Background to the appeal
Dr David Dighton specialised in cardiology but also had a private practice as a General Practitioner (GP). He had no formal training as a GP. Patient A became one of his general practice patients in 2011 and he prescribed a large number of drugs to her for around six years. These included strong painkillers, sleeping tablets, antidepressants and tranquilisers. Over the same period the patient had also been prescribed several of the same drugs from her own GP. Dr Dighton had not notified Patient A’s GP that he was treating her as a private patient and prescribing drugs. In 2017, the patient was diagnosed with prescription drug dependency (amongst other things). Dr Dighton’s actions took place against a background of interventions by the GMC:
- in 2011 he was issued with a letter of advice from the GMC relating to his prescribing; and
- in 2016 he appeared before and received a warning from the Investigation Committee in a case relating to his prescribing of benzodiazepines.
The case brought against Dr Dighton by the GMC
The case that was brought by the GMC to the Medical Practitioners Tribunal (Tribunal) alleged that the doctor had:
- prescribed excessively a number of different drugs to Patient A;
- failed adequately to assess or appropriately refer her to mental health services;
- kept inadequate records;
- failed to inform her GP that he had issued the patient with prescriptions;
- lacked adequate expertise to treat her.
In reaching its conclusion on impairment the Tribunal expressed ‘grave concerns in relation to Dr Dighton’s poor practice over a six-year period despite an advice letter in 2011 and a warning in 2016.’ It described ‘his lack of insight as “intractable” such that “he is unlikely to remediate and there is a material risk of repetition.” The combination of lack of insight, unfocused training, lack of any apology and lack of reflective practice meant that the risk of repetition could not be regarded as low.’
Before the Tribunal made the decision on the appropriate sanction, the doctor gave evidence. He stated he had stopped working as a GP following a discussion with an adviser from the CQC who had impressed on him that GP work was a speciality; he referred to his clinical experience from the 1970s of prescribed drugs and that he had been deceived by the patient who he described as ‘clever and manipulative’. By prescribing drugs in a manner that was different to established practice, he was ‘trying to make an academic point.’ He had not apologised to the patient, saying that she was happy with her treatment. He rejected the suggestion that he posed a risk to patients in the future: he had removed ‘all contentious issues.’ The Tribunal’s decision was to suspend Dr Dighton for 12 months with review.
Why did we appeal?
We decided to appeal this decision on the basis that the suspension order was insufficient to protect the public and that the registrant ought to have been struck off. We argued that the Tribunal’s approach to deciding the sanction was irrational and wrong; the Tribunal had failed to take sufficient regard of the relevant guidance on sanctions and finally that the Tribunal took an irrational approach to the registrant’s insight into his misconduct.
A few weeks after we lodged our appeal, the doctor applied for and was granted voluntary erasure* from the GMC register. A few days later the GMC notified the parties that this decision would be stayed pending the outcome of our appeal.
At the hearing, we argued that a suspension order and a voluntary erasure order would be insufficient for the protection of the public. This was a particularly serious case where the correct outcome was erasure and any other outcome would undermine the importance of upholding confidence in the medical profession and the importance of maintaining standards.
Our submissions on seriousness referred to the actions of the doctor in prescribing addictive medicines to a vulnerable patient whom he considered to demonstrate addictive behaviour. The doctor (who did not attend the appeal hearing) repeated his submissions that this appeal and the hearing were unnecessary given the decision of the GMC to grant his application for voluntary erasure.
The Court allowed the appeal, quashed the suspension order and substituted its own order for erasure. The judgment includes mention of:
- The fact that the Authority’s appeal was properly brought before the Court and that our appeal right could be frustrated if a registrant was able to avoid the scrutiny of an appeal by opting for voluntary erasure.
- A reminder to panels that they are bound to apply the sanctions guidance properly and they are under a duty to reach a decision on sanction in a way that would protect the public.
- In relation to assessments of insight and the prospect of developing insight, the Court pointed to the fact that the Tribunal had found the registrant had no insight into his misconduct, blamed his patient, and had not apologised: therefore the MPT’s decision to suspend (and in effect give the doctor another chance to develop insight) was unreasonable and inconsistent with the evidence before it. In a previous NMC appeal brought by the PSA the Court had referred to this as ‘an exercise in wishful thinking that the panel had engaged in’.
- The Court also stated that statutory regulation of the medical profession is designed to prevent the sort of risks which the doctor had caused his patient and his ‘resistance to regulatory control’ was relevant to his lack of insight and means that he cannot be trusted to practise as a doctor again.
Find out more
You can find out more about our power to appeal final fitness to practise decisions on our Decisions about practitioners page. You can also find out more about how our power to appeal contributes to public protection in these case studies.
You can read the full Court judgment here.
*Voluntary erasure is a process whereby a doctor can choose to give up their registration. Where there are unresolved concerns about a doctor’s fitness to practise and a final hearing has not yet started, the GMC’s case examiners will consider the request. Where the case is being considered by a tribunal, then the registrar refers the application for determination by the tribunal. For more information please see the GMC website.
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Notes to the Editor
- The Professional Standards Authority for Health and Social Care oversees 10 statutory bodies that regulate health and social care professionals in the UK.
- We assess their performance and report to Parliament. We also conduct audits and investigations and can appeal fitness to practise cases to the courts if we consider that sanctions are insufficient to protect the public and it is in the public interest.
- We also set standards for organisations holding voluntary registers for health and social care occupations and accredit those that meet them.
- We share good practice and knowledge, conduct research and introduce new ideas to our sector. We monitor policy developments in the UK and internationally and provide advice on issues relating to professional standards in health and social care.
- We do this to promote the health, safety and wellbeing of users of health and social care services and the public. We are an independent body, accountable to the UK Parliament.
- Our values are – integrity, transparency, respect, fairness and teamwork – and we strive to ensure that they are at the core of our work.
- More information about our work and the approach we take is available at www.professionalstandards.org.uk