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[This edited version of the report has been prepared by Dr Robert N Moles]

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UK GMC Fitness to Practice Panel 25 January 2007

Determination on impaired fitness to practise Dr Al-Alousi Forensic Pathologist

“Dr Al-Alousi: At the start of these proceedings, Mr Hopkins QC, admitted on your behalf all of the allegations against you. The Panel has recorded that the allegations, having been admitted, were found proved.

Background

In considering whether your fitness to practise is impaired, the Panel has taken into account all of the documentary adduced and the oral evidence of Professor C, the expert witness called on behalf of the General Medical Council (GMC). It has borne in mind the submissions made by Mr Ainsworth on behalf of the GMC and those made by Mr Hopkins on your behalf. The allegations against you in essence revolve around the conclusions you reached in the reports you prepared for the Coroner in respect of Child A (dated 22 October 2003 and 12 March 2004) and Child B (dated 24 February 2004). The Panel has heard that the Police were treating the deaths of Child A and Child B as suspicious, given that they had both died suddenly and had previously been healthy. You had learned from the police that both children had taken cannabis shortly before their deaths. In its deliberations, the Panel has considered your actions in respect of each child separately.

Child A

At the material time you were working as a Senior Lecturer /Honorary Consultant in Forensic Pathology at The University of Leicester. You were also a Consultant Pathologist to the Home Office. On 30 July 2003 you carried out a post-mortem on the body of Child A. It has been accepted by both Counsel that you carried out a thorough examination of the body of Child A and that you recorded your findings appropriately. At this stage you were not able to diagnose the cause of Child A's death. On 4 September 2003 you took further specimen blocks. You have accepted that you did not take specimen blocks from the right ventricle. Professor C's evidence was that it would be best practice to have done so, but the Panel further notes that at that time there were no official guidelines available to pathologists on the checks required at a post-mortem.

You have also accepted that you did not consider a specialised examination of the electrical conducting system of the heart. The Panel has heard from Professor C that this type of test is very demanding, and is carried out in rare circumstances, and by a specialist cardiac pathologist. Through your Counsel, you have accepted that you should have considered cardio-vascular causes of death, if necessary, by seeking the opinion of a specialist cardiac pathologist, and that you did not do so. In your initial report to the Coroner dated 22 October 2003, you noted the deceased was believed to have smoked about two joints of cannabis within a few hours of his death. You commented on the fact that “apart from myocardial fibrosis, there was no natural disease which could have caused death or contributed to the cause of death.” In your report you concluded by stating that, “having excluded other conditions from the possible causation of death, in my opinion the cause of death should be issued as myocardial ischaemia and cannabis abuse.”

Professor C confirmed that there is some scientific evidence published that supports an association between cannabis use and cardiac ischaemia or infarction. Professor C made clear that this evidence was not sufficient to support a causative link, although it was reasonable to consider the possible role of cannabis use, given the history you had received from the police and the toxicology report. You did not explain the petechiae, although you referred to its presence. The Panel finds this to be a minor error. You have accepted that you did not appreciate the proper significance of the main pathological evidence. In addition you did not consider arrhythmogenic right ventricular cardiomyopathy (ARVC) as a cause of death. In your report, you referred to status lymphaticus. The Panel has heard that this is now a discredited medical finding. Although you dismiss it in your reports, the Panel considers that it was not necessary to mention it at all.

The Panel accepts Professor C's comments in his report that at this stage of proceedings, “The initial impression formed at the autopsy of this being a drugs-related death appears to have maintained and blinkered a more open-minded and critical review of the evidence as it became available.” (sic). The scientific paper from Forensic Science International 2001 by Bachs and Morland did not support your view that cannabis was a cause of death, and did not purport to do so. Professor C considered that your explanation and interpretation of your findings were “limited in its breadth and may indeed be, in significant parts, erroneous.” He was of the view that your conclusions “are not properly justified on the basis of the published paper” and that you should have “more critically assessed its relevance and scientific merit.” You have admitted that your conclusions were significantly flawed and inaccurate. In addition there was no toxicological evidence to show that the cannabis was the cause of death and you could not prove that cannabis had a role in Child A's death. You have accepted, and the Panel has therefore found proved, that your opinions were therefore speculative and that your actions in this regard were inappropriate and unprofessional.

You were asked to reconsider your report. Dr D and Dr E (both specialist cardiac pathologists) provided reports. The Panel notes that their conclusions differ. Dr D, in her report of 2 December 2003, commented on the left ventricular myocardium, noted symptoms/signs being consistent with arrhythmogenic right ventricular cardiomyopathy (ARVC). Dr D considered that the death of Child A was due to a cardiomyopthathy. She noted that Cannabis can be associated with cardiovascular complications. Dr E, in his report of 2 February 2004, supported the views expressed by Dr D in terms of the findings in the heart. He commented: “A possible role for recent cannabis abuse in precipitating sudden death due to ischoaemic heart disease is at best speculative.” He felt it was inappropriate to exclude the underlying heart disease from the main cause of death, and concluded, by stating the cause of death in this case was “Idiopathic left ventricular fibrosis”.

You reviewed the case of Child A on 12 March 2004. By this time, you had received the reports of Dr E and Dr D. Notwithstanding this, you did not take account of their views in providing a supplementary statement to the Coroner. Professor C noted in his report: “There appears to have been a failure to maintain an open-minded approach to identification of the cause of death and bias, based on police information, has been allowed to colour excessively the conclusions reached, in spite of representations from the family of the deceased to reconsider.”(sic). The Panel is concerned that having reached a flawed conclusion on the cause of death, you did not significantly revise your opinion in the light of the reports from the specialist cardiac pathologists. Despite your report having been reviewed by a senior colleague, Dr F, the Panel considers that this failure to recognise your error and act appropriately is the most serious aspect of this case.

You stated that to simplify the Coroner's enquiry into this death and to assist the deceased's parents to come to terms with the death of Child A you did not object to re-phrasing the cause of death as left ventricular focal myocardial fibrosis and myocardial ischaemia. You wrongly stated that left ventricular focal myocardial fibrosis and myocardial ischaemia were synonymous. The Coroner recorded a verdict that Child A died of natural causes and that the cause of death was arrhythmogenic cardiomyopathy. You have accepted that your actions in relation to your supplementary statement were unprofessional, misleading, inappropriate and likely to bring the reputation of the medical profession into disrepute.

Child B

Many of the criticisms that have been found proved in relation to Child A are repeated in the case of Child B. On 29 July 2003 you carried out a post-mortem on the body of Child B. You have accepted that you did not consider retaining the heart for examination by a specialist in cardiac pathology and that you only took three specimen blocks from the heart. In the report you prepared for the Coroner, dated 24 February 2004, you concluded that the cause of death was coronary artery ischaemia and cannabis abuse. You wrongly suggested that the death must have been due to cannabis and no other condition.

You have accepted that you did not consider that the scarring of the heart might have been caused by inflammation of the heart muscle (a healed myocarditis), nor did you consider arrhythmogenic cardiomyopathy as a cause of death. You again improperly considered status lymphaticus. Your conclusions were significantly flawed and inaccurate in that you relied upon and misinterpreted a scientific paper of Bachs and Morland and you could not prove that cannabis had a role in Child B's death. You have accepted that your opinions in relation to Child B were speculative, and your actions were misleading, inappropriate, unprofessional and likely to bring the reputation of the medical profession into disrepute.

Panel's finding on impairment

The Panel accepts that these rare incidents occurred closely in time and have striking similarities. However, the Panel's view is that these were separate incidents and it has considered them individually. Errors were made by you over a period of months. The Panel does not consider the events to be a single incident, or an isolated lapse from the standards expected. In considering whether your fitness to practise is impaired, the Panel has borne in mind the GMC's Indicative Sanctions Guidance, including the issue of the public interest. The Guidance states that the public interest includes, amongst other things, the protection of patients and the maintenance of public confidence in the profession. Professional bodies such as the police and coroners place reliance on the information provided by pathologists. The families of the deceased were entitled to an accurate diagnosis of the cause of death. It is therefore important that the conclusions stated in such reports can be verified. Moreover, when reviewing cases, it is important that this is carried out in a professional manner, and the views of other recognised experts are taken into account. You have accepted that the conclusions reached in the report concerning the cause of death of Child A and Child B were significantly flawed and inaccurate and that your opinions were speculative. You have further accepted that your actions were misleading, inappropriate, unprofessional and likely to bring the reputation of the medical profession into disrepute.

In addition, the Panel has also had in mind the GMC's publication Good Medical Practice (May 2001). This refers to a number of requirements in providing care, including the need to recognise and work within the limits of your professional competence and be willing to consult colleagues. The Panel has found that you have breached this guidance. In all the circumstances, the Panel has found your fitness to practise is impaired by reason of your misconduct. The Panel will now invite further submissions from both Counsel as to the appropriate sanction, if any, to be imposed on your registration. Submissions on sanction should include reference to the Indicative Sanctions Guidance, using the criteria as set out in the guidance to draw attention to the issues, which appear relevant to this case.”

Determination on sanction

“Dr Al-Alousi: The Panel has considered what action, if any, to take in relation to your registration. In doing so, it has taken into account all the evidence adduced throughout this hearing, and has borne in mind the submissions made by both Counsel. Mr Ainsworth, on behalf of the General Medical Council (GMC), has invited the Panel to consider making a direction suspending your registration; Mr Hopkins has invited the Panel to consider taking no action on your registration. The Panel has borne in mind that any sanction imposed must be proportionate and appropriate, and that its purpose is not to be punitive, but to protect members of the public and the public interest. The public interest includes, amongst other things, not only the protection of patients, but also the maintenance of public confidence in the profession. In considering whether to take action against your registration, the Panel has balanced the public interest against your own interests, bearing in mind your personal circumstances, and has taken into account the principle of proportionality. The Panel has had regard to the GMC's Indicative Sanctions Guidance.

The Panel has taken into account the evidence submitted at this stage of the proceedings, including the oral evidence of Detective Superintendent G and Dr H. It is clear from their evidence that you are considered to be a highly respected, reliable and clinically competent Consultant Pathologist, who provides an excellent service, and who is willing to listen to the opinions of others. The Panel has also had regard to the outstanding testimonials submitted on your behalf. These, too, attest to your high clinical standing amongst colleagues. The Panel has taken into account the mitigation advanced on your behalf by Mr Hopkins. It has been accepted by both Counsel that that the causes of death in respect of Child A and Child B were not “ run of the mill” and that both cases were difficult, requiring expertise greater than your own. In his evidence, Professor C commented that the autopsies in respect of Child A and Child B were carried out to an extremely high standard. The Panel has heard that, apart from your conduct concerning Child A and Child B, there have been no other complaints to the GMC during 24 years of practising in the United Kingdom.

It has been submitted on your behalf that you have demonstrated insight into the seriousness of your actions. At the outset of the hearing you made full admissions to the allegations against you. The Panel has heard that as a result of the errors of judgement you made concerning Child A and Child B, you have now put safeguards in place to prevent such mistakes from recurring. Mr Hopkins has explained that you now take histology samples from the right ventricle and between 4 to 6 histology samples from the left ventricle of all the hearts that you examine for the purposes of a post mortem. In all cases of young people (below the age of 35) where the cause of death is not clear, the heart is sent to Dr I, Consultant Pathologist, specialising in cardiac pathology. He has further explained that in drug related cases, samples are taken from the left and right hand side of the heart and that the heart is retained whilst you are waiting for toxicology reports. The Panel also notes that of your own volition and at your own expense, from 29 November to 1 December 2006 you attended a Combined Adult and Congenital Cardiovascular Pathology course at the National Heart and Lung Institute.

The Panel first considered whether it would be appropriate and proportionate to conclude your case without imposing any sanction. It has borne in mind the mitigation advanced on your behalf, as well as the circumstances of your case. In view of the serious nature of its findings regarding your misconduct, the Panel is satisfied that it is necessary in the public interest to take action in relation to your registration. The Panel then went on to consider whether it would be sufficient and appropriate to impose conditions on your registration. In doing so, it has considered the factors set out in the GMC's Indicative Sanctions Guidance in relation to when it may be appropriate to impose conditions on a Doctor's registration. The Panel has concluded that you have learnt from these incidents and you have shown insight into these matters by changing your practice. The Panel considers that it is unlikely that there is a risk of recurrence provided that the changes you have implemented in your practice are sustained.

However, whilst noting the steps you have taken to change your practice, the Panel seeks assurances that these changes are sustainable. The Panel would wish such arrangements to be formalised and to be reviewed after a period of time. In particular, the Panel wishes you to convert the set of procedures already outlined by your Counsel into a formal protocol. This should be done in agreement with a senior colleague. You should make arrangements for evidence to be provided to the GMC of the implementation of the protocol. Taking these matters into account, the Panel is satisfied that the imposition of conditions on your registration would be sufficient to protect patients and the public interest, and would be a proportionate response to its findings of fact. It considers that a direction suspending your registration would be disproportionate and would be unduly punitive.

Accordingly, the Panel has determined to impose the following conditions on your registration for a period of 12 months:
1. You must formalise a protocol detailing your management of the heart tissue in post mortem cases where the deceased is aged less than 35 and where there is not an immediately apparent non-cardiac cause of death.
2. You must formalise this protocol with the agreement of a senior colleague, who will act as your supervisor solely in relation to your compliance with this protocol. This supervisor should be a qualified pathologist who is on the specialist register of the GMC and who is at least as senior as yourself.
3. a You must maintain a log detailing your compliance with the protocol in all relevant cases.
b. You should make this log freely available to your supervisor and, on request, to the GMC.
4. You must allow the GMC to exchange information with your supervisor, where necessary.
5. You must notify the GMC promptly of any post you accept for which registration with the GMC is required and provide the GMC with the contact details of your employer.
6. You must allow the GMC to exchange information with your employer, or any organisation for which you provide medical services, and any individual involved in your supervision.
7. You must inform the GMC of any formal disciplinary proceedings taken against you, from the date of this determination.
8. You must inform the GMC if you apply for employment outside the UK.
9. You must inform the following parties that your registration is subject to the conditions, listed at 1 to 8 above:
Any organisation or person employing or contracting with you (including HM Coroner) to undertake medical work;
Any locum agency or out-of-hours service you are registered with or apply to be registered with (at the time of application);
Any prospective employer (at the time of application).

In reaching its decision to impose conditions on your registration for a period of 12 months, the Panel considers that this will give you sufficient time in which to demonstrate that you have sustained the changes in your practice. Before the end of this period of conditional registration a Fitness to Practise Panel will meet to review your case. A letter will be sent to you about the arrangements for the review hearing which you will be expected to attend. At that hearing, the Panel reviewing the case will expect to receive the following:  
An assessment from your supervisor on your protocol and your log  
A copy of the protocol
A copy of the log

The effect of this direction is that, unless you exercise your right of appeal, your registration will be subject to these conditions for a period of 12 months, beginning 28 days from the date when written notice of this direction has been deemed to have been served upon you. Having regard to the measures outlined by your Counsel regarding your current practice arrangements, and the Panel's view that there it is unlikely that there is a risk of recurrence of these events, the Panel is not minded to impose these conditions immediately, unless either Counsel wishes to make submissions on this matter.”

Confirmed 25 January 2007 Chairman

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