Fitness to PractiSe Panel of the
medical practitioners tribunal service
18 march - 3 April 2013
7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ
Name of Respondent Doctor: Dr Nikolaos PAPANIKOLAOU
Registered Qualifications:Ptychio Iatrikes 2000 Aristotelian University of Thessaloniki
Area of Registered Address:Greece
Reference Number: 6058166
Type of Case: New case of impairment by reason of: misconduct
Panel Members:Dr B Crompton, Chairman (Medical)
Mrs L Reid (Lay)
Prof R Mansel (Medical)
Legal Assessor: Mr N Parry
Secretary to the Panel:Mrs K Millea
Representation:
GMC: Ms A Felix, Counsel, instructed by GMC Legal
Doctor:Not present but represented on 18-19 March 2013 by MrMLambis, Counsel, instructed by RadcliffesLeBrasseur Solicitors.
allegation
“That being registered under the Medical Act 1983, as amended:
1.Between February 2008 and February 2009, you were employed as a Specialist Registrar in Obstetrics and Gynaecology by Basildon and Thurrock General Hospitals NHS trust; Found proved
Patient A
2.On 21 March 2008, you reviewed Patient A at
a.11.00am, Found proved
b.6.25pm; Found proved
3.You failed to
a.deliver Patient A at the 6.25pm following a prolonged bradycardia which lasted for 3 minutes, Found proved
b.repeat the fetal blood sampling taken at 6.25pm without delay, Found proved
c.deliver Patient A immediately by caesarean section at 7.30pm; Found proved
Patient B
4.On 13 May 2008 you carried out a forceps delivery of Patient B; Found proved
5.You failed to ensure that there were no retained swabs by
a.performing a vaginal examination,Not found proved
b.counting the swabs before and post delivery; Not found proved
6.Your record keeping was not adequate in that you failed to record
a.the date and time of the procedure,Not found proved
b.the name of the Obstetrician,Not found proved
c.a vaginal examination at the end of the procedure,Not found proved
d.a swab count; Not found proved
Patient C
7.On 17 May 2008, you reviewed Patient C at 9.10am; Found proved
8.You failed to
a.adequately assess Patient C, Found proved
b.carry out an immediate caesarean section; Found proved
9.You inappropriately carried out fetal blood sampling;Found proved
10.You did not adequately document your actions in that the entries made were
a.late, Not found proved
b.inaccurate;Not found proved
Patient D
11.On 17 May 2008 you
a. reviewed Patient D, a high risk patient, at 11.17am,Found proved
b.carried out a vaginal examination at 12.20pm;Found proved
12.You failed to
a.document your findings in the case records,Found proved
b.inform and discuss the management of Patient D with the consultant;Found proved
13.You inappropriately proceeded with a kiwi cup instrument delivery;Found proved
14.You failed to
a.abandon the kiwi cup instrument delivery after the third attempt,Found proved
b.proceed with a caesarean section;Not found proved
Patient E
15.On 4 June 2008 you delivered Patient E following which you sutured
Patient E’s episiotomy;Found proved
16.You failed to ensure that there were no retained swabs by
a.performing a vaginal examination,Found proved
b.counting the swabs before and post delivery;Found proved
17.Failed to record the incident in the notes;Found proved
Patient F
18.On 28 July 2008 you reviewed Patient F at 4.10am;Found proved
19.You inappropriately changed the management plan from a caesarean section to a vaginal delivery;Found proved
20.You failed to
a.discuss the change in management plan with the Consultant,Found proved
b.record at 06.00am your
i. interpretation of the CTG,Found proved
ii. decision to continue with the trial of a vaginal birth;Found proved
Patient G
21.On 25 September 2008, you
a.held a consultation with patient G (the consultation) Admitted and found proved
b.performed a surgical operation on patient G including excision of vulval cysts, hysteroscopy and endometrial biopsy (the operation) Admitted and found proved
22.During and subsequent to the consultation, you failed to
a.adequately assess Patient G, Admitted and found proved
b.undertake the consent process adequately, Admitted and found proved
c.appropriately assess the uterus; Admitted and found proved
23.In the operation you
a.perforated Patient G’s uterus, Admitted and found proved
b.departed from standard operation techniques in that you failed to pre-dilate the cervix prior to introducing the hysteroscope, Admitted and found proved
c.Failed to
i.promptly recognise that you had perforated the uterus, Admitted and found proved
ii.insert a hysteroscope to confirm or deny the presence of perforation, Admitted and found proved
iii.promptly stop the procedure and ask for help; Admitted and found proved
24.You did not adequately document
a.your clinical findings during the consultation, Admitted and found proved
b.the change of management of Patient G, Admitted and found proved
c.your discussions with the consultant gynaecologist and anaesthetist, Admitted and found proved
d.the consent process in relation to the operation, Admitted and found proved
e.your findings from the vaginal examination, Admitted and found proved
f.the steps you undertook when performing the operation, Admitted and found proved
g.difficulties you experienced during the operation; Admitted and found proved
Patient H
25.Between March 2010 and May 2011, you were employed as a Specialist registrar in Obstetrics and Gynaecology by Basingstoke and North Hampshire Hospital NHS Trust; Admitted and found proved
26.On 9 January 2011, you reviewed Patient H at
a.5.40am, Admitted and found proved
b.6.30am; Admitted and found proved
27.During both reviews you failed to
a.adequately assess Patient H, Admitted and found proved
b.adequately monitor the fetal scalp PH of Baby A; Admitted and found proved
28.During or following consultation with Patient H on 9 January 2011, you
a.Failed to
i. seek the assistance of a senior medical colleague, Admitted and found proved
ii. categorise Patient H’ caesarean section category 1; Admitted and found proved
b.Did not adequately document
i. the abnormality in the fetal heart rate trace, Admitted and found proved
ii. the delay in cervical dilation; Admitted and found proved
And that by reason of the matters set out above your fitness to practise is impaired because of your misconductFound proved”.
Determination on proceeding in absence
MsFelix:
At the outset of these proceedings DrPapanikolaou was not present but was represented by MrLambis, Counsel, instructed by RadcliffesLeBrasseur Solicitors. The defence made an application to adjourn proceedings, which the Panel rejected. The case was then opened and paragraphs 21 to 28 of the allegation were admitted on DrPapanikolaou’s behalf. The Panel announces these as admitted and found proved.
The defence then withdrew from the proceedings. MrLambis informed the Panel that this was the result of instructions in part from DrPapanikolaou, and the instructing solicitors and medical defence organisation.
You have applied to proceed with the hearing in the absence of the defence, pursuant to rule 31 of the General Medical Council (GMC) (Fitness to Practise) Rules Order of Council 2004. You referred the Panel to the case of R v Jones [2002] UKHL 5. You submitted that DrPapanikolaou has chosen to be absent from this hearing and has been jointly responsible for instructing his legal representatives to withdraw. You submitted that, in the circumstances, the Panel should proceed.
In reaching its decision the Panel has accepted the advice of the Legal Assessor, that it has the discretion to continue the hearing if it sees fit to do so and that it should look at the overall reality of the situation. The Panel has taken account of all of the circumstances of the case and has borne in mind the factors set out in R v Jones.
The Panel has already determined that the defence had sufficient time to prepare a case with regard to the particulars that they were informed about on 21December2012. It is satisfied that DrPapanikolou has deliberately and voluntarily absented himself, and now his representatives, from these proceedings. Although this may cause some disadvantage to his case, that is a matter for him. As stated in its determination on adjournment, the Panel considers it to be in the public interest to proceed with this hearing expeditiously.
In all the circumstances, the Panel has determined that it is in the public interest to proceed to hear the case in the absence of the doctor and his representatives, and that to do so does not cause injustice.The Panel will not draw any adverse inference from their absence and will ensure that the hearing proceeds fairly notwithstanding their non-attendance. The Panel will take reasonable steps during the evidence to test the GMC’s case and make such points on behalf of the doctor as the evidence permits.
Determination on facts
Ms Felix:
At the outset of these proceedings DrPapanikolaou was not present but was represented by MrLambis, Counsel, instructed by RadcliffesLeBrasseur Solicitors. The defence made an application to adjourn proceedings, which the Panel rejected. The case was then opened. Paragraphs 21 to 28 of the allegation were admitted on DrPapanikolaou’s behalf, and they were announced as admitted and found proved. The defence then withdrew from the proceedings and the Panel determined to proceed in the absence of the doctor and his representatives.
The Panel has considered each of the outstanding paragraphs of the allegation separately. In doing so, it has considered all of the documentary and oral evidence adduced, and your submissions on behalf of the General Medical Council (GMC).
The Panel has borne in mind that the burden of proof rests on the GMC throughout and that the standard is the civil standard of proof, namely the balance of probabilities.
The Panel has accepted the advice of the Legal Assessor. It has not drawn any adverse inference from the absence of the practitioner and has based its findings on the evidence, drawing inferences where appropriate without speculating on matters outside the evidence. The Legal Assessor also advised the Panel in relation to hearsay evidence and expert evidence.
The Panel has made the following findings of fact.
Paragraph 1 - Between February 2008 and February 2009, you were employed as a Specialist Registrar in Obstetrics and Gynaecology by Basildon and Thurrock General Hospitals NHS trust - has been found proved.
The details of DrPapanikolaou’s employment are not disputed and can be inferred from the documentation before the Panel.
Patient A
Paragraph 2 - On 21 March 2008, you reviewed Patient A at
a. 11.00am- has been found proved.
b. 6.25pm - has been found proved.
The reviews are recorded in Patient A’s medical records.
Paragraph 3 - You failed to
a. deliver Patient A at [the] 6.25pm following a prolonged bradycardia which lasted for 3 minutes - has been found proved.
The medical records show that DrPapanikolaou did not deliver PatientA at the 6:25pm review.
In his report dated 5December2012, the GMC expert witness MrI stated that deceleration or bradycardia of this type is an indication of acute compromise of the fetus. He stated that a decision to proceed with caesarean section would therefore have been indicated. He further stated that, in proceeding with fetal blood sampling, DrPapanikolaou did not consider urgent birth and that, in his opinion, DrPapanikolaou’s decision was inappropriate. Although in oral evidence MrI stated that not all obstetricians would agree, he went on to say that “99%” would agree.
In the circumstances, the Panel is satisfied that, by not delivering PatientA at the 6:25pm review, DrPapanikolaou did not do what he ought to have done.
b. repeat the fetal blood sampling taken at 6.25pm without delay - has been found proved.
Fetal blood sampling is noted in PatientA’s medical records, but no note is made of a repeat sampling later on.
In his report dated 5December2012, MrIconcluded that DrPapanikolaou failed to “either deliver the patient immediately by caesarean section at 19.30hrs or repeat the fetal blood sampling without further delay.” The Panel has been provided with NICE guidelines which indicate that fetal blood sampling should have been repeated after 30minutes.
In the circumstances, the Panel is satisfied that DrPapanikolaou ought to have repeated the fetal blood sampling but did not do so.
c. deliver Patient A immediately by caesarean section at 7.30pm - has been found proved.
In his report dated 5December2012, MrI stated that DrPapanikolaou was informed at 19:30hrs that the STAN (ST waveform analysis of fetal Electrocardiogram) machine was not recording appropriately and decided to repeat the fetal blood sampling after the siting of the epidural. In MrI’s opinion “this was an unnecessary delay which led to the fetal compromise. It was necessary to deliver the patient immediately at this stage by caesarean or at worse repeat the FBS at 19.30…”
The Panel is satisfied that DrPapanikolaou did not deliver Patient A immediately by caesarean section at 7.30pm, which was a course of action he ought to have taken.
Patient B
Paragraph 4 - On 13 May 2008 you carried out a forceps delivery of Patient B - has been found proved.
This is noted in an entry in PatientB’s medical records, which is signed by DrPapanikolaou.
Paragraph 5 - You failed to ensure that there were no retained swabs by
a. performing a vaginal examination - has not been found proved.
The medical records note that DrPapanikolaou was not present at the end of the procedure, because he had to leave to carry out an emergency caesarean section. The midwife continued the procedure by repairing the episiotomy. In these circumstances, the Panel does not consider that DrPapanikolaou should have performed a vaginal examination before he left.
b. counting the swabs before and post delivery - has not been found proved.
DrPapanikolaou could not have counted the swabs at the end of the procedure because he was not present, having been called to an emergency caesarean section.
Paragraph 6 - Your record keeping was not adequate in that you failed to record
a. the date and time of the procedure - has not been found proved.
The date and time of the procedure were already recorded in the “operation notes” section on the “summary of labour” form. The Panel does not consider that it would have been necessary to record them again, in the “procedure” section of the medical records.
b. the name of the Obstetrician - has not been found proved.
The Panel assumes that this subparagraph refers to whether or not DrPapanikolaou failed to record his name. The Panel considers that he identified himself by signing the record.
c. a vaginal examination at the end of the procedure - has not been found proved.
The Panel has already determined that DrPapanikolaou was not present at the end of the procedure and did not carry out a vaginal examination.
d. a swab count - has not been found proved.
The Panel has already determined that DrPapanikolaou was not present at the end of the procedure and did not perform a swab count.
Patient C
Paragraph 7 - On 17 May 2008, you reviewed Patient C at 9.10am - has been found proved.
DrPapanikolaou made a retrospective note of this review in PatientC’s medical records.
Paragraph 8 - You failed to
a. adequately assess Patient C - has been found proved.
In his report dated 5December2012, MrI concluded that DrPapanikolaou’s note in the medical records was incomplete and of a poor standard. For example, he did not document fully the CTG abnormality or the length of the bradycardia. MrI concluded that DrPapanikolaou’s poor record keeping was also a reflection of a poor standard of care.
The Panel accepts the expert evidence. It is satisfied that DrPapanikolaou’s record of assessment is inadequate and that, on the basis of this and the inappropriate course of action described at subparagraph 8(b), it can infer that DrPapanikolaou’s assessment of the patient was not adequate.
b. carry out an immediate caesarean section - has been found proved.
In his report dated 5December2012, MrI stated that DrPapanikolaou’s decision to perform fetal blood sampling rather than proceed with immediate caesarean section was extremely inappropriate in view of (1) deceleration of more than three minutes, which is an indication of acute fetal compromise and warrants urgent delivery of the baby; (2) the presence of meconium stained liquor, which was another indication of fetal hypoxia; and (3) indication that instrumental delivery would not have been appropriate in this case.
The Panel accepts the expert evidence and is satisfied that DrPapanikolaou should have carried out an immediate caesarean section.
Paragraph 9 - You inappropriately carried out fetal blood sampling - has been found proved.
In considering paragraph 8(b) it has been established that fetal blood sampling was not the appropriate course of action.
Paragraph 10 - You did not adequately document your actions in that the entries made were
a. late - has not been found proved.
The Panel does not consider that DrPapanikolaou’s entries were made unacceptably late. In view of the decisions and procedures taking place, the Panel is not critical of him completing the medical record at 10:50am, which was five minutes after he completed the caesarean section.
b. inaccurate - has not been found proved.
The Panel agrees with MrI that the entries were incomplete and of a poor standard. However, it considers that the information which was recorded was accurate.
Patient D
Paragraph 11 - On 17 May 2008 you
a. reviewed Patient D, a high risk patient, at 11.17am - has been found proved.
The medical records note that Patient D was seen by a registrar at 11.17am, and in an earlier entry the registrar was recorded as being in theatre. This accords with the medical records of another patient which indicate that DrPapanikolaou was in theatre at that time. The Panel therefore infers that it was DrPapanikolaou who reviewed PatientD at 11.17am.
b. carried out a vaginal examination at 12.20pm - has been found proved.
This is recorded in the medical records.
Paragraph 12 - You failed to
a. document your findings in the case records - has been found proved.
There is no note of DrPapanikolaou’s findings in respect of his review of PatientD at 11.17am or the vaginal examination at 12.20pm. MrI’s conclusion in his report dated 5December2012 is that this fell seriously below the standard expected. The Panel is satisfied that it was a failure.