Fitness to Practise Panel
Session beginning 5 September 2005 to 9 September 2005
Reconvened on 18 November 2005, 27 March 2006, 15-16 and 18 – 19 January 2007, 19 February 2007
St James’s Building, 79 Oxford Street, Manchester, M1 6FQ
Dr Kenneth SHORROCK
Registration number: 2428013
This case has been considered by a Fitness to Practise Panel applying the General Medical Council’s Preliminary Proceedings Committee and Professional Conduct Committee (Procedure Rules) 1988.
Mr Taylor:
At all relevant times Dr Shorrock was a registered medical practitioner employed as a Consultant Pathologist at the Royal Halifax Hospital.
On 31 January 2000, on the instruction of Her Majesty’s Coroner, Dr Shorrock undertook a post-mortem examination of Gladys Allen at Dewsbury and District Hospital. Mrs Allen had died on 28 January 2000 shortly after undergoing the operation of left nephrectomy (removal of the left kidney), which had been performed by Mr Syed, locum consultant urologist. The indication for the operation was cancer of the kidney.
Following the post-mortem examination, Dr Shorrock produced and signed an undated report, referred to as “the first report”. In the first report Dr Shorrock recorded that Mrs Allen had collapsed very soon after the end her operation ”with profuse bleeding from the abdomen”. Dr Shorrock also recorded ”There is a tube drain in the left side of the abdomen. The attached bag is tense with clotted blood”, but he did not determine or record the volume of the bag (“the drain bag”) or the volume or weight of its contents. In addition, Dr Shorrock recorded that ”venous cannulae are also present”, but he did not record the number of cannulae or their gauges. Nor did he record the presence of the epidural catheter inserted before the operation.
Dr Shorrock also stated in the first report that “The aorta shows severe atheroma. The left renal artery has been transected close to its origin. There is a nylon suture. On the posterior aspect of the tie there is a small perforation of the aorta through an atheromatous plaque” but he did not measure or record the size of the perforation.
Dr Shorrock recorded the presence of “a small quantity of blood remaining within the peritoneal cavity” but he did not measure or record its volume. Nor did he take any photographs or make any drawing or sketch to illustrate his findings.
In the first report, Dr Shorrock concluded that Mrs Allen “underwent necessary surgery for a large tumour involving the left kidney”. Furthermore, he recorded the following “In my opinion there is no definite evidence of any avoidable deficiency in the medical or surgical treatment that she received”. Dr Shorrock certified the cause of death as, Intra-abdominal haemorrhage due to (or as a consequence of), Nephrectomy for Carcinoma of the Kidney.
The Panel has heard that Dr Shorrock’s first post-mortem report was submitted to the Coroner (Mr Whittaker) shortly after the post-mortem on Mrs Allen on 31 January 2000. After consideration of that report Mr Whittaker determined that it was not necessary to hold an inquest into her death.
Eleven months later, around December 2000, Mr Whittaker telephoned Dr Shorrock to request that he re-consider his findings recorded in the first post-mortem report. Dr Shorrock said to the Panel that Mr Whittaker had told him that he had received information concerning other patients on whom Mr Syed had operated, and this raised questions about Mr Syed’s clinical performance. Following this conversation Dr Shorrock produced a second post-mortem report and this was dated 20 December 2000.
In this second report Dr Shorrock expressed his findings in terms identical to those which he had used in his first report, except that he deleted the word ”necessary” in the sentence “(Mrs Allen) underwent necessary surgery for a large tumour involving the left kidney”. He also deleted the entire sentence “In my opinion there is no definitive evidence of any avoidable deficiency in the medical or surgical treatment she received”.
Dr Shorrock’s second report contained no mention of the existence of the first report, no indication that it was an amended version of that report, and no indication of the amendments that had been made to that report. He gave no reasons for those amendments.
On 27 September 2001 Dr Shorrock signed, indicating that he believed its contents to be true, a witness statement that incorporated the text of his first report. This included the passages “(Mrs Allen) underwent necessary surgery for a large tumour involving the left kidney” and “In my opinion there is no definitive evidence of any avoidable deficiency in the medical or surgical treatment she received”.
Five days later, on 2 October 2001 Dr Shorrock signed, indicating that he believed its contents to be true, a second witness statement in which he expressed the view that it was ”likely that death was contributed to by inadvertence, both before and during the operation”.
Eight weeks after that, on 30 November 2001 Dr Shorrock signed, indicating that he believed its contents to be true, a third witness statement in which he said that he had no recollection of the size of the drain bag. In relation to blood in the peritoneal cavity, Dr Shorrock wrote ”I did not measure this specifically” and also that the description in his reports ”would suggest to me that there would have been less than about 200 or 300ml in total”.
Almost a year later, on 13 November 2002, Dr Shorrock signed, indicating that he believed its contents to be true, a fourth witness statement. In this statement Dr Shorrock said that at post-mortem he had found ”a hole (perforation) in the aorta where the stump of the renal artery would normally be found.” In addition Dr Shorrock exhibited a series of diagrams which he had drawn, which included the descriptive comment ”artery divided flush to leave hole (perforation) in aorta”.
The Panel has heard that on 12 April 2002 Mr Syed was charged with the manslaughter of Mrs Allen. Dr Shorrock was called by the Crown to give evidence at his trial which took place at Leeds Crown Court between 30 April and 23 May 2003. The Panel is aware of the pressures which are on a witness giving evidence at a criminal trial and it considers that Dr Shorrock did not fall short of the proper professional standards when he gave evidence in that trial. It is a matter of public record that Mr Syed was acquitted of the manslaughter charge, but this was not because of any shortcomings in the pathology evidence.
Nevertheless, the Panel has found that Dr Shorrock had no sufficient reason to change the material facts he described in his first report to those described in his fourth statement, namely, changing from “the left renal artery has been transected close to its origin” to “A hole (perforation) in the aorta where the stump of the renal artery would normally be found.”
Similarly, the Panel has found that Dr Shorrock had no sufficient reason to change the opinion expressed in his first report to that expressed in the second statement, namely, changing from “no definite evidence of any avoidable deficiency in the medical or surgical treatment she received” to “Likely that death was contributed to by inadvertence, both before and during the operation.”, as the findings made at the post-mortem examination cannot change.
The Panel has found that Dr Shorrock’s actions in relation to the second post-mortem report, the witness statements dated 27 September 2001, 2 October 2001, 30 November 2001 and 13 November 2002, and the change in the post-mortem findings that had been expressed in the first report were unprofessional, inconsistent, unreasonable, inappropriate, and not based upon the medical and pathological information available to him; and that they were likely to bring the medical profession into disrepute.
The Panel considers that Dr Shorrock’s actions, as described above, demonstrate a serious departure from standard of conduct expected of a medical practitioner.
Good Medical Practice (1998 edition, applicable until May 2001) states that registered medical practitioners have authority to sign a variety of documents on the assumption that they will only sign statements they believe to be true. This means that doctors must take reasonable steps to verify any statement before they sign a document. Doctors must not sign documents which they believe to be false or misleading. The Panel considers that this principle applies when completing post-mortem reports. Factual findings made at post-mortem examination should not be altered retrospectively unless there is sufficient objective evidence that makes it appropriate to do.
The Panel has been directed to guidance from the Royal College of Pathologists dated August 1993 and entitled ‘Guidelines For Post-mortem Reports’. This guidance states in its introduction that “the post-mortem report clearly should inform the clinician, coroner, general practitioner and pathologist. The format must be flexible and widely comprehensible.” However, the guidance does not give specific detail relating to the provision of supplementary reports.
The Panel has heard expert evidence from Professor Peter Vanezis and Professor Derrick Pounder. They described the standard procedure for recording findings at post-mortem. Professor Vanezis stated that all pathologists have a responsibility to provide accurate reports. If an initial report is limited in its content then a pathologist would be limited with the amount of information that could be included in any subsequent reports. If a pathologist believes that there is a cause of concern then this should be flagged up in the report. If matters are not mentioned then it is appropriate to assume that there are no issues relating to that area of surgery. The Panel notes that no criticism has been made either by the GMC, or the expert witnesses, of the findings contained within Dr Shorrock’s first post-mortem report.
Professor Vanezis also described the procedure a pathologist should follow when asked to produce a supplementary post-mortem report. Any additional information should be provided to the coroner in the form of a supplementary report which should be read in conjunction with the first report. It should not replace the first report. In addition, reference should be made to the first report’s existence. He further stated that if a pathologist had reason to change his conclusions or opinion, an explanation should be given as to why he has deemed this necessary.
Professor Pounder agreed with this opinion. He too stated that when supplementary reports are issued it is important to make reference to the existence of an earlier report. In Professor Pounder’s opinion Dr Shorrock had a duty to make reference to the existence of the first report. In addition, the second report should have given the reasons for his change of view.
In relation to the first statement that Dr Shorrock provided to police on 27 September 2001, Professor Vanezis accepted that it is common practice to alter the format of a conventional post-mortem report when providing a witness statement to the police. In conclusion, Professor Vanezis expressed his opinion that the discrepancies between the first and second reports that Dr Shorrock provided were evidence that his conduct had fallen below the standards to be expected of a pathologist. Professor Pounder agreed with Professor Vanezis’ opinion. They both agreed that on occasion it may be necessary to amend an initial post-mortem report but, if this is done, then full reasons for the change must be stated.
Dr Shorrock gave oral evidence to the Panel and he said that he had a very clear recollection of the post-mortem examination that he carried out on Mrs Allen. He said that, although some of the descriptions relating to the perforation in the aorta and the position of the suture had changed, the overall descriptions given in his reports and statements describe the same observations made at the first post-mortem examination. Dr Shorrock conceded that he might have used words imprecisely, but he denied that he was attempting to mislead anyone who might read the reports or statements. The Panel accepts that Dr Shorrock did not act in a malicious or dishonest way. However, his shift from “the left renal artery has been transacted close to its origin” to “a hole (perforation) in the aorta where the stump of the renal artery would normally be found” has significant implications as to the competence of the operating surgeon.
The Panel has heard Dr Shorrock’s explanation as to why he changed his opinion from the first report to his second statement dated 2 October 2001 regarding the necessity for surgery and possible inadvertence before and during the operation. Dr Shorrock explained that he made these changes, at least in part, because of information he received from the coroner.
In relation to the witness statement provided to police on 27 September 2001, Dr Shorrock explained to the Panel that he was providing the police with a copy of his first report and that by signing to say its contents were true he was actually attesting to its truth as a document of record rather than commenting specifically on the statement’s content. Furthermore, Dr Shorrock was expecting to provide additional witness statements based on the findings contained within the second post-mortem report.
Dr Shorrock told the Panel that he believed he was justified in changing his conclusions in his second report because of information he had received from the coroner concerning Mr Syed’s clinical practice. On receiving this additional information Dr Shorrock considered that there was evidence that Mrs Allen’s nephrectomy operation had gone wrong.
Good Medical Practice gives guidance for dealing with problems relating to the professional conduct or performance of colleagues. It states that where there are serious concerns about a colleague’s performance it is essential that steps are taken to investigate the concerns. Furthermore, doctors must assist the coroner by responding to enquiries and by offering all relevant information to an inquest or inquiry into a patient’s death. The Panel believes that by acknowledging and acting upon the concerns raised by the coroner Dr Shorrock followed this guidance. However the Panel takes the view that by providing inconsistent reports and statements Dr Shorrock acted unprofessionally and inappropriately.
The Panel considers that Dr Shorrock’s actions in changing post-mortem findings after eleven months, without a satisfactory explanation, and in changing his opinion on the standard of surgery, again without a satisfactory explanation, bring the profession into disrepute and demonstrate a serious departure from the standards of conduct that the public is entitled to expect from a medical practitioner. Dr Shorrock’s two reports and four statements were produced over a period of almost two years. Over this time he made significant changes to his initial post-mortem findings without any explanation as to why he had done so. Furthermore, he changed his position from believing that the surgery had been carried out necessarily and without definite evidence of any avoidable deficiency, to a position where he said that the surgery had been carried out incorrectly. Both of the forensic pathologists who gave expert evidence before the Panel took the view that Dr Shorrock’s conduct fell below the standard to be expected of a pathologist carrying out a post-mortem examination and reporting on it to the coroner’s court and to the criminal court. The Panel has already found proved that Dr Shorrock’s actions were unprofessional, inconsistent, unreasonable, inappropriate, not based upon the medical and pathological information available to him and likely to bring the profession into disrepute.
The Panel has accepted the advice of the Legal Assessor. He advised that, in deciding on the seriousness of the misconduct, the Panel must exercise its professional judgement by assessing the facts found proved, taking into account factors relating to the conduct itself.
The Panel has been referred to, and it has carefully considered, the words of Lord Justice Auld in Meadow v General Medical Council [2006] EWCA Civ 1390. Paragraph 200 of the judgment states:
“As Lord Clyde noted in Roylance v General Medical Council [2000] 1 AC 311, PC, at 330F – 332E ”serious professional misconduct” is not statutorily defined and is not capable of precise description or delimitation. It may include not only misconduct by a doctor in his clinical practice, but misconduct in the exercise, or professed exercise, of his medical calling in other contexts, such as that here in the giving of expert medical evidence before a court. As Lord Clyde might have encapsulated his discussion of the matter in Roylance v Clyde, it must be linked to the practice of medicine or conduct that otherwise brings the profession into disrepute, and it must be serious. As to seriousness, Collins J, in Nandi v General Medical Council [2004] EWHC (Admin), rightly emphasised, at paragraph 31 of his judgment, the need to give it proper weight, observing that in other contexts it has been referred to as “conduct which would be regarded as deplorable by fellow practitioners”.
The Panel has borne in mind that Mrs Allen’s post-mortem examination was carried out in respect of what was thought to be a non-suspicious death. However subsequent reports and statements were provided in the context that blame, and ultimately criminal responsibility, might attach to the operating surgeon. In those circumstances it was important that those reports and statements should be both accurate and transparent, and based on the findings that Dr Shorrock made at his post-mortem examination. If he took into account any extraneous evidence, such as from the coroner, then the exact nature of this evidence should have been stated clearly in any subsequent report or statement.
Taking all these matters into consideration the Panel considers that Dr Shorrock has been guilty of serious professional misconduct.
In deciding whether to take action in relation to Dr Shorrock’s registration, the Panel has carefully considered the issue of proportionality and it has had regard to the Indicative Sanctions Guidance published by the GMC.
The Panel first considered whether to conclude this case by taking no action. However, the Panel is mindful that it has three duties, namely, the protection of the public, the maintenance of public confidence in the medical profession and the maintenance of proper standards of behaviour by medical practitioners. In view of this, the Panel considered that it would not be appropriate to take no further action.
The Panel then went on to consider the mitigating circumstances in this case, in particular that the charge relates to a single case that has not been repeated. Dr Shorrock has acknowledged that the information he provided in the reports and statements was inconsistent, and he told the Panel that he has changed his practice for providing supplementary reports since the relevant events took place. The Panel believe that Dr Shorrock has shown insight into the events surrounding Mrs Allen’s post-mortem examination and he has changed his working practice accordingly to prevent a repetition of these events.
Dr Shorrock was appointed as a Home Office Forensic Pathologist on 10 October 2000. Mr Arlidge told the Panel that since January 2006 to January 2007 Dr Shorrock had carried out 115 forensic post-mortem examinations and the Panel has not been informed that there have been any complaints about these. Mr Arlidge also submitted that the Panel’s findings relate to a series of misjudgements on a single case, and that there was no evidence of dishonesty. The Panel accepts this.
The Panel has been provided with a number of testimonials submitted on Dr Shorrock’s behalf, most of which were written before the start of the hearing in September 2005. Mr Arlidge reported that his solicitor had contacted the majority of these referees, and that all of those contacted stood by their original testimonial despite the passage of time and in full knowledge of the allegations against Dr Shorrock. Of those testimonials, Professor Whitewell, Consultant Pathologist and a professional colleague of Dr Shorrock, described him as “an extremely hard and conscientious worker”, performing his post-mortems examinations “thoroughly and with care arriving at the appropriate conclusions after careful consideration.” Likewise, Professor Milroy, Consultant Pathologist, stated that following Dr Shorrock’s appointment as senior lecturer in forensic pathology at the University of Sheffield on 1 April 2000, he had continued to work in a thoroughly competent, professional and honest manner. Having reviewed Dr Shorrock’s work on a number of occasions Professor Milroy was of the opinion that the standard of his work had never fallen below that to be expected of a Home Office accredited forensic pathologist. The Panel has also noted the testimonials from Dr Cary, Consultant Forensic Pathologist partner at Forensic Pathologist Services, and Her Majesty’s Coroners, Dr Dorries, Dr Saul, Dr Stearns, Dr Dolman, Dr Cotter and Dr Reid, all of who speak highly of Dr Shorrock’s professional abilities.
The Panel is bound to consider most carefully whether the public interest demands that it should take action in respect of Dr Shorrock’s registration. The public interest clearly includes ensuring that patients and members of the public can have confidence in the profession. The Privy Council has previously emphasised that the public interest can also include not depriving the public of the services of an otherwise competent doctor (Privy Council judgement in the case of Dr Willem Bijl v The General Medical Council (Privy Council appeal No. 78 of 2000)).
Usually the Panel would consider possible sanction in order of increasing severity, in order to ensure that the minimum appropriate sanction is imposed. However, in this case Mr Roussak, for the GMC, has submitted that erasure would be the appropriate sanction. For this reason the Panel considered the full range of sanctions available to it.
The Panel considered the possibility of erasure, but it decided against erasure as Dr Shorrock’s offence is at the lower end of the spectrum of serious professional misconduct. There has been no evidence of dishonesty on the part of Dr Shorrock, or of persistent lack of insight into the seriousness of his conduct and its possible consequences. In the light of this, the Panel took the view that Dr Shorrock’s continued registration with the GMC would not compromise patient safety or the public interest.
As the Panel had rejected the GMC’s bid for erasure it considered whether suspension would be appropriate. However, as Dr Shorrock’s serious professional misconduct was at the lower end of the spectrum it considered that suspension would be a disproportionate sanction.
The Panel considered the possibility of conditions, but it decided that there were no conditions that would be workable, measurable, achievable or proportionate in this case.
The Panel also considered whether to issue a reprimand. In this regard it took into account the GMC’s Indicative Sanctions Guidance, May 2004, applicable at the time, which states the following:
“Where the Committee decide that it is not sufficient to conclude a case of SPM or conviction with no action, a reprimand is the lowest sanction that can be applied. Although this term does not appear in the legislation, it is open to the Committee to express an opinion about the doctor’s behaviour on concluding the case. A reprimand therefore, may be appropriate where the offence is at the lower end of the spectrum of serious misconduct in order to mark the fact that the behaviour was unacceptable and must not happen again. A reprimand does not affect the doctor’s registration but it is disclosed if anyone enquires about the history of the doctor’s fitness to practise.”
In the light of this guidance, and in all the circumstances, the Panel has determined to conclude this case with a reprimand. It considers that this is a proportionate and appropriate sanction in the light of Dr Shorrock’s serious professional misconduct.
That concludes this hearing.
