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Swindon Coroner's Court: The Swindon and Marlborough NHS Trust, January - February 2008: Bupivicaine, an epidural anaesthetic administered intravenously by a midwife following birth leading to a cardiac arrest and thereby causing the Mother's death (Mayra Cabrera); issues raised at the Inquest also included a general review of 'wrong route drug errors' and what could be done to minimise them in the future, a review of the responsibilties of the then Chief Pharmacist, whether the then Chief Pharmacist had failed to ensure that there was in place a safe system for the storage of all medicinal products in the Trust, whether the then Chief Pharmacist was 'a controlling or directing mind' for the Trust in terms of Corporate Manslaughter and whether any failure by the then Chief Pharmacist was therefore ascribable to the Trust: Jury returned Verdicts of Gross Negligence Manslaughter in respect of the Administration and Storage of Bupivicaine.
General Medical Council: Dr Kong Lan Keng Lun (Lan), September 2007: Consultant Radiologist, failing to diagnose and treat breast carcinomas in an NHS Hospital and failing to manage, teach and supervise effectively the staff within the Radiology Department: his Fitness to Practise found to be impaired - Conditions imposed on his Registration for two years.
General Medical Council: Mr Sohail Ahmed, June 2007: Consultant Opthalmologist, who had undergone successfully a review of his Professional Performance as directed by The Fitness to Practise Panel in August 2006, returned to face the original allegations: his Fitness to Practise found to be impaired in respect of those original allegations - Conditions imposed on his Registration for one year.
General Dental Council: Mrs Joanna Chyzy, February and July 2007: General Dental Practitioner faced numerous complaints made by patients about the standard of treatment administered; Found Guilty of Serious Professional Misconduct: Erasure of her Name directed.
General Medical Council: Mr Sohail Ahmed, August 2006, Consultant Ophthalmologist – appearing before The Fitness to Practice Panel – concerns raised in respect of his Ptosis surgery, his failure to seek within a reasonable time an ultra sound scan and a vitro-retinal opinion for a young patient with a severe penetrating eye injury and his diagnosis of and management of patients at risk of Giant Cell Arteritis: an assessment of his professional performance directed.
Winchester Coroner’s Court: Dr Ibrihim Jalloh, June 2006, GP working in an Out of Hours capacity, attending a patient suffering from the side effects of Sulphasalizine – whether GP put himself sufficiently into a position to make an appropriate diagnosis and not then to refer the patient to hospital.
General Medical Council: Dr Irfan Shah, May 2006, Junior Doctor unable to decide whether to remain in hospital medicine or to enter general practice – lies told on several occasions, both orally and in written applications – dishonesty admitted – Registration suspended for nine months.
General Dental Council: Mr Vincent Matich, April 2006, General Dental Practitioner, making dishonest claims for payment by the Dental Practice Board in respect of work not carried out – Erasure directed.
General Dental Council: Mr Glen Simons, February 2006, General Dental Practitioner accessing and downloading indecent images of children and young persons – convicted in the Crown Court but conviction set aside by the Court of Appeal, Criminal Division as Judge had admitted evidence later ruled in the CACD to have been inadmissible – Conduct Hearing before the GDC on the evidence led before the Crown Court – and supplemented by more evidence obtained using more advanced retrieval equipment - Erasure directed.
Ipswich Crown Court: Mid Essex Hospitals NHS Trust, 30–31 January 2006, Health and Safety Defence – failure to have in place a safe system for the effective dissemination to medical and nursing staff of safety notices sent to a NHS hospital by the then Medical Devices Agency, such failure alleged by the Health and Safety Executive to have caused or contributed to the death of a nine year old boy during the administration of general anaesthesia prior to routine surgery. A Newton Hearing was held by Gross J. to test the significantly different and opposing opinions of two senior consultant anaesthetists as to the actual system then in place for the dissemination to medical and nursing staff of such safety notices when the system then in place was representative of many NHS hospitals. Defence submissions upheld, death not treated therefore as an aggravating feature. A further opportunity to consider the level of both a fine and an order for costs to be imposed on an NHS Trust.
Kettering Coroner’s Court: NHS Trust, January 2006, Planned Caesarean Section at 37 weeks for Mother with a complicated past medical history of cervical adenocarcinoma, whether a paediatrician should have been present at the birth, baby in respiratory distress, complications arising and death following within seven hours.
Teesside Coroner’s Court: Department of Health, September 2005, Single Use Instruments used in Adeno-Tonsillectomies, whether single use instruments could or should have been sterilised and reused following concerns that CJD, the human form of BSE, could be contracted.
General Medical Council: Mr Andrew Gbinigie, August 2005, Consultant Obstetrician and Gynaecologist – appearing before the Professional Performance Committee, following concerns raised in respect of his management of sixteen patients, diagnosed as suffering from various gynaecological complaints – refusal to accept the GMC’s Statement of Requirements – Assessors’ recommendations for further training not upheld by the PPC.
Sheffield Coroner’s Court: Dr Sharma, May 2005, Psychiatrist employed by a NHS Trust, alleged failure to see patient in need of an urgent psychiatric assessment before a Bank Holiday weekend – arrangements made for other members of the psychiatric team to see and assess – patient diving through open high window to his death.
Warrington Coroner’s Court: Dr Ranawickrema, April 2005, GP employed under a contract to provide medical services to the inmates of HM Prison, Styal, prisoner able to steal and ingest liquid medication - application of Article 2 – suicide or systems failure.
Warrington Coroner’s Court: Dr Ranawickrema, January 2005, GP employed under a contract to provide medical services to the inmates of HM Prison, Styal, prisoner able to hang herself despite concerns raised about her mental state and known to be at risk of self-harm - application of Article 2 – suicide or systems failure.
Kettering Coroner’s Court: NHS Trust, December 2004, Failure to ensure that a patient known to be disturbed and suffering from depression could not leave the hospital or its grounds – patient threw herself off the roof of a local car park to her death - suicide or systems failure.
Bradford Coroner’s Court: West Yorkshire Metropolitan Ambulance Service Trust, October 2004, Known alcoholic, who had been brought into hospital by ambulance paramedics, created a nuisance, allowed to leave the main entrance only to fall over just outside, left on the ground – when transferred to a local police station, whether the likelihood of a skull fracture should have been recognised and thereafter treated - death in custody - application of Article 2 – accidental death or systems failure.
General Dental Council: Dr Hennie Bruwer, May 2004, Orthodontist on Specialist Register – appearing before the Professional Conduct Committee – allegations of making misleading statements about the accessibility and availability of orthodontic treatment under National Health Service regulations –Registration suspended for four months.
The Royal Free Hampstead NHS Trust, The City of London Magistrates Court, 16 April 2004, Health and Safety Defence – loss of a radioactive source train, most likely in the clinical waste, following its use in brachytherapy – risk to health of employees and public.
The Queen v Clandillon, HH Judge Jones at Basildon Crown Court, 8–9 March 2004, Health and Safety Prosecution – risk to health and safety of residents in registered Mental Nursing Home – scalding of incompetent and vulnerable resident during bathing – no thermostatic mixer valve fitted.
City of London Coroner’s Court: NHS Trust, December 2003, Death of prisoner on remand – overdose of another prisoner’s medication – transferred to hospital where death occurred – application of Article 2 – Coroner’s duty to investigate – suicide or systems neglect.
The Queen v Earls Court Ltd and Unusual Rigging Ltd., HH Judge Boal Q.C. at the Central Criminal Court, 18-19 September and 3 October 2003, Health and Safety Prosecution – unsafe system of work for riggers – a failure by both companies to conduct their undertakings in such a way so as to ensure that persons not in their employment, were not exposed to risks of falling whilst carrying out maintenance and refurbishment work in the roof void of Exhibition Hall 1.
General Medical Council: Dr John Rees, July 2003, Locum Consultant Haematologist – appearing before the Professional Conduct Committee – allegation of inappropriate treatment of elderly male patient diagnosed as suffering from Myelodysplastic Syndrome and whether fully consented.
Circle Britannia Ltd, Eastbourne Magistrates’ Court, 15 July 2003, Health and Safety Defence – unsafe system of work for effecting repairs to a fragile roof – fall by employee through the roof, suffering near fatal injury.
Chelmsford Coroner’s Court: NHS Trust, May 2003, Death of young boy – undergoing routine surgery to repair a finger damaged in a bicycle accident – blockage in breathing system angle piece causing irreversible cerebral anoxia – whether accidental death contributed to by system neglect – application of Article 2.
General Medical Council: Mr Andrew Gbinigie, March 2003, Consultant Obstetrician and Gynaecologist – appearing before the Professional Conduct Committee – termination of a near 20 week foetus at an abortion clinic and allegations of inappropriate behaviour towards members of staff.
Inner London Crown Court: Ravinder Singh Panesar, January 2003, General Medical Practitioner – appearing before the Crown Court – allegations of forgery of prescriptions, whilst employed as a Civilian Medical Officer by the Ministry of Defence in London.
General Medical Council: Mr M.A.R.A. Al-Fallouji, July 2002, Consultant General Surgeon with particular interests in upper gastro-intestinal and colo-rectal surgery – appearing before the Professional Conduct Committee – allegations of inappropriate behaviour and inappropriate language in and out of theatre towards members of the medical and nursing staff and allegations of providing false criticisms in letters about junior medical colleagues.
Teesside Crown Court: Richard Cox, November 2001, General Dental Practitioner – appearing before the Crown Court – allegation of conspiracy to defraud the Dental Practice Board, involving the suborning of two members of staff to make claims for false exemption to pay the patient’s statutory charge and for fictitious courses of treatment.
General Medical Council: Doctor Michael Harbinson, August 2001, General Practitioner with a specialist interest in male circumcision – appearing before the Professional Conduct Committee – allegations of failing to explain to two mothers alternative methods of treatment to circumcision for penile complaints, placing one mother under inordinate pressure to have her baby son circumcised and failing to refer both babies to an appropriate medical practitioner for an opinion regarding circumcision.
General Medical Council: Doctor Tom Onen, July 2001, Consultant Psychiatrist, specialising in substance misuse – appearing before the Professional Conduct Committee – allegations of inappropriate and/or irresponsible private prescribing of controlled drugs to addicts.
The Queen v General Demolition Ltd. , The Common Serjeant of London at the Central Criminal Court, 23 February 2001, Health and Safety Prosecution – unsafe system of work for refurbishment of office block in the City of London.
The Trustees of the Natural History Museum, Blackfriars Crown Court, 16 February 2001, Health and Safety Prosecution – radioactivity naturally occurring in minerals – risk to health of employees and public.
General Medical Council: Doctor Janusz Wszeborowski, January 2001, Staff Grade obstetrician and gynaecologist - appearing before the Professional Conduct Committee - allegations of applying and using forceps with undue force.
General Medical Council: Doctor Wilhelm Bijl November 2000, Staff Grade obstetrician and gynaecologist - appearing before the Professional Conduct Committee - allegations of clinical incompetence and professional negligence.
General Medical Council: Mr. Richard Neale June - July 2000, Consultant Obstetrician and Gynaecologist - appearing before the Professional Conduct Committee - allegations of clinical incompetence and professional negligence arising out of urogynaecological and gynaecological surgery.
The Queen v The University of Cambridge, McKinnon J. at Chelmsford Crown Court, 24 September 1999, Health and Safety Prosecution - unsafe system of work for delivery and storage of radioactive sources within the Department of Biochemistry.
The Queen v Murphy & Lee, The Recorder of London at the Central Criminal Court, 5 January 1999, Manslaughter - Hospital Doctors - Great Ormond Street Hospital - intrathecal injection of Vincristine - whether negligent / grossly negligent.
The Queen v The Norfolk & Norwich Health Care NHS Trust, Newman J. at Norwich Crown Court, 17 December 1998, Health and Safety Prosecution - risk to health and safety during cardiac angiography.
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