2024-09-25

Case law applicable in GMC proceedings

case law, GMC, honesty, law, misconduct, probability, proof, remediation, standards

Estimated reading time at 200 wpm: 5 minutes

The General Medical Council (GMC) plays a pivotal role in upholding the standards of the medical profession in the United Kingdom. Its Fitness to Practise proceedings serve to ensure that medical practitioners adhere to the highest ethical and professional standards, thereby safeguarding patients and maintaining public confidence in the medical field. In these proceedings, case law serves as a cornerstone, providing a framework for interpreting and applying the relevant statute and regulations. The reliance on legal precedents ensures consistency and predictability in decision-making, fostering a sense of fairness and transparency in the regulatory process.

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Case law

Case references will be added an updated periodically

Case law

1. Burden and Standard of Proof:

Re B (Children) [2008] UKHL 35: Establishes that the standard of proof in GMC proceedings remains the balance of probabilities, even for serious allegations.
Abrahaem v GMC [2008] EWHC 183 (Admin): At a review hearing, the doctor bears a persuasive burden to demonstrate their fitness to practise has been restored.

2. Evidence and Inference:

Roomi v GMC [2009] EWHC 2188: A doctor is only obliged to answer specific allegations.
Virdee v GPhC 2015 EWHC 169: The more improbable an allegation, the stronger the evidence required.
Soni v GMC (2015) EWHC 364: where matters are inherently improbable, they may need more cogent evidence in order to be persuaded, para 61- “…the principle must nonetheless apply that before an inference could properly be drawn, the Panel had to be able safely to exclude, as less than probable, other possible explanations…”
Byrne v GMC [2021] EWHC 2237: Improbable events necessitate stronger evidence.
Khan v GMC [2021] EWHC 374: Tribunals can consider inconsistencies and denials in assessing credibility.
McLennan v GMC [2020] CSIH 12: Clear explanations are needed for improbable conclusions.
Radeke v General Dental Council [2015] EWHC 778 & Wiszniewski v Central Manchester HA [1998] EWCA 596: Discusses the possibility of drawing an adverse inference from a practitioner’s failure to provide evidence, even if they are unfit to attend a hearing.

3. Dishonesty:

Ivey v Genting Casinos 2017 UKSC 67: Defines the test for dishonesty, considering both subjective belief and objective standards.
Wingate Evans and Malins v SRA (2018) CA 1WLR 3969: ‘… Honesty is a basic moral quality which is expected of all members of society. It involves being truthful about important matters and respecting the property rights of others. Telling lies about things that matter or committing fraud or stealing are generally regarded as dishonest conduct. These observations are self-evident and they fit with the authorities cited above. The legal concept of dishonesty is grounded upon the shared values of our multi-cultural society. Because dishonesty is grounded upon basic shared values, there is no undue difficulty in identifying what is or is not dishonest.’

4. Misconduct and Impairment:

CHRE v NMC and Grant [2011] EWHC 927: Outlines a test to assess if actions bring the profession into disrepute or breach fundamental tenets.
Remedy UK v GMC [2010] EWHC 1245: Defines two types of misconduct: related to professional practice and morally culpable conduct.
Yeong v GMC [2009] EWHC 1923: A finding of impairment may be necessary to uphold professional standards.
GMC v Meadow [2006] EWCA Civ 1390: Provides guidance on classifying misconduct as ‘serious’ enough to impair fitness to practise.
Calhaem v GMC [2007] EWHC 2606: Emphasises considering misconduct within the context of the doctor’s entire practice.
Basson v General Medical Council [2018] EWHC 505 (Admin) (21 February 2018) sets out that sexual motivation means that the conduct was done either in pursuit of sexual gratification or in pursuit of a future sexual relationship.

5. Remediation:

Meadow v GMC [2006] EWCA Civ 1390: The tribunal must consider the doctor’s conduct at the time of the events and any relevant factors since then, such as remediation and likelihood of repetition, to determine current impairment.

6. Sanctions and Public Interest:

Chaudhury [2017] EWHC 2561: Stresses the importance of balancing the tripartite public interest
Raschid and Fatnani v GMC [2007] 1 WLR 1915: The primary concern is the reputation of the profession
Bramhall [2021] EWHC 2109: Sanctions Guidance should be considered but is not binding
PSA v GMC and Doree [2017] EWCA Civ 319: Insight and remorse can be found even without direct oral evidence
Kimmance v GMC [2016] EWHC 1808: Defines what is expected to demonstrate insight and remediation
Sawati v GMC [2022] EWHC 283: Upholds the right to deny an allegation
Al Nageim v GMC [2021] EWHC 877: Absence of evidence for mitigation is not automatically aggravating

Parameter	Semmelweis Reflex	Doublethink	Cognitive Dissonance	Groupthink
Proponent(s)	Ignaz Semmelweis (mid-19th century)	George Orwell (1949)	Leon Festinger (1957)	Irving Janis (1972)
Focus	Immediate rejection of proposals, ideas or new knowledge.	Internalised control and often maintained by external pressure.	Internal conflict	Group conformity
Source of Tension	Probably none unless the above return in which case cognitive dissonance may emerge.	Contradictory thoughts imposed from outside and often accepted.	Conflicting ideas within an individual or group minds	Pressure to maintain group harmony
Level of Tension	None – as nothing to consider immediately after rejection.	Suppressed, may manifest indirectly	High, consciously felt	Varies – can be high for dissenters, low for those conforming
Risk or advantage to individual or organisation	Stagnation, missed opportunities	Loss of critical thinking, vulnerability to manipulation	Potential for growth if dissonance is addressed constructively and not defensively – else risk worsens	Suppression of individuality; potential for harmful choice.
Risk to Society	Impedes progress, can harm others (e.g. ignoring medical advances)	Fuels authoritarianism, large-scale manipulation	Can lead to irrational behaviour	Leads to flawed decision-making, erosion of ethics
Mitigation	Critical evaluation of evidence, willingness to change course – if ideas return.	Resisting indoctrination, fostering independent thought	Self-awareness, open-mindedness, seeking diverse perspectives	Encouraging dissent, establishing processes for questioning assumptions
Resolution	Often requires a crisis or overwhelming evidence to break through resistance	Requires breaking free of external control which can be incredibly difficult	Changing beliefs/behaviour, finding new information or justifications to align with actions	Challenging group norms, breaking cohesiveness, can involve confrontation, ostracism, or the group dissolving

Stage	Cost/Price (£)	Tax/Duty (£)	Tax/Duty Type	Calculation	Calculation
1. Manufacturer’s Cost	2	0	N/A	This is a hypothetical cost of production.
2. Specific Duty Added	2	5.89	Specific Duty	£294.72 per 1000 cigarettes / 1000 * 20	Fixed amount per pack.
3. Manufacturer’s Profit	7.89	0	N/A	(Assumed to bring the total to £7.89)	This is a hypothetical profit margin.
4. Ad Valorem Duty Included	9	1.11	Ad Valorem Duty	16.5% of £9.00 (approx. retail price before VAT)	Included within the retail price, not added separately.
5. Retailer’s Profit	10.11	0	N/A	(Assumed to bring the total to £10.11)	This is a hypothetical profit margin.
6. Final Retail Price (excl VAT)	13	0	N/A	(Includes specific duty and ad valorem duty)	This is the price displayed on the shelf, excluding VAT.
7. VAT Added	13	2.6	Value Added Tax (VAT)	20% of £13.00	Applied at the point of sale.
Total	15.6	9.6	Approximately 61.5% of the final price (£15.60) is tax – due to the simplified conservative assumptions about manufacturer and retailer costs and profit margins.

Documentation Issue	Critique
Vague Descriptors	Terms like “distressed state,” “emptiness,” and “intense anger” lack specific behavioural anchors. The descriptions are mere observations without any real substance. How was the intensity of the anger manifested? What did the patient say? How did she appear? Was she grimacing? Without concrete examples, these descriptors are open to interpretation and do not provide a clear picture of the patient’s presentation.
Generalised Interventions	Phrases like “explored coping mechanisms” and “discussed strategies” are so general that they amount to padding. No one will know what specific coping mechanisms were explored. How did this worker actually attempt to help the patient? What exact strategies were discussed? How were these tailored to the patient’s individual needs and the nature of their emotional instability?
Lack of Measurable Outcomes	The record mentions the patient feeling “slightly calmer” but lacks objective measures to assess the effectiveness of the interventions. How was this improvement gauged? Is it just ‘your’ word for saying so? Many services will accept such records as ‘standard’ because of cultural norms.
Ambiguous Plan	The plan to “continue to work on developing skills” and “encourage the patient to practice techniques” is vague and lacks specific, measurable goals. What specific skills will be targeted? What techniques were discussed ‘between sessions’? How will progress be monitored? What constitutes “practice” in this context, and how will adherence be assessed?
Omission of Risk Assessment	Given the nature of EUPD and the potential for self-harm, the record should include a formal risk assessment. What specific risk factors were considered? How was the risk of self-harm evaluated and managed?
Limited Patient-Specific Insight	While the record mentions EUPD, it does not provide specific insights into how this diagnosis informs the interventions or the plan. How were the chosen strategies tailored to the patient’s unique challenges related to their personality disorder?

Cognitive Activity	Description
1. Information synthesis	Gathering and integrating diverse information; evaluating reliability and relevance of each piece
2. Evidence evaluation	Critically assessing quality and strength of available evidence; identifying gaps
3. Principle balancing	Weighing competing ethical principles; reconciling guidelines with case-specific considerations
4. Stakeholder consideration	Analysing individual patient needs/rights; considering regulatory and societal requirements
5. Consequence projection	Anticipating potential outcomes; assessing short-term and long-term consequences
6. Risk-benefit analysis	Systematically evaluating risks; weighing risks against potential benefits
7. Legal framework integration	Incorporating relevant legal standards; ensuring compliance with statutory obligations
8. Ethical reasoning	Applying ethical frameworks; resolving ethical dilemmas in forensic psychiatric practice
9. Interdisciplinary integration	Synthesising perspectives from various disciplines; reconciling conflicting viewpoints
10. Decision refinement	Iteratively reviewing and adjusting decisions; fine-tuning to address all relevant factors
11. Uncertainty management	Acknowledging areas of uncertainty; developing mitigation strategies
12. Prioritisation	Determining relative importance of factors; focusing on critical elements
13. Cognitive bias recognition	Identifying potential biases; implementing strategies to minimise their impact
14. Justification formulation	Developing clear, logical rationale; ensuring transparent and defensible reasoning
15. Contextual adaptation	Tailoring approach to specific case factors; recognising unique case influences

Case law applicable in GMC proceedings

Table of Contents

Case law

1. Burden and Standard of Proof:

2. Evidence and Inference:

3. Dishonesty:

4. Misconduct and Impairment:

5. Remediation:

6. Sanctions and Public Interest:

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