PUBLIC RECORD - MPTS...2020/01/27 · PUBLIC RECORD Dates: 20/01/2020 - 27/01/2020 Medical...

Record of Determinations – Medical Practitioners Tribunal

MPT: Dr MOHAMMED 1

PUBLIC RECORD Dates: 20/01/2020 - 27/01/2020 Medical Practitioner’s name: Dr Magdy MOHAMMED

GMC reference number: 4676911

Primary medical qualification: MB BCh 1983 Cairo

Type of case Outcome on impairment New - Misconduct Impaired

Summary of outcome Conditions, 12 months. Review hearing directed Immediate order imposed

Tribunal:

Legally Qualified Chair Mr Patrick Cox Lay Tribunal Member: Mr Colin Sturgeon Medical Tribunal Member: Dr Gabrielle Downey Tribunal Clerk: Ms Rosanna Sheerin

Attendance and Representation:

Medical Practitioner: Not present and not represented GMC Representative: Mr Peter Warne, Counsel

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,


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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 - 23/01/2020 Background 1. Dr Mohammed qualified in Egypt in 1983. The allegation that has led to Dr Mohammed’s hearing can be summarised as his involvement in online prescribing and it is alleged that he did not make the necessary checks to ensure that such prescribing was necessary and safe. 2. The initial concerns were raised with the GMC in June 2017 following a referral from the Care Quality Commission who stated that they had concerns about the prescribing activity of a number of GMC registered doctors who were prescribing via an online healthcare provider – Medinfoservices Ltd (“Medinfoservices”). One of these doctors was Dr Mohammed. Dr Mohammed had come to the attention of the CQC whilst they were carrying out an inspection of the healthcare provider as an unregistered provider. The CQC subsequently provided the GMC with further documentation which included copies of four prescriptions relating to patients within the UK which had been approved by Dr Mohammed. In respect of these prescriptions, the CQC indicated that in order for the patient to obtain the prescription, they had to complete an online patient questionnaire (“OPQ”). The CQC were able to provide the blank version of the OPQ but were unable to provide copies of the OPQ’s that had actually been completed by each of patients A to D. 3. Further information was later provided to the GMC in respect of another patient, patient E. Patient E had died on 1 December 2016 and in a report dated 23 January 2017 prepared on the instructions of the Procurator Fiscal, Stranraer, forensic pathologists Ms A and Ms B had found that the primary cause of death was Dihydrocodeine poisoning. Enquires had shown that on 7 October 2016, Dr Mohammed had prescribed Patient E Dihydrocodeine along with another drug - Atarax. (As further background, Mr Warne for the GMC made it clear that in relation to the death of Patient E, Police Scotland had taken no action against Dr Mohammed. In an email dated 17 January 2018, the Crown Office and Procurator Fiscal Service had indicated that “The Police carried out this investigation however although they could establish that the deceased had purchased drugs from this Pharmacy, they were unable to establish delivery of these drugs to the deceased and also whether the deceased ever took them”). The Outcome of Applications Made during the Facts Stage 4. The Tribunal granted an application made by Mr Peter Warne, Counsel for the GMC, to proceed with the hearing in Dr Mohammed’s absence, pursuant to Rules 15


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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). The Tribunal’s full decision on the application is included in Annex A. The Allegation and the Doctor’s Response 5. The Allegation made against Dr Mohammed is as follows:

Patient A

1. On 22 November 2016 you issued a prescription for Dihydrocodeine for Patient A (‘the first prescription’) via an online provider of medical services (‘Medinfoservices’). To be determined

2. At the time of issuing the first prescription you failed to:

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

i. whether Patient A had a history of:

1. gastrointestinal problems; To be determined

2. musculoskeletal problems; To be determined

3. alcohol or drug addiction; To be determined

4. mental health issues; To be determined

5. allergies; To be determined

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

b. adequately examine Patient A, in that you failed to carry out a physical examination to establish the underlying cause of Patient A’s pain; To be determined

c. state:

i. the correct dosage; To be determined

ii. the maximum dose; To be determined


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

i. to avoid any other medication containing codeine and paracetamol; 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

e. refer Patient A for:

i. musculoskeletal examination; To be determined

ii. a scan; To be determined

iii. physiotherapy; To be determined

f. inform Patient A’s General Practitioner (‘GP’) of the prescription. To be determined

Patient B

3. On 22 November 2016 you issued a prescription for Clonazepam for Patient B (‘the second prescription’) via Medinfoservices. To be determined

4. At the time of issuing the second prescription you failed to:

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

i. whether Patient B had epilepsy; To be determined

ii. whether Patient B had a history of:

1. hepatic problems; To be determined

2. renal problems; To be determined

3. sleep apnoea; To be determined


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4. pulmonary insufficiency; To be determined

5. myasthenia gravis; To be determined




iii. current mental state; To be determined

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

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

c. state:



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

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





iv. the risks of:

1. driving and working machinery whilst taking the medication; To be determined


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2. paradoxical anxiety; To be determined

v. the management of any present medical conditions; To be determined

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

Patient C

5. On 28 December 2016 you issued a prescription for Diazepam and Zopiclone for Patient C (‘the third prescription’) via Medinfoservices. To be determined

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

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

i. Patient C’s liver; To be determined

ii. Patient C’s kidneys; To be determined

iii. whether Patient C had a history of:







iv. any other medication that Patient C was taking; To be determined

v. Patient C’s current mental state; To be determined

b. adequately examine Patient C, in that you failed to examine Patient C’s mental health; To be determined

c. state:


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iii. the duration of the prescription; To be determined

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

i. to avoid:

1. any other medication containing benzodiazepine or sedative; To be determined

2. driving and working machinery; To be determined





iv. the risks of:


2. sleep walking; To be determined

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

Patient D

7. On 27 January 2017 you issued a prescription for Diazepam for Patient D (‘the fourth prescription’) via Medinfoservices. To be determined

8. At the time of issuing the fourth prescription you failed to:

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

i. Patient D’s liver; To be determined


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ii. Patient D’s kidneys; To be determined

iii. whether Patient D had a history of:








iv. any other medication that Patient D was taking; To be determined

v. Patient D’s current mental state; To be determined

b. adequately examine Patient D, in that you failed to examine Patient D’s mental health; To be determined

c. state:




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

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




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iv. the risks of:



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

Patient E

9. On 7 October 2016 you issued a prescription for Atarax (hydroxyzine) and Dihydrocodeine for Patient E (‘the fifth prescription’) via an online provider of medical services. To be determined

10. At the time of issuing the fifth prescription you failed to:

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

i. any presenting symptoms; To be determined

ii. the history of any presenting symptoms; To be determined

iii. the length of any itch; To be determined

iv. the presence of a rash; To be determined

v. Patient E’s liver; To be determined

vi. Patient E’s kidneys; To be determined

vii. whether Patient E had a history of:

1. cardiac problems; To be determined

2. dermatological issues and their treatment; To be determined



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6. gastrointestinal problems; To be determined

viii. any other medication that Patient E was taking; To be determined

b. adequately examine Patient E, in that you failed to examine:

i. for evidence of severe urticaria/pruritis; To be determined

ii. Patient E’s heart; To be determined

iii. for evidence of Patient E’s underlying pain; To be determined

c. state:




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

i. to avoid:

1. any other medication containing codeine and paracetamol; To be determined

2. alcohol; To be determined

3. other sedating medication; To be determined





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3. cardiac symptoms; To be determined

4. excessive drowsiness; To be determined

iv. in relation to the sedating properties of Atarax and the likelihood of increased sedation when taken with Dihydrocodeine; To be determined

e. refer Patient E for:

i. an ECG; To be determined

ii. blood tests; To be determined

iii. a dermatology opinion; To be determined

iv. musculoskeletal examination; To be determined

f. inform Patient E’s GP of the prescription. To be determined

Expert Witness Evidence 6. The Tribunal received both written and oral evidence from GMC expert witness Dr A, GP. Dr C provided an initial report with appendices dated 5 July 2018, and a supplementary report dated 21 October 2019. The standard the expert stated that she used in his assessment was that of a reasonably competent prescribing doctor in primary care. 7. The Tribunal determined that Dr C’s oral evidence supported both her reports. The Tribunal found Dr C to be a credible witness. Her views and opinions were clear and she gave lengthy and detailed evidence which assisted the Tribunal. She made appropriate concessions in her evidence and the Tribunal determined they were able to rely upon her testimony. Documentary Evidence 8. The Tribunal had regard to the documentary evidence provided by the parties. This evidence included, but was not limited to:

• Prescription dated 22 November 2016 for Patient A; • Prescription dated 22 November 2016 for Patient B;


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• Prescription dated 28 December 2016 for Patient C; • Prescription dated 27 January 2017 for Patient D; • Prescription dated 7 October 2016 for Patient E; • CQC Documentation (including the template online patient questionnaire)

(OPQ); • Police Scotland Documentation in relation to Patient E; • Patient E’s Medical Records; • Dr C, GMC Expert reports dated 5 July 2018 and 21 October 2019; • Employer Responses from: TXM Healthcare, Dr Mohammed’s Responsible

Officer, North Middlesex University Hospital NHS Trust, Royal Cornwall Hospitals NHS Trust, Manchester University NHS Trust, Luton and Dunstable Hospital;

• Dr Mohammed’s Rule 7 Response and email correspondence dated 2 June 2017 and 4 February 2019;

• Dr Mohammed’s Response to Concerns Declaration and related email correspondence dated 2017 and 2018;

• Dr Mohammed’s Appraisal dated August 2017; • CPD in relation to Dr Mohammed; • BNF Documentation.

The Tribunal’s Approach 9. 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 Mohammed does not need to prove anything. The standard of proof is that applicable to civil proceedings, namely the balance of probabilities, i.e. whether it is more likely than not that the events occurred. 10. The majority of the allegations relate to alleged failures on the part of the Doctor. The Tribunal adopted the following approach to those failures. At the facts stage, the Tribunal had to consider whether there was any evidence to show that there had not been such a failure. If there was no such evidence, then the GMC had discharged their burden of proof. If there was some evidence that there had not been such a failure, the Tribunal had to consider whether or not in light of that evidence and having regard to the other evidence, it could be satisfied on the balance of probabilities that there had indeed been a failure. 11. In particular, in this case the Tribunal was provided with the OPQ. This had been obtained from the website through which the various medications had been obtained. There was no suggestion by the GMC that the OPQ would not have been completed by all the patients in this case. The Tribunal therefore determined that all the patients who had obtained prescriptions in this case had completed the OPQ. 12. The Tribunal also bore in mind that had there had been a failure, then whether or not that failure would constitute misconduct was not a matter for the Tribunal to


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consider at this stage. If a failure was found proved, the Tribunal would at stage two have to then consider if that failure amounted to misconduct. The Tribunal’s Analysis of the Evidence and Findings 13. The Tribunal has considered each outstanding paragraph of the Allegation separately and has evaluated the evidence in order to make its findings on the facts. Patient A Paragraph 1 14. The Tribunal has been provided with a copy of the prescription of Dihydrocodeine for Patient A dated 22 November 2016 purported to be signed by Dr Mohammed. The Tribunal has also noted that when Dr Mohammed was asked for comments following provision of the Rule 7 letter from the GMC he confirmed that he understood that his role was to approve a repeat prescription for patients on the Medinfoservices company data base and therefore confirmed his employment with the healthcare provider. There was no evidence before the Tribunal to suggest that it was not Dr Mohammed who had signed the prescription. Accordingly, the Tribunal has found paragraph 1 proved. Paragraph 2 (a)(i)(1-4) 15. In relation to each of Paragraphs 2(a)(i)(1 to 4), the Tribunal had regard to the OPQ. 16. The OPQ does allude to some of the issues that Dr C indicated in both her report and her oral evidence which would need to be addressed before safely prescribing Dihydrocodeine. 17. In relation to gastrointestinal problems, the OPQ asks if the patient has been diagnosed with chronic bowel disorders. In relation to musculoskeletal problems, the OPQ asks if the patient has been diagnosed with Myasthenia gravis (severe muscular weakness). In relation to alcohol or drug addiction, the OPQ asks if the patient consumes alcoholic beverages. It also asks if the patient has ever had problems such as drug abuse after taking certain medicines. In relation to mental health issues, the OPQ asks if the patient has suffered from or currently has suicidal thoughts. 18. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in paragraph 2(a)(1-4) the allegations. 19. Having considered the evidence of Dr C, the Tribunal was satisfied that:


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a. as only “Yes/No” answers were sought and; b. given the complexity of any of these potential problems and; c. the fact that those problems were not directly addressed in the OPQ,

“Yes/No” answers to the questions which did allude to the matters itemised in Paragraphs 2(a)(i) (1 to 4) could not provide an adequate medical history.

20. The Tribunal therefore found each of the allegations in relation to Paragraphs 2(a)(i)(1 to 4) proved. Paragraph 2(a)(i)(5) 21. In relation to Paragraph 2(a)(i)(5), the allegation is that the Doctor did not make enquiries in relation to allergies. Dr C accepted in her oral evidence that there was a question in relation to allergies on the OPQ (“Did you ever have problems (allergic reaction, side effects or drug abuse) after taking certain medicines?”). Dr C expressed dissatisfaction with the wording. However, the allegation is that there were inadequate enquires in relation to allergies and there is a direct question on that point. This is in contrast to e.g. gastrointestinal problems above (Paragraph 2(a)(i)(1) where although there is a question which alludes to gastrointestinal problems) (have you suffered from or do you currently have chronic bowel disorders) that does not cover the whole range of gastrointestinal problems. Therefore, in relation to Paragraph 2(a)(i)(5) the Tribunal found this paragraph not proved. Paragraph 2(a)(ii) 22. In relation to Paragraph 2(a)(ii), the allegation is that an inadequate history was taken in relation to any other medication that Patient A was taking. However, in the OPQ, there was a question directly asking if the patient was currently taking any other medicines. The Tribunal therefore found this paragraph not proved. Paragraph 2b 23. The Tribunal has determined that no evidence has been provided to it that any physical examination was carried out by Dr Mohammed on Patient A. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that any physical examinations were carried out as part of his role on any of the patients to whom prescriptions were issued via the online service. Accordingly, the Tribunal has found paragraph 2b proved.


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Paragraph 2(c)(i) 24. In his submissions on facts Mr Warne submitted that the GMC did not wish to pursue this paragraph of the Allegation following the oral evidence of the GMC expert witness. Accordingly, the Tribunal has found paragraph 2(c)(i) not proved. Paragraph 2(c)(ii) 25. The Tribunal has noted the contents of the copy of the prescription dated 22 November 2016 for Patient A in which it states: “1 X DHC Dihydrocodeine 60mg 56 rtabs 1 tab twice a day when needed” 26. As no maximum dose is noted in the prescription the Tribunal has found paragraph 2(c)(ii) proved. Paragraph 2d in its entirety 27. The Tribunal has been provided with the contents of the Police Scotland Cybercrime Unit Report in relation to Patient E. This contained documentation which was obtained from Patient E’s computer. Patient E, like Patient A, had been prescribed Dihydrocodeine. Amongst the documentation obtained from Patient E’s computer was a print out in relation to Dihydrocodeine. This contained safeguarding advice. The heading at the top appeared to show it was from “Tweens Pharmacy”. Other evidence showed Tweens Pharmacy were the pharmacy which dispensed medicines prescribed by doctors employed by Medinforservices. 28. The Tribunal therefore determined that in relation to Patient E there was evidence that he had been provided with this safeguarding advice in relation to Dihydrocodeine. The Tribunal further determined that if there was evidence that Patient E had been provided this safeguarding advice, it was reasonable for the Tribunal to assume that Patient A had been provided with the same safeguarding advice. 29. The Tribunal has considered the evidence of the GMC expert in which she stated that the information contained within this document was too dense. She indicated that there were certain safeguarding issues which needed to be emphasised to the patient even if they were addressed in the documentation. For instance, the patient should be told to avoid any other prescribed or over the counter medication containing other benzodiazepine or sedative and also advised to take the lowest dose for the shortest time to avoid dependence.


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30. The Tribunal therefore determined that in respect of all the matters contained within paragraph 2(d) the safeguarding advice given was not adequate and accordingly finds those matters proved. Paragraph 2e in its entirety 31. The Tribunal has determined that no evidence has been provided to it that Patient A was referred for a musculoskeletal examination, a scan or physiotherapy. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had made any referral for Patient A. Accordingly, the Tribunal has found paragraph 2e in its entirety proved. Paragraph 2f 32. The Tribunal has determined that no evidence has been provided to it that Patient A’s General Practitioner was informed of the prescription Dr Mohammed approved. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had informed Patient A’s GP. Accordingly, the Tribunal has found paragraph 2f proved. Patient B Paragraph 3 33. The Tribunal has been provided with a copy of the prescription of Clonazepam for Patient B dated 22 November 2016 purported to be signed by Dr Mohammed. The Tribunal has also noted that when Dr Mohammed was asked for comments following provision of the Rule 7 letter from the GMC he confirmed that he understood that his role was to approve a repeat prescription for patients on the Medinfoservices company data base and therefore confirmed his employment with the healthcare provider. There was no evidence before the Tribunal to suggest that it was not Dr Mohammed who had signed the prescription. Accordingly, the Tribunal has found paragraph 3 proved. Paragraph 4(a)(i) 34. In relation to Paragraph 4(a)(i), the allegation is that the Doctor failed to take an adequate medical history from Patient B in that he did not make enquires in relation to whether Patient B had epilepsy. On the OPQ, the patient is asked “Have you ever suffered from or do you currently have epilepsy…?”. The Tribunal found that this question did constitute an enquiry into whether or not Patient B had epilepsy and accordingly found this paragraph not proved.


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Paragraph 4(a)(ii)(1-4,6-7) 35. In relation to each of Paragraphs 4(a)(ii)(1-4) and (6-7), the Tribunal had regard to the OPQ. 36. In relation to each of these matters, there are either questions that allude to that issue but do not directly address that issue (e.g. there is a question which alludes to renal problems – have you ever suffered from or do you currently have kidney disease) or there are no questions that even allude to that issue (there are no questions in relation to sleep apnoea). 37. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in Paragraphs 4(a)(ii) 1-4 and 6-7. 38. Having considered the evidence of Dr C, the Tribunal was satisfied that:

a. As only “Yes/No” answers were sought and; b. given the complexity of any of these potential problems and; c. the fact that those problems were not directly addressed in the OPQ;

those questions which did allude to those problems could not provide an adequate medical history. 39. In relation to those matters where there are no questions which even allude to that issue, the Tribunal was satisfied that there was no adequate history taken. 40. The Tribunal therefore found each of the allegations in relation to Paragraphs 4(a)(ii)(1-4) and (6-7) to be proved. Paragraph 4(a)(ii)(5) 41. In relation to Paragraph 4(a)(ii)(5), the allegation is that the Doctor failed to take an adequate medical history from Patient B in that he did not make enquires in relation to whether Patient B had Myasthenia gravis. On the OPQ the patient is asked “Have you been diagnosed with Myasthenia gravis…?”. The Tribunal found that this question did constitute an enquiry into whether or not Patient B had myasthenia gravis and accordingly found this paragraph not proved. Paragraph 4(a)(ii)(8) 42. In relation to Paragraph 4(a)(ii)(8), the allegation is that the Doctor failed to take an adequate medical history from Patient B in relation to whether he had allergies. Dr C accepted in her oral evidence that there was a question in relation to allergies on the OPQ “Did you ever have problems (allergic reaction, side effects or


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drug abuse) after taking certain medicines?”. Dr C expressed dissatisfaction with the wording. However, the allegation is that there were inadequate enquires in relation to allergies and there is a direct question on that point. The Tribunal found that this question did constitute an enquiry into whether or not Patient B had allergies and accordingly found this paragraph not proved. Paragraph 4(a)(iii) 43. In relation to Paragraph 4(a)(iii), the allegation is that the Doctor failed to take an adequate medical history from Patient B in that he did not make enquires in relation to Patient B’s current mental state. There is a question asking “Have you been diagnosed with suicidal thoughts?”. Again, the Tribunal was satisfied that this did not constitute taking an adequate medical history in relation to Patient B’s current mental state and therefore found this paragraph proved. Paragraph 4(a)(iv) 44. In relation to Paragraph 4(a)(iv), the allegation is that an inadequate history was taken in relation to any other medication that Patient B was taking. There was a question on the OPQ directly asking if the patient was currently taking any other medicines. The Tribunal therefore found this paragraph not proved. Paragraph 4b 45. The Tribunal has determined that no evidence has been provided to it that any examination was carried out by Dr Mohammed on Patient B. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that any examinations were carried out on any patients. Accordingly, the Tribunal has found paragraph 4b proved. Paragraph 4(c)(i) 46. The Tribunal has considered the evidence of the GMC expert witness in which she states in her report:

“In my opinion, the prescription was incorrectly written and should have been initially 1 mg once daily for 4 nights, dose to be increased over 2–4 weeks, usual dose 4–8 mg daily, adjusted according to response, dose usually taken at night; may be given in 3–4 divided doses if necessary dose 8mg”. For anxiety the dose is 1-2mg at night

and that is the usual maximum dose.” 47. In her oral evidence to the Tribunal Dr C stated that if a patient is already on such medication that any further medication must be verified with the prescribing physician. She stated that Dr Mohammed should only have prescribed the dosage of


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Clonazepam he did if he had prior knowledge of Patient B’s prescribing history and therefore was aware that the patient was on an established treatment plan. 48. The Tribunal has accepted the evidence on the GMC expert and has found paragraph 4(c)(i) proved. Paragraph 4(c)(ii) 49. The Tribunal has noted the contents of the copy of the prescription dated 22 November 2016 for Patient B in which it states: “1 X Clonazepam 1 tab at night Clonazepam 2.0mg 100 tabs” 50. As no maximum dose is noted in the prescription the Tribunal has found paragraph 4(c)(ii) proved. Paragraph 4d in its entirety 51. The Tribunal has not been provided with any evidence that Dr Mohammed had provided any safeguarding advice to Patient B in relation to the use of Clonazepam. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had given any safeguarding advice to any patients. 52. The Tribunal has determined that Dr Mohammed failed to provide safeguarding advice to Patient B and has therefore found paragraph 4d proved in its entirety. Paragraph 4e 53. The Tribunal has determined that no evidence has been provided to it that Patient B’s General Practitioner was informed of the prescription Dr Mohammed approved. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had informed Patient B’s GP. Accordingly, the Tribunal has found paragraph 4e proved. Patient C Paragraph 5 54. The Tribunal has been provided with a copy of the prescription for Diazepam and Zopiclone for Patient C dated 28 December 2016 purported to be signed by Dr Mohammed. The Tribunal has also noted that when Dr Mohammed was asked for comments following provision of the Rule 7 letter from the GMC he confirmed that he understood that his role was to approve a repeat prescription for patients on the


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Medinfoservices company data base and therefore confirmed his employment with the healthcare provider. There was no evidence before the Tribunal to suggest that it was not Dr Mohammed who had signed the prescription. Accordingly, the Tribunal has found paragraph 5 proved. Paragraphs 6(a)(i)(ii) 55. In relation to paragraph 6(a)(i)(ii), the allegation is that the Doctor failed to take an adequate history in that he did not make enquiries in relation to Patient C’s liver or kidneys. In relation to both those issues, there are questions which allude to those issues. 56. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in Paragraphs 6(a)(i)(ii). 57. Having considered the evidence of Dr C, the Tribunal was satisfied that:


those questions which did allude to those problems could not provide an adequate medical history. 58. The Tribunal therefore found each of the allegations in relation to Paragraphs 6(a)(i)(ii) proved. Paragraphs 6(a)(iii)(1-5) 59. In relation to paragraph 6(a)(iii)(1-5), in relation to each of these matters, there are either questions that allude to that issue but do not directly address that issue (e.g. there is a question which alludes to mental health issues – have you ever suffered from or do you currently have suicidal thoughts) or there are no questions that even allude to that issue (there are no questions in relation to sleep apnoea). 60. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in Paragraphs 6(a)(iii)(1-5) 61. Having considered the evidence of Dr C, the Tribunal was satisfied that:



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those questions which did allude to those problems could not provide an adequate medical history. In relation to those matters where are no questions which even allude to that issue, the Tribunal was satisfied that there was no adequate history taken. 62. The Tribunal therefore found each of the allegations in relation to Paragraphs 6(a)(iii) 1-5 proved. Paragraph 6(a)(iii)(6) 63. In relation to Paragraph 6(a)(iii)(6), the allegation is that the Doctor failed to take an adequate medical history from Patient C in that he did not make enquires in relation to whether Patient C had myasthenia gravis. On the OPQ the patient is asked “Have you ever suffered from or do you currently have myasthenia gravis. The Tribunal found that this question did constitute an enquiry into whether or not Patient B had myasthenia gravis and accordingly found this paragraph not proved. Paragraph 6(a)(iv) 64. In relation to Paragraph 6(a)(iv), the allegation is that an inadequate history was taken in relation to any other medication that Patient C was taking. There was a question on the OPQ directly asking if the patient was currently taking any other medicines. The Tribunal therefore found this paragraph not proved. Paragraph 6(a)(v) 65. In relation to Paragraph 6(a)(v), the allegation is that the Doctor failed to take an adequate medical history from Patient C in that he did not make enquires in relation to Patient C’s current mental state. There is a question on the OPQ asking “Have you been diagnosed with suicidal thoughts?”. Again, the Tribunal was satisfied that this did not constitute taking an adequate medical history in relation to Patient C’s current mental state and therefore found this paragraph proved. Paragraph 6b 66. The Tribunal has determined that no evidence has been provided to it that any examination was carried out by Dr Mohammed on Patient C. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that any examinations were carried out. Accordingly, the Tribunal has found paragraph 6b proved. Paragraph 6c in its entirety 67. The Tribunal has noted the contents of the copy of the prescription dated 28 December 2016 for Patient C in which it states:


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“1 X Diazepam 1 tab a day Diazepam 10mg 56 tabs 1 X Zopiclone Zopiclone 7.50mg 56ftabs 1 tab at night” 68. In her report Dr C states:

“…Diazepam belongs to the group of drugs known as Benzodiazepines and Zopiclone is a non-benzodiazepine night sedative. Diazepam, according to the BNF, is indicated for: Muscle spasm of varied aetiology, acute muscle spasm, Tetany, Muscle spasm in cerebral spasticity or in postoperative skeletal muscle spasm, anxiety, insomnia with anxiety, Severe acute anxiety, Control of acute panic attacks, Acute alcohol withdrawal, acute drug induced dystonic reactions, as a pre-med/pre surgery and status epilepticus. It is contraindicated in acute pulmonary insufficiency; marked neuromuscular respiratory weakness; sleep apnoea syndrome; unstable myasthenia gravis and to be used with caution in the elderly or those with a history of personality disorder, alcohol or drug dependence. Common side effects are drowsiness, ataxia, (unsteadiness), confusion, amnesia and paradoxical agitation. It is also likely to cause dependence with repeated use. Special precautions should be taken in those patients with liver or kidney disease as its effect may be amplified in those with kidney or liver

disease…” 69. In her oral evidence Dr C stated that in order to prescribe a 10mg dosage of Diazepam factors such as a patient’s weight, height and tolerance would need be established by the prescribing physician. The Tribunal has not been provided any evidence that such factors were ascertained by Dr Mohammed. 70. The Tribunal has also noted that there is no evidence of the maximum dosage provided on the prescription. Further, there is no evidence that the duration was noted on the prescription. 71. Accordingly, the Tribunal has found paragraph 6c in its entirety proved in relation to Diazepam. 72. In her oral evidence Dr C stated that a 7.5mg dosage of Zopiclone was inappropriate for a patient in their seventies. She said the appropriate initial dose for such a patient was 3.75mg unless they were already on an established treatment plan which would need to be confirmed with the patient’s doctor. The Tribunal has not been provided any evidence that this was established by Dr Mohammed.


MPT: Dr MOHAMMED 23

73. The Tribunal has also noted that there is no evidence of the maximum dosage provided on the prescription. Further, there is no evidence that the duration was noted on the prescription. 74. Accordingly, the Tribunal has found paragraph 6c in its entirety proved in relation to Zopiclone. Paragraph 6d 75. The Tribunal has not been provided with any evidence that Dr Mohammed had provided any safeguarding advice to Patient C in relation to the use of Diazepam and Zopiclone. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had given any safeguarding advice to any patients. 76. The Tribunal has determined that Dr Mohammed failed to provide safeguarding advice to Patient C and has therefore found paragraph 6d proved in its entirety. Paragraph 6e 77. The Tribunal has determined that no evidence has been provided to it that Patient C’s General Practitioner was informed of the prescription Dr Mohammed approved. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had informed Patient C’s GP. Accordingly, the Tribunal has found paragraph 4e proved. Patient D Paragraph 7 78. The Tribunal has been provided with a copy of the prescription of Diazepam for Patient D dated 27 January 2017 purported to be signed by Dr Mohammed. The Tribunal has also noted that when Dr Mohammed was asked for comments following provision of the Rule 7 letter from the GMC he confirmed that he understood that his role was to approve a repeat prescription for patients on the Medinfoservices company data base and therefore confirmed his employment with the healthcare provider. There was no evidence before the Tribunal to suggest that it was not Dr Mohammed who had signed the prescription. Accordingly, the Tribunal has found paragraph 7 proved. Paragraphs 8(a)(i)(ii) 79. In relation to paragraph 8(a)(i)(ii), the allegation is that the Doctor failed to take an adequate history in that he did not make enquiries in relation to Patient D’s


MPT: Dr MOHAMMED 24

liver or kidneys. In relation to both those issues, there are questions which allude to those issues. 80. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in Paragraphs 8(a)(i)(ii). 81. Having considered the evidence of Dr C, the Tribunal was satisfied that:


those questions which did allude to those problems could not provide an adequate medical history. 82. The Tribunal therefore found each of the allegations in relation to Paragraphs 8(a)(i)(ii) proved. Paragraphs 8(a)(iii)(1-5) 83. In relation to paragraph 8(a)(iii)(1-5), in relation to each of these matters, there are either questions that allude to that issue but do not directly address that issue (e.g. there is a question which alludes to mental health issues – “Have you ever been diagnosed with suicidal thoughts?” or there are no questions that even allude to that issue (there are no questions in relation to sleep apnoea). 84. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in Paragraphs 8(a)(iii)(1-5). 85. Having considered the evidence of Dr C, the Tribunal was satisfied that:


those questions which did allude to those problems could not provide an adequate medical history. In relation to those matters where are no questions which even allude to that issue, the Tribunal was satisfied that there was no adequate history taken. 86. The Tribunal therefore found each of the allegations in relation to Paragraphs 8(a)(iii) 1-5 proved.


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Paragraph 8(a)(iii)(6) 87. In relation to Paragraph 8(a)(iii)(6), the allegation is that the Doctor failed to take an adequate medical history from Patient D in that he did not make enquires in relation to whether Patient D had Myasthenia gravis. On the OPQ the patient is asked “Have you been diagnosed with myasthenia gravis...?” . The Tribunal found that this question did constitute an enquiry into whether or not Patient D had myasthenia gravis and accordingly found this paragraph not proved. Paragraph 8(a)(iii)(7) 88. In relation to Paragraph 8(a)(iii)(7), the allegation is that the Doctor did not make enquiries in relation to allergies. Dr C accepted in her oral evidence that there was a question in relation to allergies on the OPQ (“Did you ever have problems (allergic reaction, side effects or drug abuse) after taking certain medicines?”). Dr C expressed dissatisfaction with the wording. However, the allegation is that there were inadequate enquires in relation to allergies and there is a direct question on that point. Therefore, in relation to Paragraph 8(a)(iii)(7) the Tribunal found this paragraph not proved. Paragraph 8(a)(iv) 89. In relation to Paragraph 8(a)(iv), the allegation is that an inadequate history was taken in relation to any other medication that Patient D was taking. There was a question on the OPQ directly asking if the patient was currently taking any other medicines. The Tribunal therefore found this paragraph not proved. Paragraph 8(a)(v) 90. In relation to Paragraph 8(a)(v), the allegation is that the Doctor failed to take an adequate medical history from Patient D in that he did not make enquires in relation to Patient D’s current mental state. There is a question on the OPQ asking whether or not the patient has been diagnosed with suicidal thoughts. Again, the Tribunal was satisfied that this did not constitute taking an adequate medical history in relation to Patient D’s current mental state and therefore found this paragraph proved. Paragraph 8b 91. The Tribunal has determined that no evidence has been provided to it that any examination was carried out by Dr Mohammed on Patient D. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that any examinations were carried out. Accordingly, the Tribunal has found paragraph 8b proved.


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Paragraph 8c in its entirety 92. The Tribunal has noted the contents of the copy of the prescription dated 27 January 2017 for Patient D in which it states: “1 X Diazepam 1 tab a day when needed Diazepam 10mg 56 tabs” 93. In her report Dr C states:

“…Diazepam belongs to the group of drugs known as Benzodiazepines and Zopiclone is a non-benzodiazepine night sedative. Diazepam, according to the BNF, is indicated for: Muscle spasm of varied aetiology, acute muscle spasm, Tetany, Muscle spasm in cerebral spasticity or in postoperative skeletal muscle spasm, anxiety, insomnia with anxiety, Severe acute anxiety, Control of acute panic attacks, Acute alcohol withdrawal, acute drug induced dystonic reactions, as a pre-med/pre surgery and status epilepticus. It is contraindicated in acute pulmonary insufficiency; marked neuromuscular respiratory weakness; sleep apnoea syndrome; unstable myasthenia gravis and to be used with caution in the elderly or those with a history of personality disorder, alcohol or drug dependence. Common side effects are drowsiness, ataxia, (unsteadiness), confusion, amnesia and paradoxical agitation. It is also likely to cause dependence with repeated use. Special precautions should be taken in those patients with liver or kidney disease as its effect may be amplified in those with kidney or liver

disease…” 94. In her oral evidence Dr C stated as with Patient C that in order to prescribe a 10mg dosage of Diazepam factors such as a patient’s weight, height and tolerance would need be established by the prescribing physician. The Tribunal has not been provided any evidence that such factors were ascertained by Dr Mohammed. 95. The Tribunal has also noted that there is no evidence of the maximum dosage provided on the prescription. Further, there is no evidence that the duration was noted on the prescription. 96. Accordingly, the Tribunal has found paragraph 8c in its entirety proved. Paragraph 8d in its entirety 97. The Tribunal has not been provided any evidence that Dr Mohammed had provided any safeguarding advice for Diazepam to Patient D. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had given any safeguarding advice.


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98. The Tribunal has determined that Dr Mohammed failed to provide safeguarding advice to Patient D and has therefore found paragraph 8d proved in its entirety. Paragraph 8e 99. The Tribunal has determined that no evidence has been provided to it that Patient D’s General Practitioner was informed of the prescription Dr Mohammed approved. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had informed Patient D’s GP. Accordingly, the Tribunal has found paragraph 8e proved. Patient E Paragraph 9 100. The Tribunal has been provided with a copy of the prescription of Atarax and Dihydrocodeine for Patient E dated 7 October 2016 purported to be signed by Dr Mohammed. The Tribunal has also noted that when Dr Mohammed was asked for comments following provision of the Rule 7 letter from the GMC he confirmed that he understood that his role was to approve a repeat prescription for patients on the Medinfoservices company data base and therefore confirmed his employment with the healthcare provider. There was no evidence before the Tribunal to suggest that it was not Dr Mohammed who had signed the prescription. Accordingly, the Tribunal has found paragraph 7 proved. Paragraph 10(a)(i) 101. In relation to Paragraph 10(a)(i), the allegation is that the Doctor failed to take an adequate medical history from Patient in that he did not make enquiries in relation to any presenting symptoms. On the OPQ the patient is asked “What is the disorder or complaint for which you request this medication?”. The Tribunal found that this question did constitute an enquiry into Patient E’s presenting symptoms and accordingly found this paragraph not proved. Paragraphs 10(a)(ii-vi) 102. In relation to paragraph 10(a)(ii-vi), the allegation is that the Doctor failed to take an adequate history in that he did not make enquiries in relation to Patient E’s history of presenting symptoms, the length of any itch, the presence of a rash, and Patient E’s liver or kidneys. In relation to both those the liver and kidneys, there are questions which allude to those issues. In relation to other matters, that are no questions that even allude to those issues.


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103. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in Paragraphs 10(a)(ii-vi). 104. Having considered the evidence of Dr C, the Tribunal was satisfied that:


those questions which did allude to those problems could not provide an adequate medical history. In relation to those matters where are no questions which even allude to that issue, the Tribunal was satisfied that there was no adequate history taken. 105. The Tribunal therefore found each of the allegations in relation to Paragraphs 10(a)(ii)-(vi) were proved. Paragraphs 10(a)(vii)(1-6) 106. In relation to paragraph 10(a)(vii)(1-6), in relation to each of these matters, there are either questions that allude to that issue but do not directly address that issue (e.g. there is a question which alludes to mental health issues – “Have you ever diagnosed with suicidal thoughts?”) or there are no questions that even allude to that issue (there are no questions in relation to dermatological issues and their treatment). 107. The Tribunal considered whether or not the OPQ constituted taking an adequate medical history in relation to the matters itemised in Paragraphs 10(a)(vii)(1-6). 108. Having considered the evidence of Dr C, the Tribunal was satisfied that:


those questions which did allude to those problems could not provide an adequate medical history. In relation to those matters where are no questions which even allude to that issue, the Tribunal was satisfied that there was no adequate history taken. 109. The Tribunal therefore found each of the allegations in relation to Paragraphs 10(a)(vii) (1-6) proved.


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Paragraph 10(a)(viii) 110. In relation to Paragraph 10(a)(viii), the allegation is that an inadequate history was taken in relation to any other medication that Patient E was taking. There was a question on the OPQ directly asking if the patient was currently taking any other medicines. The Tribunal therefore found this paragraph not proved. Paragraph 10b in its entirety 111. The Tribunal has determined that no evidence has been provided to it that any examination was carried out by Dr Mohammed on Patient E. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that any examinations were carried out. Accordingly, the Tribunal has found paragraph 10b in its entirety proved. Paragraph 10(c) in its entirety 112. In her expert report Dr C in relation to the medication prescribed by Dr Mohammed states:

“Atarax (Hydroxyzine) • Hydroxyzine is contra-indicated in patients with prolonged QT-interval or who have risk factors for QT-interval prolongation; • Avoid use in the elderly due to increased susceptibility to the side-effects of Hydroxyzine; • Consider the risks of QT-interval prolongation and torsade de pointes before prescribing to patients taking drugs that lower heart rate or plasma-potassium concentration; • In adults, the maximum daily dose is 100 mg; • In the elderly, the maximum daily dose is 50 mg (if use of

Hydroxyzine cannot be avoided); • The lowest effective dose for the shortest period of time should be prescribed. It is contraindicated i.e. should not be prescribed where there is a history of predisposition to QT Acquired or congenital QT interval prolongation interval prolongation. It should only be prescribed “with caution” where there is a history of bladder outflow obstruction; breathing problems; cardiovascular disease; decreased gastrointestinal motility; dementia; elderly (in adults); epilepsy; hypertension; hyperthyroidism; myasthenia gravis; prostatic hypertrophy (in adults); pyloroduodenal obstruction; stenosing peptic ulcer; susceptibility to angle-closure glaucoma; urinary retention. The dose should be lowered where there is a history of liver or kidney impairment due to risk of


MPT: Dr MOHAMMED 30

increased side effects and overdose…

In my opinion, in order to safely prescribe Atarax, a GP would need a full history of presenting complaint, length of itch , presence of a rash, a liver and kidney history to exclude the possibility of overdose, a cardiac history and a history of all medications being taken, including over the counter medication (medications are often responsible for itch/pruritis).”

Dihydrocodeine Dihydrocodeine is potent analgesic usually prescribed for moderate to severe pain, dangerous in overdose, should be prescribed at the lowest dose possible for the shortest time, is addictive, has side effects such as constipation but serious side effects such as worsening of liver disease and may be fatal in overdose. For moderate pain, the recommended dose is 30-60mg 4-6 hourly and in severe pain, 60-120mg 12 hourly. Side effects include drowsiness, constipation, confusion, dependence and hyperalgesia, (a condition of abnormal pain sensitivity) and tolerance, (higher doses needed for the same effect). It is to be used with caution in those patients with liver disease, renal disease (increased effect) and respiratory conditions, (respiratory depression). In my opinion, given the potency of Dihydrocodeine, the risk of unintentional overdose with similar codeine based medication, its potential for abuse or diversion and the need for a GP to examine a patient if they required that level of analgesia would make it unlikely that such information could be gleamed from any on line questionnaire. In my opinion, a patient would need to be seen face to face and

examined…” 113. The Tribunal has determined, having regard to the expert evidence in relation to the Dihydrocodeine that as with Patient A, in relation to Patient E, Dr Mohammed prescribed a correct dosage but with no maximum dosage or duration of treatment. In relation to the Atarax the Tribunal has determined that Dr Mohammed prescribed an incorrect dosage, with no maximum dosage or duration of treatment. The Tribunal therefore found paragraph (c)(i) not proved in relation to Dihydrocodeine but proved in relation to Atarax. In relation to paragraphs (c)(ii) and (c)(iii), the Tribunal found these proved in relation to both Dihydrocodeine and Atarax. Paragraph 10d in its entirety 114. As outlined in the reasoning in relation to paragraph 2d the Tribunal determined that there was evidence that Patient E had been provided safeguarding advice in relation to Dihydrocodeine There was no evidence he had been provided with any safeguarding advice in relation to Atarax. The Tribunal has considered the


MPT: Dr MOHAMMED 31

evidence of the GMC expert in which she provided the reasons she was unhappy with the contents of the information as she stated that the information in relation to Dihydrocodeine was too dense and that she would expect a physician to personally discuss safeguarding advice. 115. The Tribunal has determined that whilst Patient E received this information in relation to the medication prescribed in relation to safeguarding it does not consider such documentation to be sufficient. Accordingly, the Tribunal has found paragraph 10d in its entirety proved. Paragraph 10e in its entirety 116. The Tribunal has determined that no evidence has been provided to it that Patient E was referred for an ECG, blood tests, a dermatology opinion or musculoskeletal examination. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had made any referral for Patient E as part of his role to approve repeat prescriptions for patients on the Medinfoservices company data base. Accordingly, the Tribunal has found paragraph 10e in its entirety proved. Paragraph 10f 117. The Tribunal has determined that no evidence has been provided to it that Patient E’s General Practitioner was informed of the prescription Dr Mohammed approved. The Tribunal also noted that Dr Mohammed in his response to the Rule 7 letter did not contend that he had informed Patient E’s GP. Accordingly, the Tribunal has found paragraph 8e proved. The Tribunal’s Overall Determination on the Facts 118. The Tribunal has determined the facts as follows:

Patient A

1. On 22 November 2016 you issued a prescription for Dihydrocodeine for Patient A (‘the first prescription’) via an online provider of medical services (‘Medinfoservices’). Found proved

2. At the time of issuing the first prescription you failed to:

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

i. whether Patient A had a history of:

1. gastrointestinal problems; Found proved


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2. musculoskeletal problems; Found proved

3. alcohol or drug addiction; Found proved

4. mental health issues; Found proved

5. allergies; Found not proved

ii. any other medication that Patient A was taking; Found not proved

b. adequately examine Patient A, in that you failed to carry out a physical examination to establish the underlying cause of Patient A’s pain; Found proved

c. state:

i. the correct dosage; Found not proved

ii. the maximum dose; Found proved

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

i. to avoid any other medication containing codeine and paracetamol; Found proved

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


1. an allergic reaction; Found proved

2. a worsening of their condition; Found proved

e. refer Patient A for:

i. musculoskeletal examination; Found proved

ii. a scan; Found proved

iii. physiotherapy; Found proved


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f. inform Patient A’s General Practitioner (‘GP’) of the prescription. Found proved

Patient B

3. On 22 November 2016 you issued a prescription for Clonazepam for Patient B (‘the second prescription’) via Medinfoservices. Found proved

4. At the time of issuing the second prescription you failed to:

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

i. whether Patient B had epilepsy; Found not proved

ii. whether Patient B had a history of:

1. hepatic problems; Found proved

2. renal problems; Found proved

3. sleep apnoea; Found proved

4. pulmonary insufficiency; Found proved

5. myasthenia gravis; Found not proved




iii. current mental state; Found proved

iv. any other medication that Patient B was taking; Found not proved

b. adequately examine Patient B, in that you failed to examine Patient B’s mental health; Found proved

c. state:

i. the correct dosage; Found proved


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

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





iv. the risks of:

1. driving and working machinery whilst taking the medication; Found proved

2. paradoxical anxiety; Found proved

v. the management of any present medical conditions; Found proved

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

Patient C

5. On 28 December 2016 you issued a prescription for Diazepam and Zopiclone for Patient C (‘the third prescription’) via Medinfoservices. Found proved

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

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

i. Patient C’s liver; Found proved

ii. Patient C’s kidneys; Found proved whether Patient C had a history of:


MPT: Dr MOHAMMED 35







iii. any other medication that Patient C was taking; Found not proved

iv. Patient C’s current mental state; Found proved

b. adequately examine Patient C, in that you failed to examine Patient C’s mental health; Found proved

c. state:



iii. the duration of the prescription; Found proved

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

i. to avoid:

1. any other medication containing benzodiazepine or sedative; Found proved

2. driving and working machinery; Found proved





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iv. the risks of:


2. sleep walking; Found proved

e. inform Patient C’s GP of the prescription. Found proved

Patient D

7. On 27 January 2017 you issued a prescription for Diazepam for Patient D (‘the fourth prescription’) via Medinfoservices. Found proved

8. At the time of issuing the fourth prescription you failed to:

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

i. Patient D’s liver; Found proved

ii. Patient D’s kidneys; Found proved

iii. whether Patient D had a history of:








iv. any other medication that Patient D was taking; Found not proved

v. Patient D’s current mental state; Found proved


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b. adequately examine Patient D, in that you failed to examine Patient D’s mental health; Found proved

c. state:




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

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





iv. the risks of:



e. inform Patient D’s GP of the prescription. Found proved

Patient E

9. On 7 October 2016 you issued a prescription for Atarax (hydroxyzine) and Dihydrocodeine for Patient E (‘the fifth prescription’) via an online provider of medical services. Found proved

10. At the time of issuing the fifth prescription you failed to:

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


MPT: Dr MOHAMMED 38

i. any presenting symptoms; Found not proved

ii. the history of any presenting symptoms; Found proved

iii. the length of any itch; Found proved

iv. the presence of a rash; Found proved

v. Patient E’s liver; Found proved

vi. Patient E’s kidneys; Found proved

vii. whether Patient E had a history of:

1. cardiac problems; Found proved

2. dermatological issues and their treatment; Found proved




6. gastrointestinal problems; Found proved

viii. any other medication that Patient E was taking; Found not proved

b. adequately examine Patient E, in that you failed to examine:

i. for evidence of severe urticaria/pruritis; Found proved

ii. Patient E’s heart; Found proved

iii. for evidence of Patient E’s underlying pain; Found proved

c. state:

i. the correct dosage; Found proved in relation to Atarax Found not proved in relation to Dihydrocodeine


MPT: Dr MOHAMMED 39



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

i. to avoid:

1. any other medication containing codeine and paracetamol; Found proved

2. alcohol; Found proved

3. other sedating medication; Found proved






3. cardiac symptoms; Found proved

4. excessive drowsiness; Found proved

iv. in relation to the sedating properties of Atarax and the likelihood of increased sedation when taken with Dihydrocodeine; Found proved

e. refer Patient E for:

i. an ECG; Found proved

ii. blood tests; Found proved

iii. a dermatology opinion; Found proved

iv. musculoskeletal examination; Found proved


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f. inform Patient E’s GP of the prescription. Found proved

Determination on Impairment - 24/01/2020 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 as set out before, Dr Mohammed’s fitness to practise is impaired by reason of his alleged misconduct. The Evidence

2. The Tribunal has taken into account all the evidence received during the facts stage of the hearing, both oral and documentary. 3. The Tribunal has now received the statement from Dr Mohammed’s Responsible Officer, Dr D dated 21 November 2019. Submissions

4. On behalf of the GMC, Mr Warne submitted that the facts found proved by the Tribunal in relation to Dr Mohammed’s prescribing to five patients amounts to serious misconduct and that Dr Mohammed’s fitness to practise is currently impaired as a result. He submitted that it appears that Dr Mohammed took a cavalier attitude to prescribing in a dangerous fashion with the potential of serious consequences. He submitted that Dr Mohammed had prescribed in a dangerous fashion for a period of months and that he may have carried on doing so if the matter had not been raised with him by National Medicines & Healthcare products Regulatory Agency. He submitted that the medication Dr Mohammed was prescribing for these patients were all red flag drugs apart from Atarax and therefore his negligence in prescribing was at the top end of the scale. Mr Warne submitted that the medication Dr Mohammed was prescribing for these patients were desirable drugs which could easily be abused and could lead to dependence or overdose. He submitted that on the facts found proved in this case fellow practitioners would consider Dr Mohammed’s actions to be deplorable. 5. Mr Warne drew the Tribunal’s attention to the caselaw including; Grant [2011] EWHC 927 (Admin) and Cohen (2008) EWHC 581. 6. The misconduct, he submitted, had the ability to undermine public confidence in the profession. He submitted that the findings of fact indicated that Dr Mohammed’s conduct fell below the standard to be expected of a registered medical practitioner. Mr Warne submitted that Dr Mohammed’s fitness to practise is currently impaired.


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The Relevant Legal Principles

7. The Tribunal reminded itself that at this stage of proceedings, there is no burden or standard of proof and the decision on impairment is a matter for the Tribunal’s judgment alone. 8. In approaching the decision, the Tribunal was mindful that consideration of impairment arising out of misconduct involves a two-stage process; first, to consider whether or not the findings of fact, or any of them, amount to serious misconduct on the part of the doctor and then, if so, secondly, to consider whether or not the doctor’s fitness to practise is currently impaired by reason of that serious misconduct. These are two distinct questions. 9. The Tribunal reminded itself that misconduct can involve an act or acts which fall short of the rules and standards ordinarily required to be followed, in this case as set out in GMP (2013), GMC’s Document Good practice in prescribing and managing medicines and devices (2013) and National Institute for Health and Care Excellence (NICE) (NG46) Guidelines on Controlled drugs: safe use and management published 12 April 2016. 10. The Tribunal’s task is to determine whether Dr Mohammed’s fitness to practise is impaired today looking forward to the future. It must take into account Dr Mohammed’s actions in his prescribing of controlled medication to patients without:

• Undertaking an adequate medical history, • Carrying out a physical examination, • Prescribing correct dosages, • Providing adequate safeguarding advice,

The Tribunal also took account of evidence provided regarding insight and remediation. Any likelihood of repetition is relevant. 11. The Tribunal has been mindful 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. 12. The Tribunal also took account of the criteria for impairment identified by Dame Janet Smith in the 5th Shipman report:


MPT: Dr MOHAMMED 42

“Do our findings of fact … 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 d. has in the past acted dishonestly and/or is liable to act dishonestly in the

future.”

The Tribunal’s Determination on Impairment

Misconduct 13. The Tribunal first considered whether the facts found proved in Dr Mohammed’s case amounted to misconduct.

14. The Tribunal had regard to the decision of Jackson J in Calhaem v GMC [2007] EWHC 2606 (Admin), and his exposition of the term ‘misconduct’ in the context of section 35C (2) of the Medical Act 1983, as set out in paragraph 39 of the judgment. Jackson J said this:

“(1) Mere negligence does not constitute "misconduct" within the meaning of section 35C(2)(a) of the Medical Act 1983. Nevertheless, and depending upon the circumstances, negligent acts or omissions which are particularly serious may amount to "misconduct".

(2) A single negligent act or omission is less likely to cross the threshold of "misconduct" than multiple acts or omissions. Nevertheless, and depending upon the circumstances, a single negligent act or omission, if particularly grave, could be characterised as "misconduct".”

15. The Tribunal determined that Dr Mohammed has breached the following paragraphs of GMP (2013 edition) in relation to Patients A-E which state:

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 needs9 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


MPT: Dr MOHAMMED 43

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…

18 You must make good use of the resources available to you.

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 Clinical records should include:

a. relevant clinical findings b. the decisions made and actions agreed, and who is making the

decisions and agreeing the actions c. the information given to patients.

16. The Tribunal determined that Dr Mohammed has breached the following paragraphs of the GMC’s Document “Good practice in prescribing and managing medicines and devices” in relation to Patients A-E:

20. In Consent: patients and doctors making decisions together, we say:

• 3 For a relationship between doctor and patient to be effective, it should be a partnership based on openness, trust and good communication. Each person has a role to play in making decisions about treatment or care.

21. Together with the patient, you should make an assessment of their condition before deciding to prescribe a medicine. You must have or take an adequate history, including:

a any previous adverse reactions to medicines…

22. You should encourage your patients to be open with you about their use of alternative remedies, illegal substances and medicines obtained online, as well as whether in the past they have taken prescribed medicines as directed.


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23. You should identify the likely cause of the patient’s condition and which treatments are likely to be of overall benefit to them. 24. You should reach agreement with the patient on the treatment proposed, explaining:

a the likely benefits, risks and burdens, including serious and common side effects; b what to do in the event of a side effect or recurrence of the condition; c how and when to take the medicine and how to adjust the dose if necessary, or how to use a medical device d the likely duration of treatment e arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine, and for issuing repeat prescriptions.

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. You should check that the patient has understood the information, and encourage them to ask questions to clarify any concerns or uncertainty. You should consider the benefits of written information, information in other languages and other aids for patients with disabilities to help them understand and consider information at their own speed and to retain the information you give them.

30 You must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. This means you must share all relevant information with colleagues involved in your patient’s care within and outside the team, including when you hand over care as you go off duty, when you delegate care or refer patients to other health or social care providers. This should include all relevant information about their current and recent use of other medicines, other conditions, allergies and previous adverse reactions to medicines. 33 If a patient has not been referred to you by their general practitioner, you should also:

a consider whether the information you have is sufficient and reliable enough to enable you to prescribe safely; for example, whether:

i you have access to their medical records or other reliable information about the patient’s health and other treatments they are receiving


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ii you can verify other important information by examination or testing

b ask for the patient’s consent to contact their general practitioner if you need more information or confirmation of the information you have before prescribing. If the patient objects, you should explain that you cannot prescribe for them and what their options are.

60 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 dialogue and obtain the patient’s consent in accordance with the guidance at paragraphs 20–29. 61 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.

60 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 dialogue and obtain the patient’s consent in accordance with the guidance at paragraphs 20–29. 64 If the patient has not been referred to you by their general practitioner, you do not have access to their medical records, and you have not previously provided them with face-to-face care, you must also:

… b explain how the remote consultation will work and what to do if they have any concerns or questions c follow the advice in paragraphs 30–34 on Sharing information with colleagues.

17. The Tribunal has determined that Dr Mohammed failed to adhere to the following NICE Guidelines:

• CG113 Generalised Anxiety Disorders and Panic Disorders in Adults: Management (Patients C and D);

• CG115 Alcohol Use Disorders: Diagnosis,


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Assessment and Management of Harmful Drinking and Alcohol Dependence (Patients A, B, C, D, E);

• NG46 Controlled (Patients A, B, C, D, E).

Misconduct in relation to Patients A, B, C, D, E 18. The Tribunal considered whether Dr Mohammed’s actions prescribing the medications he did to Patients A, B, C, D and E without adhering to the various guidelines referred to above and GMP amounted to misconduct. The Tribunal has determined that all five patients were prescribed drugs of abuse and notwithstanding this in respect of all five patients Dr Mohammed failed:

• To take an adequate patient history, • To provide adequate safeguarding advice, • To prescribe correct maximum dosage; • To refer patient where required; • To inform the patients’ GP of the prescription.

19. The Tribunal has also found proved that in respect of Patients B, C, D and E, Dr Mohammed did not prescribe the correct dosage of medication. The Tribunal has also found proved that in respect in relation to Patients B, C and D, Dr Mohammed did not undertake a proper examination of the patient in relation to their mental health. The Tribunal accepted the evidence of the GMC Expert that having regard to the medicines that they requested Dr Mohammed should have undertaken a proper examination of the patient in relation to mental health. In relation to Patients A and E, Dr Mohammed did not undertake a physical examination of the patient. The Tribunal accepted the evidence of the GMC Expert that having regard to the medicines that they requested Dr Mohammed should have undertaken a physical examination of the patient. The Tribunal was in no doubt that Dr Mohammed’s actions in this regard fell short of the standards of conduct that the public and patients are entitled to expect from all registered medical practitioners. The Tribunal found that Dr Mohammed’s actions were serious and that that he knew or ought to have known that he should not have prescribed such medication for these five patients. 20. The Tribunal determined that by prescribing in the manner which he had Dr Mohammed’s actions fell short of the relevant standards required by guidance in GMP (2013), NICE and Good practice in prescribing and managing medicines and devices set out above. His conduct would be regarded as deplorable by other practitioners and amounts to serious misconduct.


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Impairment 21. The Tribunal went on to consider whether Dr Mohammed’s fitness to practise is currently impaired as a result of his misconduct. It has borne in mind that impairment does not necessarily follow on from a finding of misconduct and that a Tribunal should consider the issues of insight, remediation and the risk of repetition, in determining whether past misconduct should lead to a finding of current impairment of fitness to practise. Whilst the Tribunal has considered the submissions made, the matter of impairment is one for it to determine, exercising its own judgement. In so doing, the Tribunal has taken account of the following paragraphs of relevant case law: 22. Paragraph 62 of Silber J’s judgment in the case of Cohen in which he stated:

“Any approach to the issue of whether a doctor’s fitness to practise should be regarded as ‘impaired’ must take account of ‘the need to protect the individual patient, and the collective need to maintain confidence in the profession as well as declaring and upholding proper standards of conduct and behaviour.”

23. Paragraph 21 of Cheatle v GMC [2009] EWHC 645 (Admin), where Cranston J stated:

“There is clear authority that in determining impairment of fitness to practise at the time of the hearing regard must be had to the way the person has acted or failed to act in the past. As Sir Anthony Clarke MR put it in Meadow v General Medical Council [2006] EWCA Civ 1390; [2007] 1 QB 462:

“In short, the purpose of [fitness to practise] proceedings is not to punish the practitioner for past misdoings but to protect the public against the acts and omissions of those who are not fit to practise. The FPP [Fitness to Practise Panel] thus looks forward not back. However, in order to form a view as to the fitness of a person to practise today, it is evident that it will have to take account of the way in which the person concerned has acted or failed to act in the past” (para 32).”

24. The Tribunal adopted the test contained at paragraph 65 of Silber J’s judgement in Cohen. This can be summarised as follows: 25. Is the misconduct remediable, has it been remedied and how likely is it to recur. In relation to the last issue, the Tribunal must be satisfied it is highly unlikely to recur in order to justify a finding that a doctor’s fitness to practice was not impaired. It considered firstly whether or not the misconduct here is remediable. The Tribunal considered that this misconduct is remediable.


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26. The Tribunal then considered whether or not it has been remedied. There is some evidence of remediation. This is contained with Dr Mohammed’s Rule 7 response. For instance, he indicates that he has reviewed GMP and the Guidance in Good practice in prescribing and managing medicines and devices. However, having regard to the level of failures in regard to Dr Mohammed’s prescribing, the Tribunal considered that the remediation evidence in Dr Mohammed’s response was insufficient to enable the Tribunal to say the misconduct had been remedied. The Tribunal would at the very least expect a detailed plan of action from Dr Mohammed explaining how he proposed to remedy his misconduct and additional evidence then that that plan had been adhered to. 27. The Tribunal also considered that contained within the Rule 7 response was some evidence of insight on the part of Dr Mohammed in respect of his failures. He states for instance that “the whole activity falls below the acceptable standard at several levels”. The Tribunal considered however that it had not been provided with sufficient detailed evidence of insight by Dr Mohammed as to the potential impact of his actions on patients. The Tribunal could not say therefore say that Dr Mohammed’s failures were highly unlikely to recur, therefore a risk to the public remains. 28. The Tribunal also considered whether or not the need to uphold professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances of the case. The Tribunal considered that given the level of failures in this case and the serious consequences that could arise from those failures, the need to uphold professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances of this case. 29. For all of the reasons set out above the Tribunal has determined that Dr Mohammed’s fitness to practise is currently impaired by reason of his misconduct. Determination on Sanction - 27/01/2020 1. Having determined that Dr Mohammed’s fitness to practise is impaired by reason of his misconduct, the Tribunal has now considered what action, if any, it should take with regard to his registration. Submissions 2. On behalf of the GMC, Mr Warne submitted that the appropriate and proportionate sanction to impose was one of conditions. He drew the Tribunal’s attention to the mitigating and aggravating factors in this case. He referred the Tribunal to the relevant paragraphs of the Sanctions Guidance (SG) (November 2019).


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3. Mr Warne submitted that to take no action was not appropriate in this case as there are no exceptional circumstances. He noted that no undertakings had been offered by Dr Mohammed. In relation to the imposition of conditions he noted that Dr Mohammed has been subject to Interim Order Conditions for a period of time, has been working whilst the matter was being investigated and no issues have been raised. 4. Mr Warne noted that in his response to the Rule 7 letter Dr Mohammed had provided expressions of regret and there was a degree of remediation. He noted that the serious issues raised in this case were in relation to a single element of Dr Mohammed’s practice only. He submitted that remediation was likely and that conditions could be properly formulated. 5. He submitted that the imposition of an order of conditions would be sufficient to protect the public and address the public interest concerns that the Tribunal had identified. The Tribunal’s Determination on Sanction

6. The Tribunal reminded itself that again at this stage of proceedings, there is no burden or standard of proof and the decision on sanction is a matter for the Tribunal’s judgment alone. 7. In reaching its decision, the Tribunal has given careful consideration to SG generally. It has borne in mind that the main reason for imposing sanctions is to protect the public pursuant to the overarching objective set out in section 1 of the Medical Act 1983 (as amended), already rehearsed in the determination on impairment. Sanctions are not imposed to punish or discipline doctors, but they may have a punitive effect. 8. The Tribunal has borne in mind that in deciding what sanction, if any, to impose, it should consider the sanctions available, starting with the least restrictive. In making its decision, the Tribunal also had regard to the principle of proportionality, and it weighed Dr Mohammed’s interests with those of the public. 9. The Tribunal has given particular consideration to paragraph 17 of SG, which states:

“Patients must be able to trust doctors with their lives and health, so doctors must make sure that their conduct justifies their patients’ trust in them and the public’s trust in the profession (see paragraph 65 of Good medical practice). Although the tribunal should make sure the sanction it imposes is appropriate and proportionate, the reputation of the profession as a whole is more important than the interest of any individual doctor.”


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Aggravating and Mitigating Factors

10. The Tribunal first considered the aggravating factors in this case:

• Dr Mohammed has not engaged in a meaningful way in these regulatory proceedings;

• Multiple breaches of GMP (2013), GMC’s Document Good practice in prescribing and managing medicines and devices (2013) and National Institute for Health and Care Excellence (NICE) (NG46) Guidelines on Controlled drugs: safe use and management published 12 April 2016;

• The Tribunal determined that Dr Mohammed’s actions in relation to prescribing such medication would be considered deplorable by fellow practitioners;

• The Tribunal determined that Dr Mohammed has only provided very limited evidence of reflection or remediation;

• Dr Mohammed has failed to take appropriate steps to develop full insight.

11. The Tribunal carefully balanced the aggravating factors with the following mitigating factors:

• Lapse of time since the prescribing incidents occurred; • Dr Mohammed has abided by the IOT Conditions were which imposed in the

intervening period; • No previous Fitness to Practise history; • Contained within Dr Mohammed’s Rule 7 response was some evidence of

insight and remediation. The insight and remediation was limited but nevertheless the presence of some evidence in this regard was helpful to Dr Mohammed.

• The GMC Expert stated that it now appears Dr Mohammed is aware of his obligations in relation to the guidance in relation to prescribing;

• Dr Mohammed has stopped prescribing remotely; • No concerns expressed by his Responsible Officer, Dr D.

No action

12. In coming to its decision as to the appropriate sanction, if any, to impose in Dr Mohammed’s case, the Tribunal first considered whether to take no action. The Tribunal considered, amongst others, paragraphs 68-70 of SG which highlights that taking no action following a finding of impaired fitness to practise would only be appropriate in exceptional circumstances.


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13. The Tribunal has determined that there are no such exceptional circumstances in this case. It therefore has determined that taking no action would be neither appropriate, proportionate nor in the public interest. Conditions 14. The Tribunal next considered whether it would be appropriate to impose conditions on Dr Mohammed’s registration. It bore in mind that any conditions imposed should be appropriate, proportionate, workable and measurable. 15. In its deliberations, the Tribunal had regard to the following paragraphs of the SG:

“81) Conditions might be most appropriate in cases:

a) … b) involving issues around the doctor’s performance c) where there is evidence of shortcomings in a specific area or areas of the doctor’s practice…

82) Conditions are likely to be workable where:

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.”

16. The Tribunal considered the above paragraphs of the SG to apply in this case and bore in mind that Dr Mohammed has complied with his interim orders of conditions which have been imposed on his registration. It therefore follows that such an order would be workable and that Dr Mohammed is likely to comply with it. Suspension 17. The Tribunal did consider the next most restrictive sanction namely whether imposing a period of suspension on Dr Mohammed’s registration would be appropriate and proportionate.


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18. The Tribunal has had regard to the serious breaches of GMP. As a result of those serious breaches the Tribunal considered that it was certainly arguable that suspension was appropriate. It was, in the Tribunal’s view, a very finely balanced decision as to whether or not conditions, as opposed to suspension, were appropriate. However, having regard to:

a. The aggravating and mitigating factors outlined above; b. The Tribunal’s view that the concerns about the doctor’s practice in relation to

prescribing would best be dealt with in a setting where he was still practising; c. The overarching objective;

The Tribunal concluded that suspension would not be an appropriate or proportionate sanction. 19. The Tribunal was therefore of the view that a sanction of conditions would protect the public (by restricting Dr Mohammed’s practice), promote and maintain public confidence in the medical profession (by ensuring that his remediation continues and also by ensuring that the skills of an experienced doctor are retained) and promote and maintain proper professional standards and conduct for members of the profession (by reminding them of the need to act in accordance with GMP). 20. In all the circumstances, the Tribunal determined that a period of conditional registration was the necessary and proportionate sanction to impose in this case. 21. The Tribunal considered the appropriate length of time that conditions should be imposed. It has determined that a period of 12 months would be appropriate as this would give Dr Mohammed enough time to accrue sufficient evidence, both that he now had adequate insight into these matters and that he had remediated his actions. 22. The conditions are not confidential and will be published:

1. He 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 his current post, including:

i his job title

ii his job location

iii his responsible officer (or their nominated deputy).

b the contact details of his employer and any contracting body, including his direct line manager.


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c any organisation where he has practising privileges and/or admitting rights. d any training programmes he is in. e of the contact details of any locum agency or out of hours service he is registered with.

2. He must personally ensure the GMC is notified:

a of any post he accepts, before starting it. b that all relevant people have been notified of his conditions, in accordance with condition 10. c if any formal disciplinary proceedings against him are started by his employer and/or contracting body, within seven calendar days of being formally notified of such proceedings. d if any of his posts, practising privileges, or admitting rights have been suspended or terminated by his employer before the agreed date within seven calendar days of being notified of the termination. e if he applies for a post outside the UK.

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

(or their nominated deputy).

b He must not work until:

i his responsible officer (or their nominated deputy) has appointed his workplace reporter. ii he has personally ensured that the GMC has been notified of the name and contact details of his workplace reporter.

5. a He must design a Personal Development Plan (PDP), with specific aims

to address the deficiencies in the following areas of his practice:

• Prescribing in general; • Knowledge in relation to drugs of abuse;


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b His PDP must be approved by his responsible officer (or their nominated deputy). c He must give the GMC a copy of his approved PDP within three months of these substantive conditions becoming effective. d He must give the GMC a copy of his approved PDP on request. e He must meet with his responsible officer (or their nominated deputy), as required, to discuss his achievements against the aims of his PDP.

6. He must not prescribe, administer or have primary responsibility for drugs listed in schedules 1–4 of the Misuse of Drugs Regulations 2001. 7. He must not prescribe, administer or have primary responsibility for Opioids and benzodiazepines for the treatment of addiction.

8. He must not prescribe any drugs for himself, or anyone with whom he has a close personal relationship. 9. He must get the approval of the GMC before working in a non-NHS post or setting. 10. He must personally ensure the following persons are notified of the conditions listed at 1 to 9:

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

i his place(s) of work, and any prospective place of work (at the time of application). ii all of his contracting bodies and any prospective contracting body (prior to entering a contract). iii any organisation where he 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 he is registered with. v if any of the organisations listed at (i to iv) does not have a responsible officer, he must notify the person with responsibility for overall clinical governance within that organisation. If he is unable to


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identify that person, he must contact the GMC for advice before working for that organisation.

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

23. Shortly before the end of the period of conditional registration, Dr Mohammed’s case will be reviewed by a Medical Practitioners Tribunal. A letter will be sent to him about the arrangements for the review hearing. At the next hearing, the review Tribunal will be assisted by the following:

• Evidence that he has complied with these conditions; • An audit of prescribing practices with particular reference to:

a. GMP (2013). b. GMC’s Document Good practice in prescribing and managing

medicines and devices (2013); c. National Institute for Health and Care Excellence (NICE) (NG46)

Guidelines on Controlled drugs: safe use and management published 12 April 2016;

which have been reviewed and verified by Appraiser or RO. • A reflective piece on the impact Dr Mohammed’s behaviour has had in relation

to the all three limbs of the overarching objective. This reflective piece should clearly illustrate insight into the prescribing practices which have resulted in these proceedings. Dr Mohammed stated in his Rule 7 response he “could see several potential risks” but these were not defined. That was clearly not evidence of sufficient reflection on his part. Further, although Dr Mohammed stated in his PDP dated 19 August 2017 that he “would write a detailed reflection” on the significant event in relation to his online prescribing, he did not submit this in evidence.

• Evidence of Dr Mohammed’s attendance at a course that addresses issues relating to drugs of abuse; this should address the issues that can arise as a result of legitimately prescribing drugs which can be abused.

• Any other relevant evidence he wishes to present to assist the Tribunal, for example, evidence of his continuing professional development.

Determination on Immediate Order - 27/01/2020 1. Having determined that an order of conditions is the appropriate sanction in this case, the Tribunal has considered, in accordance with Rule 17(2)(o) of the General Medical Council (Fitness to Practise) Rules Order of Council 2004, whether Dr Mohammed’s registration should be subject to an immediate order.


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Submissions

2. On behalf of the GMC, Mr Warne, Counsel, submitted that an immediate order of conditions is required. He submitted, based on the findings made by the Tribunal in relation to Dr Mohammed’s misconduct, that an immediate order of conditions is required in order to satisfy the public interest. He drew the Tribunal’s attention to paragraphs 172- 178 of the Sanctions Guidance (November 2019) (‘the SG’). Mr Warne submitted that the public protection that is currently in place by means of the Interim Order of Conditions would not be afforded if an immediate order were not imposed. He submitted that it would not be appropriate for Dr Mohammed to be in unrestricted practice prior to the substantive order of conditions taking effect. The Tribunal’s Determination

3. The Tribunal had particular regard to paragraph 178 of SG, which states:

178 “Having considered the matter, the decision whether to impose an immediate order will be at the discretion of the tribunal based on the facts of each case. The tribunal should consider the seriousness of the matter that led to the substantive direction being made and whether it is appropriate for the doctor to continue in unrestricted practice before the substantive order takes effect.”

4. The Tribunal had regard to the principle of proportionality and balanced Dr Mohammed’s interests with the public interest. In light of the seriousness of the Tribunal’s findings in relation to Dr Mohammed’s misconduct, the Tribunal has determined that an immediate order must be made forthwith in order to protect patients and to maintain public confidence in the medical profession. 5. The immediate order of conditions will remain in force until the substantive direction of conditions takes effect, or until the outcome of any appeal is decided. The substantive sanction of conditions as already announced will take effect 28 days from when written notice is deemed to have been served upon Dr Mohammed, unless an appeal is lodged in the interim. 6. The Interim Order currently imposed on Dr Mohammed’s registration is hereby revoked. 7. That concludes this case. Confirmed Date 27 January 2020 Mr Patrick Cox, Chair


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ANNEX A – 20/01/2020 Service and proceeding in the absence of the doctor 1. Dr Mohammed is neither present nor represented at these proceedings. The Tribunal has considered whether notice of this hearing has been properly served upon Dr Mohammed in accordance with Rules 15 and 40 of the General Medical Council (Fitness to Practise) Rules 2004 (as amended)(the Rules) and Schedule 4, Paragraph 8 of the Medical Act 1983 (as amended). In so doing, it has taken into account all the information placed before it, together with Mr Warne’s submissions on behalf of the General Medical Council (GMC). 2. The Tribunal has been provided with a service bundle containing a copy of the GMC Information Letter dated 12 December 2019, which was sent to Dr Mohammed’s registered address and registered email address by the GMC. The Tribunal has had regard to the DHL tracking documentation which indicates that the GMC Information letter was signed for by ‘Ahmed’ on 14 December 2019 at 10.59am. The service bundle also contained a copy of the Notice of Hearing (NoH) dated 19 December 2019, which was sent to Dr Mohammed’s registered address and registered email address by the MPTS. The Tribunal has had regard to the DHL tracking documentation which indicates that the Notice of Hearing letter was signed for by ‘Ahmed’ on 24 December 2019 at 10.55am. 3. Having considered all the information, the Tribunal was therefore satisfied that all reasonable efforts had been made to inform Dr Mohammed of these proceedings, and that notice of this hearing had been properly served upon him in accordance with the Rules. 4. The Tribunal went on to consider whether to proceed in Dr Mohammed’s absence. 5. In accordance with the principles in R v Jones [2002] UKHL 5 and GMC v Adeogba and GMC v Visvardis [2016] EWCA Civ 162 it bore in mind that although it has the discretion to proceed to consider the case in the doctor’s absence, that discretion should be exercised with the utmost care and caution having regard to all the circumstances of which it is aware, with fairness to the practitioner being a prime consideration, but also taking into account fairness to the GMC and the overall fairness of the proceedings. The Tribunal bore in mind that in making its decision it must balance Dr Mohammed’s interests against those of the GMC and the wider public interest. 6. In making its decision, the Tribunal bore in mind the need to protect the public. This is the Tribunal’s statutory overarching objective, which includes:


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• protecting, promoting and maintaining the health, safety and well-being of the public;

• promoting and maintaining public confidence in the medical profession; and

• promoting and maintaining proper professional standards and conduct for members of that profession.

7. Mr Warne submitted that it was fair to proceed in Dr Mohammed’s absence as:

• All reasonable efforts have been made to serve the NoH on Dr Mohammed and he is fully aware of these proceedings;

• Dr Mohammed has voluntarily absented himself; • Dr Mohammed has not asked for an adjournment or postponement; and • The matter in consideration is important and needs to be resolved in the

public interest.

8. The Tribunal has noted the contents of the telephone note dated 30 December 2019 between Mr E, GMC Legal and Dr Mohammed in which it states:

“…I asked if Dr Mohammed would be attending or represented at the hearing. He said that he doesn’t have any representation at the moment, and he is not sure if he will be able to attend (Dr Mohammed didn’t explain why). I asked if he had any insurance or options such as with an MDU. Dr Mohammed said that he had tried but wasn’t successful in getting anyone to represent him. I said that I understand there may be other options available to him and directed him to the MPTS website which has lots of information for doctors going through the hearing process. I explained that he did of course have the option of attending the hearing himself without representation, but that decision is ultimately up to him. I said that I would forward him any information I could find regarding representation at hearings and confirmed again that I would re-send a hard copy of the hearing bundle.

Dr Mohammed thanked me for the call.”

9. The Tribunal has noted the email dated 17 January 2020 at 13.36 from Dr Mohammed to Mr E in which he states:

“…Unfortunately I will not be able to attend due to XXX reasons XXX Please keep me updated…”


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10. The Tribunal has noted the response from Mr E dated 17 January 2020 at 13.54 in which he requests further information from Dr Mohammed relating to his XXX issues. 11. The Tribunal has noted that Dr Mohammed has not provided any information to the GMC or this Tribunal relating to his XXX issues as alluded to in his email dated 17 January 2020. 12. The Tribunal has borne in mind that Dr Mohammed has not made any application for an adjournment. Dr Mohammed has also made no request to attend the hearing via video-link or telephone. On the basis of the information provided the Tribunal is satisfied that Dr Mohammed has voluntarily waived his right to be present and represented at this hearing and that he is aware the hearing can proceed in his absence. The Tribunal further considers that were it to adjourn today, there is no indication that Dr Mohammed would attend a future hearing. The Tribunal has therefore determined that in accordance with Rule 31, it is appropriate to proceed with the hearing in Dr Mohammed’s absence. It considered that it was fair and in the public interest to hear this case without further delay and proceed with this hearing in the absence of Dr Mohammed. 13. The Tribunal did not draw any adverse inference from Dr Mohammed’s decision not to attend the hearing.

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