, infections infancy, return

to theatre. Admitted and found proved

2. You failed to clearly indicate that your actions as outlined at paragraph 1 were retrospective changes to the:

a. Consent Form; Admitted and found proved b. Clinical Notes. Admitted and found proved

3. You knew that any retrospective changes to Patient A’s Consent Form

and Clinical Notes should be clearly indicated. Admitted and found proved

4. Your actions as described at paragraphs 1 and 2 were dishonest by

reason of paragraph 3. Admitted and found proved (2) IMPAIRMENT 4. Having announced the facts admitted and found proved, in accordance with Rule 17(2)(k) of the General Medical Council (‘GMC’) (Fitness to Practise Rules) 2004 as amended (‘the Rules’), the Tribunal then considered whether, on the basis of the facts which it has found proved, Dr Waters’ fitness to practise is currently impaired by reason of misconduct. Background 5. The following is a summary of facts of this case. 6. This case relates to a referral made to the GMC from Mr B, Deputy Medical Director of Western Sussex Hospitals NHS Foundation Trust (‘the Trust’), on 9 October 2017. The referral related to concerns regarding the care and treatment Dr Waters provided to Patient A. 7. On 15 October 2012, Dr Waters became employed at the Trust as a Consultant Obstetrician and Gynaecologist. 8. On 26 August 2016, Patient A was referred to the Trust by her General Practitioner (‘GP’) following a recurrence of pelvic pain, and pain with intercourse. Patient A had a history of endometriosis.



MPT: Dr WATERS 4

9. Patient A first saw Dr Waters pre-theatre on 23 January 2017, and Dr Waters went on to perform a ‘laparoscopy, left ureterolysis, resection of pelvic side wall nodule and rectovaginal nodule and a sigmoidoscopy’ (‘the Procedure’) on Patient A. The operation commenced at 12:30 and transfer to recovery occurred at 13:50 hours. The operation was uneventful and no criticism has been made of Dr Waters’ surgical care. Patient A was taken back to the Ward at 15:30. 10. On 24 January 2017, following concerns about Patient A’s condition, a decision was made for Patient A to return to the operating theatre where she underwent a further procedure carried out by another doctor that included the following:

‘A midline laparotomy was performed after an initial diagnostic laparoscopy which revealed at least 1 litre of blood in the abdominal cavity. Blood was identified in the Pouch of Douglas and both para-aortic gutters with bleeding from the rectovaginal area where the nodule had been excised. There was oozing from the left pelvic side wall where the other nodule had been excised. Haemostasis was achieved and Surgicell employed in the recto-vaginal space and into the left pelvic side wall. The peritoneum was sutured. The estimated blood loss was 2 litres and Patient A was transfused.’

11. On 24 January 2017, Dr Waters wrote to Patient A (typed 31 January 2017) stating that she was sorry that she had bled after her surgery, that she could not explain the cause of the bleed and arranged to have a consultation with Patient A on 7 February 2017. She also wrote to Patient A’s GP to explain that she had performed the Procedure on Patient A, Patient A had been kept in the Trust for observation overnight and, the next morning, she underwent a further procedure. 12. As a result of the complication suffered by Patient A during the Procedure, it was likely that there would need to be an investigation. Accordingly, Ms C, the Gynaecology Matron at the Trust, requested copies of Patient A’s notes. The Consent form and the Clinical notes were scanned and emailed to her in the early afternoon on 27 January 2017. 13. On 27 January 2017, Dr Waters attended Patient A and reviewed her following the second procedure. Patient A’s mother in law was also present. Dr Waters apologised to Patient A and advised her that there would be an investigation and encouraged her to write down any questions. During that review, there was an altercation between Dr Waters and Patient A’s mother-in-law during which Patient A’s mother-in-law raised her voice which left Dr Waters distressed. 14. Following Dr Waters’ review with Patient A, at around 16:30 on 27 January 2017, Dr Waters altered Patient A’s:



MPT: Dr WATERS 5

• Consent Form by adding ‘haemorrhage’, ‘return to theatre’, and ‘repair of injury’; and

• Clinical Notes, by adding ‘pre op’, ‘previous 5x [sic] did not relief pain at all’ and ‘aware of risks of haemorrhage, infections infancy [sic], return to theatre’.

15. Dr Waters knew that any retrospective changes to Patient A’s Consent Form and Clinical notes should be clearly indicated and therefore, her actions were dishonest. The Outcome of Applications Made during the Impairment Stage 16. The Tribunal granted Dr Waters’ application, made pursuant to Rule 41 XXX of the General Medical Council (Fitness to Practise Rules) 2004 as amended (‘the Rules’), for certain parts of the hearing to be heard in private. It had to sit in private when considering XXX. The application was not opposed by the GMC. The Tribunal therefore determined to hear these proceedings partly in private, exercising its discretion under Rule 41. 17. The Tribunal granted Ms Clarke’s application (on behalf of Dr Waters) made pursuant to Rule 34(13) of the Rules, for Dr D to give evidence via Telephone Link. Ms Clarke explained that Dr D’s professional commitments were such that there would be a material adverse effect on her patients were she to attend the hearing in person. This application was not opposed by the GMC. The Evidence Witness 18. The Tribunal received live evidence on behalf of Dr Waters from the following witnesses:

• Dr D, XXX via Telephone Link. She also provided a witness statement and a supplementary statement, both dated 3 February 2020; and

• Dr E, Consultant Obstetrician and Gynaecologist at the Royal Surrey County Hospital, in person. She also provided a witness statement, dated 5 February 2020.

19. Dr Waters also gave oral evidence during the course of these proceedings, and provided:

• Reflective practice document, dated January 2020; and • Witness statement, dated 4 February 2020.



MPT: Dr WATERS 6

20. The Tribunal found Dr Waters to be credible and reliable. During her evidence she was very frank and open and demonstrated genuine remorse about what had happened. There were two or three passages of her evidence that were more difficult to follow because she was trying to reconstruct her state of mind at times between 1 and 3 years ago. XXX This is a case where it was necessary to see and hear her evidence to understand its full effect. Documentary 21. The Tribunal had regard to all the documentary evidence adduced during the course of these proceedings, which included, but was not limited to:

• Reports from:

o Dr F, Consultant in Obstetrics and Gynaecology, Expert Report, dated 14 February 2018; and his Curriculum Vitae (‘CV’);

o Dr G, XXX, dated January 2020; o Mr H, XXX, dated 12 January 2020; and o Ms I, XXX, dated 13 November 2019.

• Witness statements of:

o Ms C, Gynaecology Matron at the Trust, dated 19 September

2018; and o Patient A, dated 23 September 2018; o Dr J, Anaesthetist at the Trust, dated 25 January 2020, with

enclosed documents;

• Other documents, including:

o Medical notes and Amended Medical notes, dated 13 January 2017;

o Consent form and Amended Consent form, dated 23 January 2017;

o Letters from the Trust to Patient A, dated 31 January 2017; and 10 May 2017;

o Datix, dated 16 February 2017; o Patient A’s complaint letter, dated 1 February 2017; o Meeting notes, dated 5 June 2017; and 16 June 2017; o Email correspondence between the Trust and Dr Waters, 23

June 2017; o Letter from the Trust to Patient A’s partner, dated 23 June

2017; o The Trust Investigation Report, dated 11 July 2017; o Various testimonials attesting to Dr Waters’ good character;



MPT: Dr WATERS 7

o Dr Waters’ Personal Development Plans (‘PDP’), dated February 2019 and January 2020; and

o Photographs of water damage at Dr Waters home. Submissions 22. The submissions made by both Counsel at the impairment stage are a matter of record and the following is a non-exhaustive synopsis of those submissions. Submissions on behalf of the GMC 23. Mr Peter Warne, Counsel, submitted that Dr Waters’ fitness to practise is currently impaired by reason of her misconduct. He directed the Tribunal’s attention to Good Medical Practice (2013 edition) (‘GMP’). 24. Mr Warne submitted that Dr Waters accepts:

• Her actions were dishonest; • Her actions were designed to mislead the Trust Investigation; • She betrayed the trust of a patient;

• Her behaviour was likely to damage Patient A’s trust in medical professionals; and

• Her behaviour was likely to endanger the public’s trust in doctors generally, and trust is at the heart of the doctor-patient relationship.

25. XXX 26. Mr Warne submitted that Dr Waters was a trainer in the consenting process and should have known better than anyone the importance of documenting accurately and not misleading others in the making of notes. 27. Mr Warne submitted that Dr Waters’ actions breached specific Trust guidelines and she breached many of the fundamental tenets of the medical profession, as set out in GMP, specifically paragraphs 1, 19, 21(e), 65, 68, 71 and 72. 28. Mr Warne submitted that a fellow practitioner would categorise Dr Waters’ behaviour as deplorable. 29. Mr Warne noted Dr Waters’ acceptance that her fitness to practise is currently impaired. He submitted that Dr Waters has only recently been able to deal with the gravity of what she has done and her dishonesty. 30. Mr Warne submitted that Dr Waters’ actions have breached the statutory overarching objective, in particular:



MPT: Dr WATERS 8

b. the promotion and maintenance of public confidence in the medical

profession; and c. The promotion and maintenance of proper professional standards and

conduct for the medical profession. Submissions on behalf of Dr Waters 31. In the circumstances of this case, the Tribunal considered it helpful to set out Ms Clarke’s submissions more or less verbatim. 32. Ms Clarke reminded the Tribunal of the following admissions during the course of these proceedings, namely that Dr Waters has admitted:

• The entirety of the Allegation; • That she acted dishonestly; • That what she did breaches fundamental tenets of GMP and also

Trust’s policy; and • That her conduct plainly amounts to serious professional misconduct.

Factual findings that underpin the admissions 33. Ms Clarke submitted that the following factors are relevant in this case:

a. No criticisms are made of Dr Waters’ conduct of Patient A’s operation or the fact that a recognised complication subsequently arose.

b. No criticism is made of Dr Waters’ consenting process in respect of

Patient A. c. The additions to the pre-op notes and consent form did not

fundamentally alter the overall content of the notes because the additions were consistent with the information that was already there.

d. Dr Waters has been brutally frank in her reflection statement, her

witness statement and in her evidence to the Tribunal. e. The Tribunal had every opportunity to observe Dr Waters and her

demeanour and to assess her honesty, openness and authenticity – all of which were plain and tangible.

f. The Tribunal also had the same opportunity to assess the other

witnesses called on her behalf – Dr E and Dr D – both of whom were



MPT: Dr WATERS 9

candid and impressive witnesses and neither of whom were challenged by the GMC in any respect.

g. In cross-examination by the GMC, there was no meaningful challenge

to any of the evidence she had given. Instead the cross-examination was an exploration:

i. Of the reasons why Dr Waters made the alterations to the notes

and consent form – about which she had already been and was again, utterly frank.

ii. The reasons why Dr Waters did not disclose what she had done

afterwards – which she had already dealt with at length.

h. Throughout the cross-examination, and Tribunal questioning – Dr Waters was utterly consistent with the evidence she gave in chief.

i. Dr Waters’ evidence is also consistent with the other evidence:

i. XXX ii. Statement of Dr J (anaesthetist at Patient A’s operation); in

particular his observations of her demeanour when he saw her on 25 or 26 January: ‘extremely agitated; very very upset; she seemed to be terrified of losing her job; she did not seem to be thinking straight.’

iii. Dr J’s email to her dated 28 January 2017. iv. Property damage / moving out of her house on day of operation

which demonstrates significant additional stress and worry. v. XXX vi. XXX vii. Datix report of 7 February 2017 (albeit after the incident; but

consistent with a pattern of aggressive behaviour from Patient A’s relatives)

viii. XXX ix. XXX x. XXX



MPT: Dr WATERS 10

xi. XXX xii. XXX

j. She invited the Tribunal to confidently accept Dr Waters’ evidence that what happened on 27 January 2017 was:

i. Totally out of character.

ii. An isolated incident in an otherwise unblemished and impressive career.

iii. Not premeditated or planned. It was impulsive. iv. Occurred as a result of (but she is not suggesting in any way

justified by) a combination of the following factors:

a. XXX

b. XXX

k. Subsequent to the incident, the same combination of factors meant that Dr Waters:

i. Blanked what she had done out of her mind – in effect that she

was unable to think about it or confront it until it was brought to her attention in May 2017.

ii. Gave incorrect explanations at the Trust investigation meeting in

June 2017; to the GMC in March 2019 XXX iii. Has only made the formal admission of dishonesty on 10

January 2020. iv. All the evidence is consistent with her explanations regarding

these matters:

a. XXX

b. XXX c. XXX d. XXX



MPT: Dr WATERS 11

e. XXX

v. XXX

Impairment – Dishonesty 34. Ms Clarke stated that Dr Waters does not dispute that, although it is not an inevitable consequence, the weight of the case law on the issue of dishonesty tends towards a finding of impairment when dishonesty is admitted or found proved. 35. In summary, when deciding whether Dr Waters is currently impaired on public protection or public interest/confidence grounds, Ms Clarke submitted that there are a number of factors for the Tribunal to consider:

a. Insight – Dr Waters, has demonstrated exceptional insight into her misconduct which she has eloquently expressed to the Tribunal both in her written Reflection document, her witness statement and most powerfully in her oral evidence.

b. Dr Waters’ full insight is entirely corroborated by Dr D, Dr E and Dr K

[a fellow consultant who reviewed her reflective statement]. c. The Tribunal can confidently find that this misconduct was totally out

of character XXX. Dr Waters’ actions will not be repeated.

d. Dr Waters has undertaken a significant amount of Continuing Professional Development (‘CPD’) relevant to (amongst many other things) developing insight, ethics, consenting procedures and workplace issues.

e. There is no basis for any concern as to Dr Waters’ clinical skills and

judgement, or her ability to work with others collaboratively and effectively. There is evidence from multiple sources regarding this and it is all entirely consistent that she is a valued and popular colleague with excellent clinical skills and patient care.

36. Ms Clarke submitted that there is no basis therefore to find that Dr Waters is impaired on the grounds of public protection. However, as acknowledged above and as Dr Waters herself acknowledged in evidence, Ms Clarke stated that the Tribunal must consider impairment in a wider context which also encompasses the public interest of the need to maintain confidence in the profession as well as declaring and upholding proper standards of conduct and behaviour.



MPT: Dr WATERS 12

37. On this issue, Ms Clarke submitted that she could not put it any more eloquently than Dr Waters did at the end of her evidence in chief:

‘I feel that I am impaired because trust between a patient and doctor is fundamental to every day of my work. Myself and a patient have relationship where trust is fundamental. By making additions that trust was broken. I am also a member of the public and if I saw a doctor who had done this I would feel they are impaired. I am striving to remedy my impairment but short time since I admitted has been long journey, public might think not enough time to remedy impairment’.

38. Ms Clarke submitted that Dr Waters made that concession freely and it is to her enormous credit. She stated that it is a very rare case where a doctor shows that level of insight and reflection. Ms Clarke suggested that most doctors in Dr Waters’ position ‘take their chances’ at this stage in the hope that a finding of impairment would not be made. 39. Ms Clarke submitted that, ultimately, the issue of impairment is entirely a matter for the Tribunal, and it is not of course bound by the views of Dr Waters. However, she stated that she is instructed not to go behind or undermine the courageous and frank concession that Dr Waters has made. XXX 40. XXX 41. XXX 42. XXX

43. XXX 44. XXX XXX 45. XXX 46. XXX 47. XXX



MPT: Dr WATERS 13

The Relevant Legal Principles 48. In approaching its decision, the Tribunal was mindful of the two-stage process to be adopted in accordance with the approach recommended by Cranston J in Cheatle v GMC [2009] EWHC 645 (Admin): first, whether the facts as found proved amounted to serious misconduct and secondly, whether the doctor’s fitness to practise is currently impaired by reason of that serious misconduct. 49. At both stages of the process, the Tribunal had at the forefront of its mind all three limbs of the overarching objective of the GMC set out in section 1 of the Medical Act 1983 (as amended) to:

a. Protect, promote and maintain the health, safety and well-being of the public,

b. Promote and maintain public confidence in the medical profession, and c. Promote and maintain proper professional standards and conduct for

members of that profession. 50. Whilst there is no statutory definition of impairment, the Tribunal was assisted by the guidance provided by Dame Janet Smith in the Fifth Shipman Report adopted by Cox J in CHRE v NMC and Paula Grant [2011] EWHC 297 (Admin) (‘Grant’) In particular, the Tribunal considered whether its findings of fact showed that Dr Waters’ fitness to practise is impaired in the sense that she:

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.’

51. The Tribunal bore in mind that it must determine whether Dr Waters’ fitness to practise is currently impaired by reason of misconduct, taking into account her conduct at the time of the events and any other relevant factors such as any development of insight, whether the matters are remediable or have been remedied and the likelihood of repetition (Cohen v GMC [2008] EWHC 581 (Admin)). The Tribunal was mindful that this approach can, on occasion, lead to inadequate attention being paid to the second and third parts of the statutory overarching



MPT: Dr WATERS 14

objective (cf.Grant, paragraph 91, and GMC v Chaudhary [2017] EWHC 2561 (Admin), paragraphs 49 to 53). Accordingly, the Tribunal paid particular regard to those matters when analysing this case. Misconduct 52. In determining whether Dr Waters’ fitness to practise is currently impaired by reason of misconduct, the Tribunal first considered whether the facts as admitted and found proved amounted to misconduct by reference to the rules and standards ordinarily required to be followed by a medical practitioner. It went on to consider whether that misconduct was serious misconduct capable of impairing Dr Waters’ fitness to practise. 53. The Tribunal also took account of Dr Waters’ admissions and concessions made at the outset of these proceedings. However, ultimately the decision as to whether the actions and omissions of Dr Waters as set out in the Allegation amounted to serious misconduct, is a matter for the Tribunal. 54. The Tribunal considered the paragraphs of GMP which set out the standards that a doctor must continue to meet throughout their professional career, set against Dr Waters’ actions. The Tribunal had particular regard to paragraphs 19, 21(e), 65 and 71 of GMP that state:

19 ‘Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.’ 21(e) ‘Clinical records should include: … e. who is making the record and when.’ 65 ‘You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession.’ 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. b. You must not deliberately leave out relevant information.



MPT: Dr WATERS 15

The Tribunal also had regard to the Trust’s guidance at the time under of the Allegation under the heading ‘2.4 Completed Forms’, which states:

‘2.4.1 Completed forms should be filled securely in the patients’ medical records. Any changes to a form made after it has been signed by the patient, should be initialled and dated by both patient and health professional’.

The Tribunal applied these standards to the facts found proved. In accordance with the approach of both Counsel, the Tribunal considered the facts as a whole on the basis that the admitted dishonesty is integral to the allegation relating to additions to the Consent form and the Clinical notes. 55. The Tribunal noted that Dr Waters’ dishonest conduct was within a clinical environment, where, on 27 January 2017, at around 16:30, she altered Patient A’s Consent Form by adding ‘haemorrhage’, ‘return to theatre’, and ‘repair of injury’ and the Clinical Notes, by adding ‘pre op’, ‘previous 5x [sic] did not relief pain at all’ and ‘aware of risks of haemorrhage, infections infancy [sic], return to theatre’. Further Dr Waters knew that any retrospective changes to Patient A’s Consent Form and Clinical notes should have been clearly indicated. 56. In her evidence, Dr Waters stated that Patient A’s mother in law mentioned the word ‘haemorrhage’. She explained that she amended the notes to include ‘haemorrhage’ due to her fears for an investigation into this patient’s case. Dr Waters amended the records to make the additions look as if they were contemporaneous with the consenting discussion. 57. The Tribunal noted there has been no evidence adduced to suggest any clinical failing in relation to the Procedure Dr Waters undertook on Patient A. Indeed, Dr J specifically praised Dr Waters’ meticulous approach. 58. However, the Tribunal was of the view that the integrity of patient records is important to ensuring continuity of care for medical professionals engaged with a patient’s case. Dr Waters’ actions by dishonestly amending Patient A’s records were wrong even though they did not impact on her safety. 59. In his Expert Report, under the heading ‘overall standard’, Dr F stated:

‘The overall standard of care for Patient A was seriously below that expected of a reasonably competent Obstetrician & Gynaecologist since the falsification of the contemporaneous written clinical records reflected a lack of honesty and integrity on behalf of Dr Waters, with potential repercussions for her overall performance as a Consultant in Obstetrics and Gynaecology in terms of good medical practice’.



MPT: Dr WATERS 16

60. The Tribunal accepted Dr F’s evidence and concluded that, taking account of all the circumstances in this case, Dr Waters’ dishonest conduct fell far below the standards expected and was contrary to the GMP guidance, the Trust’s guidance, and breached fundamental tenets of the medical profession. Failing (whether inadvertently or, as in this case, deliberately) to identify when entries are made in clinical notes has the potential to contribute to patient harm, though it did not do so in this case. More significantly in this case, it affects public confidence in the medical profession. 61. Therefore, the Tribunal found that Dr Waters’ dishonest conduct amounted to misconduct within Section 35C(2)(a) of the Medical Act 1983, as amended. Impairment by reason of Misconduct 62. Having found that the facts found proved amounted to misconduct, the Tribunal went on to consider whether, as a result of this, Dr Waters’ fitness to practise is currently impaired by reason of that misconduct. 63. The Tribunal first of all had regard to events pre-dating and post-dating the Allegation. It agreed with Ms Clarke that it is important, in this case, to set out its findings about the factual background in more detail than usual, XXX. Events pre-dating the Allegation 64. XXX 65. In Dr G’s XXX Report, it is stated that in 2014, whilst at the Trust, Dr Waters was told by the Division Director that her complication rate and her communication style were going to be investigated. In Dr G’s report, she stated that Dr Waters said she was not provided with any information regarding what was being investigated for approximately two years. The Tribunal noted that this is the first piece of evidence which indicated that Dr Waters had issues with her working environment within the Trust. However, it had not been presented with any further evidence in relation to this. 66. In Dr G’s XXX Report, it is stated that in February 2016, one of Dr Waters’ trainees came to see her regarding major complications but that the trainee ‘had been told not to report this’. It is stated that Dr Waters discussed this with her manager and was told ‘what is your business in this’. Dr Waters considered at this point in time, she felt she was ‘under the radar’. Dr G stated:

XXX 67. In Dr G’s XXX Report, it is stated that in September 2016, Dr Waters was advised that there were no findings from the investigation into her practice (referred



MPT: Dr WATERS 17

to in paragraph 65 of this determination, above) but told to ‘stop making allegations regarding patient safety’. 68. The events outlined in paragraphs 64 to 67 of this determination are more in the nature of general background. The more immediately significant background starts with events in November 2016. 69. In Mr H’s XXX Report, he stated he first met Dr Waters in November 2016. The Tribunal noted that he described Dr Water’s state of mind at that time in the following way:

‘XXX She was incredibly passionate about her work and was frustrated because she felt unsupported by her clinical director.’

70. In her witness statement, Dr Waters stated that around November 2016, the relationship that she was in at the time had broken down and she was dealing with a flood in her house which had caused ‘severe damp and mould’ rendering the house unhabitable (the Tribunal was provided with photographic evidence of her house during that time period). 71. Further, Dr Waters stated that the day she had to move out of her home was 23 January 2017, the day of the Procedure. Events post-dating the Allegation 72. On 3 February 2017, Ms C acknowledged a complaint made by Patient A regarding the treatment she received from Dr Waters on 23 January 2017. Ms C invited Patient A and her partner to attend the Trust for a meeting with Dr Waters. 73. On 7 February 2017, Dr Waters had a meeting with Patient A and her partner at the Trust. During this meeting, Dr Waters explained the technique that she had used in the Procedure and apologised to Patient A and her partner for the complication she had suffered. However, Dr Waters was unable to explain to them the reason for the complication. Dr Waters stated that the Trust would further investigate Patient A’s case and that she would be told the outcome of that investigation and given an opportunity to have her questions answered. During this meeting, there was a verbal altercation between Dr Waters and Patient A’s partner. This resulted in Dr Waters submitting a ‘Datix’ form on 16 February 2017, following her return to work. 74. Following Dr Waters’ meeting with Patient A and her partner on 7 February 2017, Dr Waters stated that she left the Trust XXX due to the confrontation with Patient A’s partner. Dr Waters stated ‘following this encounter, I was so shaken that I was unable to continue working’ and that she briefly returned to the Trust ‘but felt



MPT: Dr WATERS 18

like the work load was too complex and felt unsupported and difficult to continue working.’ 75. The Tribunal noted that at this stage, Dr Waters was unaware that there that there had been any complaints made against her relating to amended patient documentation. 76. On 8 February 2017, a further complaint by Patient A was received by the Trust following her meeting with Dr Waters on 7 February 2017. 77. On 10 February 2017, Ms C had a discussion with Dr Waters at the Trust, where Dr Waters stated she had been very upset following her meeting with Patient A and her partner on 7 February 2017 and did not want to see them again. 78. On 14 February 2017, Miss L, Consultant at the Trust, reviewed Patient A’s case and wrote to her following the two complaints that Patient A had made regarding her care. A further apology was given to Patient A and she was reassured that there ‘should not be any long-term sequelae’. Patient A had been ‘cross’ that Dr Waters ‘had not been compassionate or sorry about what had happened’. 79. On 20 February 2017, by her own request, Dr Waters had a meeting with Dr M, Medical Director at the Trust, XXX. 80. On 7 March 2017, a Root Cause Analysis Report for Patient A was completed. 81. On 14 March 2017, Dr Waters wrote to Patient A’s GP and explained that she had given Patient A all the factual information about what happened surrounding the Procedure and the return to theatre. Dr Waters added that Patient A had been happy with her explanation and was waiting for another interview so that she could get the rest of her answers from the review of her case. The Tribunal has not seen this letter but it is referred to in Dr G’s XXX Report. 82. The concern came to light following a meeting between Ms C and Patient A and her partner on 2 May 2017. Patient A’s partner queried whether the word ‘haemorrhage’ had been added at a later date. When Ms C checked the consent form and clinical notes against the version that had been scanned and emailed to her on 27 January 2017, she noticed that there were various discrepancies. Dr Waters was made aware of the concerns at a meeting with Mr B on 5 May 2017, which he followed up with a letter dated 10 May 2017. 83. Dr Waters was cross-examined closely about the meeting on 5 May 2017 and the letter dated 10 May 2017. In particular she was asked why she had not been able to provide an explanation at the meeting on 5 May 2017. She made the point that she had not said she could not provide an explanation. She explained that she had said nothing at all. XX. She accepted that the making of the Allegation was



MPT: Dr WATERS 19

‘momentous’. She said she saw her writing on the forms and she knew it was hers. She explained that she was ashamed and fearful about what she had done. She accepted that she would not have felt ashamed if she had not done something wrong. She said on a couple of occasions that, at that time, she did not want to explore what she had done but that she did want to explore why she had done it. It was quite difficult to understand precisely what she meant by that but, read in the context of that chapter of her evidence and of her overall evidence, it appears she meant that she was searching for an innocent explanation for her actions, in particular by thinking back to the pressure she was under in January. She explained that it is very hard to accept that she had been dishonest and that, at that time, she was in denial, XXX. 84. On 5 June 2017, the Trust began an investigation regarding Dr Waters’ amendments to the Consent form and Operation records, identified by Ms C. 85. On 16 June 2017, an Investigation Meeting was held between the Trust and Dr Waters, to explore the amendments she had made to the Consent form and the Operation records. It is recorded in the Investigation Meeting notes that Dr Waters stated:

‘However, in light of the aggressive way I had been challenged by Patient A’s mother in law, I felt some more details would be helpful. In full view of the nursing staff behind the nursing desk I added the extra words “haemorrhage”, return to theatre, repair of injury” to the consent form. This was a rushed decision I took in haste. My motivation at the time was fear born from pressure and stress of the confrontation with Patient A’s mother in law. I did not intend the amendment to look like it was part of my notes from the original consent discussion with Patient A but it was intended to be written in the space available. The word “haemorrhage” is written above the line and I did not in any way try to hide that it was an addition. I know I should have added this detail as a separate dated entry the notes, but I acted in the heat of the moment and this was a one off lapse of judgement’.

86. Dr Waters was also cross-examined closely about the meeting on 16 June 2017. She accepted that she had had time to prepare for the meeting and that she had used that time to prepare a detailed statement. Dr Waters accepted that what she had said about her motivation was not true. She said that she had minimised what she had done and that she had not been honest with herself. In response to one question she said that she had found an explanation and she never explored what she did. XXX. This meeting took place about a month after the previous meeting XXX. 87. The Tribunal considered that, by the time of the Investigation meeting, Dr Waters demonstrated that she had accepted that she was in the wrong by amending



MPT: Dr WATERS 20

Patient A’s notes. However, it noted that she was still in denial with her statement that she did not intend to mislead. 88. On 23 June 2017, Dr Waters emailed Mr N, Chief of Service at the Trust, adding further reflections to her comments made during the Investigation Meeting on 16 June 2017. In this email, Dr Waters stated:

‘I was shaken by the level of verbal abuse I encountered from the patient’s partner. I felt that if I did not request the partner to move away from the door, (which he was obstructing) and let me come out, he would have physically assaulted me […] I have never encountered aggression like this. I XXX and was feeling unsupported. I reported the matter on the Datix system […] as a staff abuse case but to this date no-one has contacted me about it. XXX

89. XXX 90. XXX 91. On 3 October 2017, the Trust referred Dr Waters to the GMC. 92. XXX 93. XXX 94. In October 2018, Dr Waters was officially dismissed from her position as a Consultant Obstetrician and Gynaecologist at the Trust. The Tribunal was not presented with any evidence in relation to the reason for her dismissal. 95. XXX 96. XXX 97. On 25 March 2019, Dr Waters’ representatives wrote to the GMC in what was referred to at this hearing as the Rule 7 letter. Much attention was focussed on the following passage:

‘[…] XXX. Dr Waters does not seek to rely on this information to excuse her actions, but she was acting wholly out of character at the time these allegations arose and in this background is relevant to why that was’.

98. The following passages were also referred to:

‘She does not recall adding the words she did, but she does not deny having done so. Her reasons for doing so have been at the very forefront of her mind



MPT: Dr WATERS 21

ever since it was brought to her attention, and she now believes writing these words were most likely to have been what amounted to a reflex act, confirming to herself and alleviating her own doubt, having examined the form, that these matters had indeed been discussed’. and: ‘As to the patient notes, as previously stated, she was adding information to improve the clarity and accuracy of the records. There was never any intention to mislead or to record something which was not an accurate reflection of her discussion with the patient’.

99. XXX 100. XXX 101. XXX Moreover, the reference to her now believing the words were attributable to a reflex act is further support for her assertion that she was, at that time, trying retrospectively to rationalise her actions in order to convince herself that there was an innocent explanation. 102. XXX 103. XXX 104. In July 2019, Dr Waters began working part-time in a clinical capacity at the Royal Surrey Hospital, where she continues to work successfully. 105. XXX 106. XXX 107. On 29 November 2019, Dr Waters XXX. At this point, Dr Waters admitted the entirety of the Allegation against her to Dr G and admitted that what she did was wrong. XXX. The Tribunal noted that this was the first time Dr Waters was able to look objectively at the motivation for her actions. 108. XXX 109. XXX Impairment 110. In determining whether a finding of current impairment of fitness to practise is necessary, the Tribunal looked for evidence of insight and remediation, and the



MPT: Dr WATERS 22

likelihood of repetition. The Tribunal was acutely aware of the danger of paying too little attention to the public interest elements of the statutory overarching objective and accordingly, it always kept in mind the three elements of the statutory overarching objective. 111. The Tribunal considered that insight is important in order for a doctor to recognise areas of their practice and behaviour that require improvement and to take appropriate and relevant steps to address them, thus reducing the likelihood of repetition. That is particularly so in a case of dishonesty. 112. The Tribunal first of all noted that Dr Waters’ conduct in January 2017 took place within her clinical responsibilities and falls within three categories of Dame Janet Smith’s Fifth Shipman Report, namely: b, c and d (as referred to in paragraph 50 of this determination, above). Further, it considered that her actions had the potential to undermine public confidence in the profession. 113. The Tribunal next had regard to the principles set out in Cohen. 114. The Tribunal considered Dr Waters’ insight since the Allegation. It noted that, although she had readily accepted throughout that what she did was wrong, she had denied any element of dishonesty during the Trust Investigation in June 2017 and in the Rule 7 letter in March 2019. In other words, from the outset, Dr Waters recognised that her actions were wrong but sought to justify it. 115. However, the Tribunal had regard to Dr Waters’ recent full admission to the Allegation prior to these proceedings and her full and frank evidence to the Tribunal. She stated that she was ‘ashamed’ and ‘distressed’ due to the impact her actions have had on a patient, the profession and herself. Whilst Dr Waters’ full insight is very recent, the Tribunal was mindful her acceptance of full responsibility for her actions XXX. 116. The Tribunal noted that Dr Waters has attended a full range of CPD with targeted courses relating to her probity. XXX. Dr Waters has reflected extensively on her actions and discussed her issues with her peers. The Tribunal noted that during her evidence, Dr Waters stated that she would like to issue Patient A an apology following these proceedings. 117. Dr Waters’ actions did not cause any harm to Patient A. The Tribunal is confident that Dr Waters would not have made any change to the Consent Form or the Clinical Notes that did not reflect the discussion she had with Patient A. However, it was mindful that Dr Waters has only very recently achieved full insight, XXX. Therefore, there may be a residual risk to herself and others should she be subjected to a stressful and high-pressured environment. Accordingly, the Tribunal is of the view that there is a potential risk, albeit a small one, to patient safety.



MPT: Dr WATERS 23

118. The Tribunal is aware that insight and remediation may be of less significance where the public interest is concerned and that there are cases, including cases of dishonesty, where it may be necessary to make a finding of impairment to maintain public confidence in the profession and/or to promote and maintain proper professional standards. This case is a finely balanced one but the Tribunal has come to the view that the fact that her full insight was achieved so shortly before the hearing means that a finding of current impairment is necessary and appropriate in the public interest so that there can be a regulatory response to ensure that her insight is stable and is maintained going forward. 119. Accordingly, the Tribunal determined that a finding of impairment was necessary in order to:



members of that profession. The Tribunal found Dr Waters’ fitness to practise is currently impaired by reason of misconduct. Determination on Sanction - 14/02/2020 Rule 41 1. This determination will be read in private. However, as this case concerns Dr Waters’ alleged misconduct, a redacted version will be published at the close of the hearing. Sanction 2. Having determined that Dr Waters’ fitness to practise is impaired by reason of her misconduct, the Tribunal moved to consider what sanction, if any, it should impose with regard to Dr Waters’ registration. The Evidence 3. The Tribunal had regard to all of the evidence both oral and documentary adduced during the course of these proceedings. Submissions



MPT: Dr WATERS 24

4. The submissions made by both Counsel at the sanction stage are a matter of record and the following is a non-exhaustive synopsis of those submissions. Submissions on behalf of the GMC 5. Mr Warne provided the Tribunal with outline written submissions. He submitted that the appropriate sanction in Dr Waters’ case is one of suspension. Suspension, he submitted, is the only sanction which would promote and maintain public confidence in the medical profession, and promote and maintain proper professional standards and conduct for the members of the profession. He directed the Tribunal’s attention to GMP and the Sanctions Guidance (November 2019 edition) (‘SG’). 6. Mr Warne directed the Tribunal’s attention to aggravating factors present in Dr Waters’ case:

• There were multiple breaches of GMP; • She was an experienced practitioner who should have known better;

given the fact she even trained others. She was not a trainee doctor; • The Tribunal found serious professional misconduct as a result of her

dishonest behaviour XXX; • The Tribunal found her conduct deplorable in terms of her notional

peer’s assessment of her behaviour; • She sought to mislead the Investigation team who were looking into a

potentially very serious clinical matter; • Her dishonesty was carried out within a clinical setting; • She betrayed the trust of Patient A; • Her conduct was likely to endanger the public’s trust in doctors

generally; and • She has only recently admitted her dishonesty.

7. Mr Warne next directed the Tribunal’s attention to mitigating factors present in Dr Waters’ case:

• She has no previous Fitness to Practise history; • XXX;

• XXX; • She has an apparent level of insight; • There has been some remediation; • She has now been frank about her dishonesty; • The dishonesty was not for financial gain (save losing position); and

• The dishonesty was at the lower end of the scale. In response to questions from the Tribunal about how Mr Warne would characterise Dr Waters’ level of insight, he stated it was ‘decent’, and in relation to Dr Waters’



MPT: Dr WATERS 25

remediation, he conceded that it had been ‘valiant’. Both of those remarks were entirely appropriate standing the evidence the Tribunal heard.

8. Mr Warne submitted that taking no action or imposing an order of conditions would not be appropriate in this case. He reminded the Tribunal that this is not a health case and he questioned whether the factors in paragraphs 84(d) and (e) of the SG were present in Dr Waters’ case. 9. Mr Warne submitted that, taking account of paragraphs 91, 92, 93, 95 and 97(a)(e)(f)(g) and all the facts in this case and the serious nature of the Allegation, suspension would be the appropriate and proportionate sanction. 10. Mr Warne commented that the factors in Ms Clarke’s submissions putting forward reasons for the Tribunal to not suspend the Dr Waters’ registration can be mitigated as the period of suspension is in the Tribunal’s gift and a review can then impose conditions. 11. In relation to the sanction of erasure, Mr Warne directed the Tribunal’s attention to Patel v GMC [2018] EWHC 171 (Admin), and Nicholas-Pillai [2009] EWHC 1048 (Admin) and submitted that erasure would be completely unnecessary given the mitigating features in this case. Submissions on behalf of Dr Waters 12. Ms Clarke handed up detailed written submissions. The Tribunal considered it helpful to set them out fully and her submissions appear in paragraphs 13 to 36. 13. Ms Clarke submitted that in the light of all the particular facts and circumstances of this case, the imposition of conditions would meet the three limbs contained in the overarching objective of protection of the public and would provide an appropriate and proportionate balance between the public interest and maintenance of public confidence and the interests of Dr Waters. 14. Ms Clarke directed the Tribunal’s attention to the SG and the following case law:

• Bawa-Garba v GMC [2018] EWCA Civ 1879; • GMC v Walton [2019] EWHC 3537 (Admin); • Professional Standards Authority v Doree [2017] EWCA Civ 319; • GMC v Chaudhary (2017] EWHC 2561 (Admin);

Assessing seriousness of the matters admitted and found proved 15. Ms Clarke reminded the Tribunal that Dr Waters has accepted that her conduct breached principles of GMP.



MPT: Dr WATERS 26

16. Ms Clarke directed the Tribunal’s attention to paragraph 57 of Chaudhary in which Jay J said:

‘First of all, I respectfully agree with the MPT that dishonesty is not necessarily a monolithic concept. That has two consequences. First of all, questions of degree obviously arise - that much must be self-evident - but secondly, that dishonesty in an individual does not have to be an all-pervading or immutable trait. A person can be dishonest just on one occasion. Secondly, I agree with the MPT that at least it was open for the MPT to consider the context of the respondent's dishonesty.’

17. Ms Clarke stated, in context of Chaudhary above, that when assessing the degree of dishonesty / seriousness, the Tribunal has accepted submissions previously made on Dr Waters’ behalf and has made findings that:

a. No criticisms are made of Dr Waters’ conduct of Patient A’s operation or the fact that a recognised complication subsequently arose and the Anaesthetist (Dr J) specifically praised Dr Waters’ meticulous approach.

b. No criticism was made of Dr Waters’ consenting process in respect of

Patient A. c. The additions to the pre-operation notes and consent form did not

fundamentally alter the overall content of the notes because the additions were consistent with the information that was already there.

d. Dr Waters’ conduct did not impact on Patient A’s safety, although

accepting the context as found by the Tribunal, that the integrity of patient records is important to ensuring continuity of care for medical professionals engaged with a patient’s case.

e. Dr Waters’ actions did not cause any harm to Patient A. ‘The Tribunal

is confident that Dr Waters would not have made any change to the Consent Form or the Clinical Notes that did not reflect the discussion she had with Patient A’

f. This was a single event which was not premeditated or planned, it was

impulsive. g. XXX

Mitigating and aggravating factors



MPT: Dr WATERS 27

18. Ms Clarke submitted that in the context of this case, the mitigating factors are of particularly important significance and the Tribunal is entitled to and should weigh them heavily in the balance when assessing proportionality and necessity:

a. XXX

i. XXX

ii. XXX iii. The conduct that is the subject of the allegations, occurred as a

result of, (but she is not suggesting in any way justified by,) a combination of the following factors:

1. XXX 2. XXX 3. XXX

iv. Subsequent to the incident, the same combination of factors led

to her relatively recent admission of dishonesty b. Insight and Remediation:

i. The Tribunal correctly recognised the importance of insight at paragraph 111 of its determination on impairment – ‘The Tribunal considered that insight is important in order for a doctor to recognise areas of their practice and behaviour that require improvement and to take appropriate and relevant steps to address them, thus reducing the likelihood of repetition. That is particularly so in a case of dishonesty.’

ii. Dr Waters has demonstrated exceptional insight into her

misconduct which she has eloquently expressed to the Tribunal both in her written reflection document, her witness statement and most powerfully in her oral evidence.

iii. Her powerful and frank concession made freely by her in

evidence regarding her view as to her current impairment is to her enormous credit and is an exceptional thing to have done. This goes beyond mere insight into the wrongdoing and is out with anything contemplated in the SG. It is a highly unusual factor which simply does not exist in most cases, and which the Tribunal is entitled to and should take into account when



MPT: Dr WATERS 28

considering which sanction is proportionate and necessary in the public interest.

iv. Dr Waters’ full insight is entirely corroborated by Dr D, Dr E and

K (a fellow consultant who reviewed her reflective statement). v. The Tribunal has found that Dr Waters has made full admissions

(to her dishonesty) and that she gave full and frank evidence to the Tribunal.

vi. The fact that, whilst Dr Waters has accepted throughout that

her actions were wrong, she had denied acting dishonestly until relatively recently, was due to her shame and distress due to the impact her actions have had on Patient A, the profession and herself, and that her acceptance of full responsibility for her actions XXX.

vii. The Tribunal has found that Dr Waters has attended a full range

of CPD with targeted courses relating to her probity. XXX. Dr Waters has reflected extensively on her actions and discussed her issues with her peers. The Tribunal noted that during her evidence, Dr Waters stated that she would like to issue Patient A an apology following these proceedings.

viii. Dr Waters has been back at work in a Locum Registrar capacity

since July 2019. She has been working very effectively in that role and she is a well-liked and trusted member of staff. There is no basis for any concern as to her clinical skills and judgement, or her ability to work with others collaboratively and effectively. There is evidence from multiple sources regarding this and it is all entirely consistent that she is a valued and popular colleague with excellent clinical skills and patient care.

xi. This misconduct (now 3 years old), was therefore totally out of

character and a one-off blemish on an otherwise exemplary career as the witness evidence, documentary evidence and many glowing testimonials demonstrate. It will not be repeated.

x. The Tribunal is also entitled to consider the extensive and

impressive range and quality of Dr Waters’ live witnesses and testimonials. The Tribunal will no doubt recall the live evidence it heard from Dr D XXX:

1. When asked how often she gives evidence on behalf of a

Doctor at the MPTS she stated that it was extremely rare



MPT: Dr WATERS 29

for her to do so XXX. She gave evidence for a Doctor at the MPTS on only 2 occasions last year:

‘XXX’

2. XXX:

‘XXX’

3. XXX 19. Ms Clarke submitted that none of the aggravating factors listed in paragraphs 50 to 56 of the SG are present in this case. 20. Ms Clarke submitted that the factors to which the GMC point may well exist, but have all been dealt with by the Tribunal in its determination, which puts these factors in their proper context. It is the context that enables a Tribunal to decide the issue of Sanction in the light of all the relevant facts. Ms Clarke commented that the GMC’s submissions do not appear to deal with the contextual factors to any meaningful degree. The context of the finding of impairment is also a relevant factor 21. Ms Clarke reminded the Tribunal of paragraph 118 of its determination, which states:

‘The Tribunal is aware that insight and remediation may be of less significance where the public interest is concerned and that there are cases, including cases of dishonesty, where it may be necessary to make a finding of impairment to maintain public confidence in the profession and/or to promote and maintain proper professional standards. This case is a finely balanced one but the Tribunal has come to the view that the fact that her full insight was achieved so shortly before the hearing means that a finding of current impairment is necessary and appropriate in the public interest so that there can be a regulatory response to ensure that her insight is stable and is maintained going forward.’

22. Ms Clarke submitted that, given the Tribunal’s findings regarding the reasons for the relatively recent achievement of full insight, together with the other factual findings set out in the Tribunal’s determination on impairment and summarised above, it is not surprising that the Tribunal found this case ‘finely balanced’ in terms of whether a finding of impairment should be made at all. 23. Ms Clarke submitted that the basis for it doing so is set out at paragraph 118 of the Tribunal’s determination on impairment.



MPT: Dr WATERS 30

24. Ms Clarke reminded the Tribunal of the evidence it heard during the hearing from Dr Waters and in particular from her mentor Dr E and Dr D to the effect that her work is important in her recovery thus far XXX. 25. Ms Clarke referred to Dr Waters’ evidence that during the last 3 years she has suffered significant financial problems XXX. 26. Ms Clarke submitted that it is plain that the Tribunal had had this very much in mind when framing the terms of paragraph 118 of its determination on impairment. Conditions 27. Ms Clarke submitted that conditions are the appropriate sanction in all the circumstances of this case. 28. Ms Clarke submitted that in many cases, the purpose of conditions is to XXX while protecting the public. XXX. 29. Conditions are therefore appropriate and workable, having regard to paragraphs 81 to 84 of the SG. There are a range of conditions set out in the conditions bank which could include for example, having a mentor and Dr Waters continuing to engage with Dr D. 30. The imposition of conditions in this case achieves the overarching objective of protecting the public because:

a. XXX b. The public will have confidence in the medical profession because on

the facts of this case a well-informed member of the public apprised of all the relevant facts, would consider that conditions are the appropriate and proportionate sanction balancing the public interest with the interests of the doctor.

c. For the same reasons, conditions would promote and maintain proper

professional standards and conduct for the members of the profession. Suspension 31. Ms Clarke submitted that, whilst suspension may be appropriate in many cases involving dishonesty, it is not the law and nor does the SG state, that where dishonesty exists, suspension is the minimum sanction.



MPT: Dr WATERS 31

32. Ms Clarke submitted in relation to paragraph 92 of the SG, that for the reasons given above, this is not such a case and it does not fall into this category. She stated that this is a case where suspension is disproportionate and unnecessary to achieve the overarching objective. Length of suspension 33. Ms Clarke submitted that if the Tribunal nevertheless concludes that a period of suspension must be imposed then for all the circumstances in this case, any period of suspension can properly be measured in weeks rather than months. She stated that a very short period of suspension would be sufficient to:

a. Mark the gravity of the conduct given the actual specific features of the case.

b. Act as a deterrent to Dr Waters and others; and c. Be a proportionate response in all the circumstances.

Erasure 34. Ms Clarke submitted that, given the GMC’s position on sanction and the Tribunal’s determination on impairment, she did not need to address the possibility of a sanction and of erasure. Review hearing 35. Ms Clarke submitted that if the Tribunal imposes an order of conditions on Dr Waters’ registration, then there will need to be a review at the end of the term. 36. Ms Clarke submitted that if a suspension is imposed then the Tribunal has a discretion whether to order a review. She acknowledged that the SG indicates that in most cases a review is likely to be necessary in order that it can consider Dr Waters’ circumstances at this time. However, given the above, the Tribunal would be entitled to conclude that a review at the end of a period of suspension would be unnecessary. The Relevant Legal Principles 37. The Tribunal took into account all of the submissions, its findings and the documentary evidence adduced during the course of these proceedings. 38. The Tribunal had regard to the advice given by the Legally Qualified Chair which is a matter of record.



MPT: Dr WATERS 32

39. The decision as to the appropriate sanction is a matter for this Tribunal’s own independent judgment. The sanction must be proportionate and tailored to the specific circumstances of the case. In reaching its decision the Tribunal took into account the SG and the statutory overarching objective, which includes the need to:



members of that profession. 40. The Tribunal recognised that the purpose of a sanction is not to be punitive, although it may have a punitive effect. Throughout its deliberations, the Tribunal applied the principle of proportionality, balancing Dr Waters’ interests with the public interest. The Tribunal’s Determination on Sanction Aggravating and Mitigating Factors 41. The Tribunal has identified the following aggravating factors in Dr Waters’ case:

• Her dishonesty was serious professional misconduct in a clinical environment;

• She sought to mislead the Trust investigation;

• She breached multiple paragraphs of GMP; • She was a senior clinician in a position of trust; • She betrayed the trust of a patient; and • Her conduct was capable of undermining the public’s trust in doctors.

42. The Tribunal has identified the following mitigating factors in Dr Waters’ case:

• One off incident that was out of character and not pre-meditated; • At the outset of these proceedings, and in her evidence, she made

open and frank admissions to the entirety of the Allegation; • She has full insight into her misconduct, albeit that it is fairly recent; • She has demonstrated extensive remediation including reflection and

discussion of her reflection with colleagues; • She has attended various targeted courses; • Her dishonesty did not involve direct financial gain (it was not

acquisitive); • XXX;



MPT: Dr WATERS 33

• No evidence of previous fitness to practise history before her regulator. 43. Whilst Dr Waters breached multiple paragraphs of GMP, the Tribunal considered that this is set against the fact it was a one-off incident in a long unblemished career. Dr Waters has now accepted that in amending Patient A’s Medical Records improperly she was attempting to mitigate the consequences for her of the Trust’s investigation. However, it considered that at that time she was ‘catastrophising’ and not thinking clearly. Dr Waters in fact co-operated with the Trust’s investigation in June 2017 where she was straightforward and accepted that she had amended Patient A’s Medical Records. While she did try to mislead the Trust’s investigation as to her intention, ultimately her intention was a matter to be inferred from her actions. She did not try to conceal her actions from those carrying out the investigation. The Tribunal’s Decision 44. In deciding what sanction, if any, to impose, the Tribunal reminded itself that it must consider each of the sanctions available, starting with the least restrictive, to establish which is appropriate and proportionate in this case. No Action 45. The Tribunal first considered whether to conclude the case by taking no action. 46. The Tribunal considered that there were some exceptional circumstances in this case which might, in other circumstances, justify taking no action. This was a one-off incident, which was totally out of character. Dr Waters has demonstrated extensive remediation. XXX. That cannot be achieved by taking no action. Moreover, taking no action would be insufficient to mark the gravity of the case. 47. Therefore, the Tribunal determined taking no action would not address the public protection or public interest concerns identified. Conditions 48. The Tribunal then considered whether imposing an order of conditions on Dr Waters’ registration would be appropriate. It bore in mind that any conditions imposed should be appropriate, proportionate, workable and measurable. The Tribunal had regard to paragraphs XXX and 82 of the SG, that state: XXX 82(a)(b)(c)(d) ‘Conditions are likely to be workable where:



MPT: Dr WATERS 34

a. the doctor has insight

b. a period of retraining and/or supervision is likely to be the most appropriate way of addressing any findings

c. the tribunal is satisfied the doctor will comply with them

d. the doctor has the potential to respond positively to remediation, or retraining, or to their work being supervised.

49. XXX 50. In so far as paragraph 82 of the SG is concerned, the Tribunal had regard to its determination on impairment. It found that Dr Waters has recently demonstrated full insight into her dishonest conduct in that she:

• Continues to engage with remediation; • XXX;

• Engaged with these regulatory proceedings; and • Has been open and frank with her colleagues in relation to GMC and

the Trust investigations. 51. The Tribunal also had regard to the progress of reflection that Dr Waters has undergone and her learning, both of which have been attested to by her professional colleagues. 52. The Tribunal was in no doubt that Dr Waters would fully comply with and respond positively to an order of conditions imposed on her registration. XXX, the Tribunal considered that imposition of conditions would adequately protect the public from risk of harm and maintain public confidence in the profession XXX. 53. In all the circumstances of this case, the Tribunal determined that placing conditions on Dr Waters’ registration was the appropriate and proportionate sanction in this case. It is the least onerous sanction necessary to:



members of that profession. 54. In determining the duration of Dr Waters’ conditions the Tribunal took into account its earlier findings and the guidance set out in the SG. Having done so, it



MPT: Dr WATERS 35

determined that a period of 12 months would be an appropriate period in all the circumstances of this case. 55. XXX. Further, it determined that an imposed period of conditional registration would also mark the gravity of the case and send out a clear signal to Dr Waters, the profession and the wider public. 56. The following conditions are not confidential and will be published:

1 She must personally ensure the GMC is notified of the following information within seven calendar days of the date these conditions become effective:

a The details of her current post, including:

i her job title

ii her job location

iii her responsible officer (or their nominated deputy) b the contact details of her employer and any contracting body, including her direct line manager

c any organisation where she has practising privileges and/or admitting rights

d any training programmes she is in

e of the contact details of any locum agency or out of hours service she is registered with.

2 She must personally ensure the GMC is notified:

a of any post she accepts, before starting it b that all relevant people have been notified of her conditions, in accordance with condition 6 c if any formal disciplinary proceedings against her are started by her employer and/or contracting body, within seven calendar days of being formally notified of such proceedings



MPT: Dr WATERS 36

d if any of her posts, practising privileges, or admitting rights have been suspended or terminated by her employer before the agreed date within seven calendar days of being notified of the termination e if she applies for a post outside the UK.

3 She must allow the GMC to exchange information with any person involved in monitoring her compliance with her conditions. 4 a She must have a workplace reporter appointed by her

responsible officer (or their nominated deputy).

b She must not work until:

i her responsible officer (or their nominated deputy) has appointed her workplace reporter

ii she has personally ensured that the GMC has been notified of the name and contact details of her workplace reporter.

5 She must only work at the level of Specialist Registrar or below.

6 She must personally ensure the following persons are notified of the conditions listed at 1 to 5:

a her responsible officer (or their nominated deputy) b the responsible officer of the following organisations:

i her place(s) of work, and any prospective place of work (at the time of application) ii all of her contracting bodies and any prospective contracting body (prior to entering a contract) iii any organisation where she has, or has applied for, practising privileges and/or admitting rights (at the time of application) iv any locum agency or out of hours service she is registered with v if any of the organisations listed at (i to iv) does not have a responsible officer, she must notify the person with



MPT: Dr WATERS 37

responsibility for overall clinical governance within that organisation. If she is unable to identify that person, she must contact the GMC for advice before working for that organisation.

c her immediate line manager and senior clinician (where there is one) at her place of work, at least 24 hours before starting work (for current and new posts, including locum posts).

XXX

XXX 57. XXX Suspension 58. The Tribunal considered whether it was necessary to suspend Dr Waters’ registration. It considered that the imposition of conditional registration would satisfy all three limbs of the statutory overarching objective and that a well-informed member of the public would considered suspension to be punitive and disproportionate given the circumstances of this case. The Tribunal also considered that an order of suspension would not address the real issues in this case; in particular, a period of suspension would do nothing to address the wider context of the case. On the other hand, imposition of conditional registration would also allow Dr Waters to continue in practice and receive professional support. The Tribunal has seen evidence that Dr Waters has exceptional skills as a doctor and allowing her to continue working, albeit under restriction, would be of benefit to her patients and her colleagues. 59. XXX. Had the Tribunal reached the view that suspension was the appropriate sanction in this case, those considerations, which are really of the nature of personal mitigation, would not have justified imposition of a lesser sanction. But in all the circumstances imposition of conditions is appropriate in this case. Review Hearing 60. The Tribunal has directed that, shortly before the end of the period of Dr Waters’ conditional registration, her case will be reviewed by a Medical Practitioners Tribunal. This Tribunal considered that a future reviewing Tribunal would be assisted by:

• XXX; • A report from Dr Waters’ nominated Workplace Supervisor; and • Up-to-date testimonials.



MPT: Dr WATERS 38

It is also open to Dr Waters to provide any other evidence she considers helpful. Determination on Immediate Order - 14/02/2020 1. Having determined that Dr Waters’ registration is to be subject to an order of conditions for a period of 12 months, the Tribunal has considered, in accordance with Rule 17(2)(o) of the Rules, whether her registration should be subject to an immediate order. Submissions 2. Mr Warne, on behalf of the GMC, submitted that an immediate order was not necessary in light of the Tribunal’s findings, there is no risk to patient safety, and it would give Dr Waters time to put the necessary arrangements in place. Ms Clarke, on behalf of Dr Waters, endorsed Mr Warne’s submissions. The Tribunal’s Decision 3. In reaching its decision, the Tribunal has exercised its own judgment, and has taken account of the principle of proportionality. The Tribunal has borne in mind that it may impose an immediate order where it is satisfied that it is necessary for the protection of members of the public or otherwise in the public interest or is in the best interests of the practitioner. It has also borne in mind the guidance given in the relevant paragraphs of the SG relating to immediate orders. 4. The Tribunal considered that, in light of its findings and the full insight that Dr Waters has demonstrated, an immediate order of conditions was not necessary in this case. The conditions imposed in large measure formalise the existing informal arrangements and the Tribunal is satisfied that Dr Waters will continue to adhere to those in the meantime. Further, it determined that the public interest did not require an immediate order of conditions; the substantive sanction was sufficient to satisfy the overarching objective. 5. The substantive direction for conditions will take effect 28 days from when the written notice is deemed to have been served upon Dr Waters, unless an appeal is lodged in the interim. 6. That concludes this case.



MPT: Dr WATERS 39

Confirmed Date 14 February 2020 Mr David McLean, Chair

PUBLIC RECORD - MPTS › ... › dr-natasha-waters-14-feb-20.pdf · 2020-04-08 · Record of...

Documents

Transcript of PUBLIC RECORD - MPTS › ... › dr-natasha-waters-14-feb-20.pdf · 2020-04-08 · Record of...