gmc committee template 180107 - general medical …webcache.gmc-uk.org/minutesfiles/minutes...

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PUBLICFITNESS TO PRACTISE PANEL OF THE

MEDICAL PRACTITIONERS TRIBUNAL SERVICE17 – 26 MARCH 2014

7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ

Name of Respondent Doctor: Dr Maria Esther RAMOS DE LOS SANTOS

Registered Qualifications: D Med 1990 Universidad Central del Este (UCE)

Area of Registered Address: Spain

Reference Number: 6146949

Type of Case: New case of impairment by reason of: deficient professional performance

Panel Members: Dr N Fyfe, Chairman (Medical)Ms V Atkinson (Lay) Ms M Karp (Lay)

Legal Assessor: Mr S Lal

Secretary to the Panel: Mrs S MontgomeryMs M Bonabana (21 & 24 March 2014)

Representation:

GMC: Ms Alexandra Felix, Counsel, instructed by GMC Legal

Doctor: Not present or represented

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ALLEGATION

“That being registered under the Medical Act 1983, as amended:

1. Between 25 October 2010 and September 2011 you were employed as a Speciality Doctor in Anaesthetics at the Hillingdon Hospital, Uxbridge; Found Proved

PATIENT A

2. On 16 February 2011 Patient A was listed for a laparoscopic right hemicolectomy; Found Proved

3. You failed to undertake an adequate pre-operative anaesthetic assessment of Patient A in that you

a. did not record all relevant information on the anaesthetic record, namely

i. Physiological observations, Found Proved

ii. Relevant physical examinations, Found Proved

iii. Relevant investigations, Found Proved

iv. That Patient A was a Jehovah’s Witness who had refused blood transfusion during major surgery, Found Proved

b. did not have Patient A’s clinical notes during your pre-operative assessment consultation with Patient A; Found Proved

PATIENT B

4. On 17 March 2011 Patient B returned to theatre for revision surgery having had a caesarean section on 16 March 2011 following which there had been continuing blood loss from the abdominal drain; Found Proved

5. On 17 March 2011 you

a. inappropriately administered thiopentone to Patient B during an emergency laparotomy for postpartum bleeding contrary to current safe UK anaesthesia practice, Found Proved

b. administered thiopentone to Patient B when there was no anaesthetic assistant present, Found Not Proved

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c. failed to intubate Patient B; Found Proved

PATIENT C

6. On 15 August 2011 whilst working with Dr L to perform a rapid sequence induction on Patient C you

a. inappropriately injected Patient C with 250mg thiopentone as a bolus, Found Proved

b. injected Patient C with 250 mg of thiopentone in disregard to the instruction of Dr L, Found Proved

c. did not know the concentration of thiopentone, Found Proved

d. in the alternative to 6(c) above, were not able to remember the concentration of thiopentone; Found Not Proved

PATIENT D

7. Patient D was booked on the trauma list on 19 July 2011 for laparoscopic appendicectomy; Found Proved

8. You were undertaking the trauma list with Dr M; Found Proved

9. In respect of Patient D you failed to

a. carry out a rapid sequence induction correctly, Found Proved b. intubate Patient D’s trachea, Found Proved c. recognise that you had intubated Patient D’s oesophagus; Found Proved

PATIENTS E & F

10. Patient E was listed for left knee arthroscopy on 4 August 2011 and Patient F was listed for right total knee replacement on 25 August 2011; Found Proved

11. In respect of each date you failed to check the anaesthetic machines; Found Proved

12. On 4 August 2011 when asked by Dr N to check the anaesthetic machines in the anaesthetic room and theatre you

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indicated that the machines were in order when in fact the sevoflurane vaporiser on the anaesthetic machine in theatre was completely empty; Found Proved

13. On 25 August 2011 you indicated to Dr N that all the anaesthetic machines had been checked and were in order when in fact the sevoflurane vaporiser was completely empty; Found Proved

PATIENT G

14. On 8 August 2011 Patient G (aged 5) was admitted for reduction and internal fixation of a fracture of his/her left elbow; Found Proved

15. You were working on the trauma list with Dr O; Found Proved

16. In respect of Patient G you

a. disregarded the explicit instruction of Dr O to

i. cannulate Patient G, Found Not Proved

ii. await Dr O’s return before inducing anaesthesia, Found Proved

b. repeatedly and unsuccessfully tried to cannulate a vein, Found Proved

c. asked and/or allowed Patient G’s mother to hold the anaesthetic mask whilst administering 7% sevoflurane and whilst you and your assistant were otherwise occupied; Found Proved

PATIENT H

17. Patient H was admitted for insertion of wire and removal of a breast lump on 26 August 2011; Found Proved

18. On 26 August 2011 whilst working on a list with Consultant Anaesthetist Dr P you

a. disregarded Dr P’s instruction not to anaesthetise Patient H until Dr P returned, Found Proved b. in breach of current guidelines induced anaesthesia in Patient H without an anaesthetic assistant present, Found Proved

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c. delegated airway management to Dr R without close supervision and assistance; Found Proved

PATIENT J

19. Patient J (a child) was listed for extractions of upper left and right incisor teeth on 15 September 2011; Found Proved

20. On 15 September 2011 whilst working on the oral surgery list with Dr Q you

a. informed Dr Q that you had checked the anaesthetic machines in both the anaesthetic rooms and theatre when you had not, Found Proved

b. failed to identify a leak in the anaesthetic machine; Found Proved

21. During the transfer of Patient J to recovery you failed to notice that Patient J

a. was not breathing properly, Found Proved

b. had become hypoxic; Found Proved

PATIENT K

22. Patient K underwent an elective caesarean section on 31 December 2010 under combined spinal epidural anaesthesia (CSE) where you were the anaesthetist; Found Proved

23. On 4 January 2011 you performed a blood patch on Patient K in breach of current guidelines in that you failed to involve a consultant or senior colleague; Found Proved

24. Your record of the history in respect of Patient K was inadequate in that you failed to record

a. the method of anaesthesia, Found Proved

b. information about whether the headache interfered with sleep and whether it occurred after mobilisation, Found Proved

c. information about neck and shoulder pain, Found Proved

d. a physical examination; Found Not Proved

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25. By letters dated 28 January 2013 and 14 March 2013 you were invited to undergo a performance assessment; Found Proved

26. You failed to submit to such performance assessment; Found Proved

And that by reason of the matters set out above your fitness to practise is impaired because your deficient professional performance.” Found Proved

Determination on Service and Proceed

Service

Ms Felix: Dr Ramos De Los Santos is neither present nor represented. You submitted that notification of this hearing has been properly served upon Dr Ramos De Los Santos in accordance with the General Medical Council (Fitness to Practise) Rules Order of Council 2004 (the Rules).

You informed the Panel that the notice of this hearing, dated 12 February 2014, was sent by FedEx, to Dr Ramos De Los Santos’ registered address on 12 February 2014 2014. The consignment document provided by FedEx, which is used to record the delivery of the package, indicates that the Notice of Hearing was delivered on 14 February 2014. The Notice of Hearing was also successfully relayed to Dr Ramos De Los Santos’ e-mail address on 12 February 2014.

The Panel is therefore satisfied that the General Medical Council (GMC) has produced evidence which demonstrates that notification of today’s proceedings has been properly served upon Dr Ramos De Los Santos in accordance with the Rules.

Proceeding in absence

You invited the Panel to proceed in the absence of Dr Ramos De Los Santos pursuant to Rule 31. You referred to the judgment of R v Jones [2002] UKHL 5, in particular paragraph 18(5) setting out the factors the Panel should take into account in considering whether to proceed in Dr Ramos De Los Santos’ absence.

You drew the Panel’s attention to the various correspondence between the GMC and Dr Ramos De Los Santos. You submitted that the Panel can properly conclude that Dr Ramos De Los Santos is well aware of the proceedings and that she has deliberately and voluntarily waived her right to attend or be represented. You also submitted that an adjournment would not assist as Dr Ramos De Los Santos has indicated, in her e-mail

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correspondence, dated 21 December 2013, that she no longer wished to participate in these proceedings.

The Panel has already determined that, in the light of the documentation provided, that notification of today’s proceedings has been properly served. That notice informed Dr Ramos De Los Santos that the Panel has the power, if she does not appear, to hear and decide upon the allegations in her absence.

The Panel has had regard to all the documentary evidence produced. It noted that Dr Ramos De Los Santos has corresponded with the GMC throughout the investigation. It acknowledges that she has in the past referred to financial difficulties and sought advice from the GMC on how to obtain assistance with her case. However, she has not provided any evidence that she has contacted the Bar Pro Bono, as advised to do, and in her most recent correspondence she has given a strong indication that she does not wish to attend the proceedings. On several occasions Dr Ramos De Los Santos has referred to matters relating to her health. However she has not, as invited to by the GMC, provided name and contact details of her treating doctor. She subsequently, in a further communication indicated that she did not ‘need to go to any doctor’. The Panel notes that she has not requested an adjournment. The Panel is therefore satisfied that Dr Ramos De Los Santos has waived her right to attend this hearing and be represented. The Panel considers that even if it were to adjourn today, it would be very unlikely that she would attend a future hearing.

The Panel is satisfied that in all the circumstances it is appropriate to proceed with the hearing in Dr Ramos De Los Santos’ absence. In reaching this decision the Panel has taken into account the seriousness of the allegations against Dr Ramos De Los Santos and is of the opinion that it is in the public interest to hear this case without further delay. Furthermore, in the Panel’s view it is in Dr Ramos De Los Santos’ interests to proceed given the concerns she has raised regarding the length of time the GMC investigation has been on-going and the effect this has had upon her. It considers that no purpose would be served by an adjournment.

Determination on facts

Ms Felix: The Panel has given careful consideration to all of the oral and documentary evidence adduced in this case. It has also taken account of the submissions you have made on behalf of the General Medical Council (GMC) and the comments made by Dr Ramos in her correspondence with the GMC. The Panel also noted the responses made by Dr Ramos to the Hillingdon NHS Trust internal investigation of January 2012.

Having read all of the witness statements which you submitted on behalf of the GMC, the Panel determined it would be assisted by hearing oral evidence from the following six witnesses, all of whom had been employed at Hillingdon Hospital at the material time.

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Dr Q, Consultant Anaesthetist Dr L, Consultant Anaesthetist and Lead Clinician for Obstetric

Anaesthesia Dr M, Consultant Anaesthetist Dr S, Consultant Anaesthetist and Associate Clinical Director Dr T, Consultant Anaesthetist and College Tutor Dr U, Consultant Anaesthetist

You made an application that these witnesses give their evidence by video-link. The Panel acceded to your application having determined there would be no injustice in so doing.

The Panel also heard oral evidence from:

Dr V , Consultant Anaesthetist and GMC Expert

The Panel received into evidence the witness statements of the following GMC witnesses in accordance with rule 34(11), all of whom were employed at the Hillingdon Hospital at the material time:

Ms W, Human Resources Business Partner Dr O, Consultant Anaesthetist Ms X, Anaesthetic Nurse Mr Y, Operating Department Practitioner (ODP) Dr N, Consultant Anaesthetist Dr R, Foundation doctor Dr P, Consultant Anaesthetist Dr Z, Staff Grade Surgeon Ms AA, Operating Department Practitioner (ODP)

It also read the witness statement of:

Mr BB, GMC Investigation Officer

Background

The Panel has been informed that Dr Ramos trained in Spain and qualified in 1990. The evidence before the Panel is that the post at Hillingdon Hospital was not Dr Ramos’ first post in the UK. However, the Panel has not been provided with any information from Dr Ramos regarding her professional background or work history.

GMC submissions You submitted that based on the evidence adduced, the Panel should find all of the factual allegations proved.

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Dr Ramos’ submissions

None were received by the Panel (She having been absent and unrepresented throughout).

Legal Assessor’s advice

The Legal Assessor advised the Panel that the burden of proof rests on the GMC and that the standard of proof required is that used in civil proceedings, namely the balance of probabilities. This standard means that a Panel may only be satisfied that an event occurred if it considers that the occurrence of the event was more likely than not.

The Legal Assessor also advised that matters of credibility and reliability of witnesses and the weight of the evidence were a matter for the Panel alone to decide.

The decision

The Panel has considered each paragraph of the allegation separately. The Panel is mindful that the burden of proof rests throughout on the GMC to the civil standard of proof. Accordingly, it has made the following findings on the facts:

Paragraph 1:‘Between 25 October 2010 and September 2011 you were

employed as a Speciality Doctor in Anaesthetics at the Hillingdon Hospital, Uxbridge.’

Has been found proved

The Panel notes the “introduction and background” of the Trust’s investigation of Dr Ramos which confirms the dates of Dr Ramos’ employment. The Panel therefore accepts that Dr Ramos was employed at the Hillingdon Hospital, Uxbridge between the dates stated.

PATIENT A

Paragraph 2: ‘On 16 February 2011 Patient A was listed for a laparoscopic

right hemicolectomy.’Has been found proved

The Panel took account of Patient A’s medical records, which note that she was listed for a laparoscopic right hemicolectomy on 16 February 2011.

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Paragraph 3a: ‘You failed to undertake an adequate pre-operative

anaesthetic assessment of Patient A in that you did not record all relevant information on the anaesthetic record, namely

i. Physiological observations,

ii. Relevant physical examinations,

iii. Relevant investigations,

iv. That Patient A was a Jehovah’s Witness who had refused blood transfusion during major surgery.’


Patient A was a 73 year old woman who presented with iron deficiency anaemia, was found to have a carcinoma of the caecum and was listed for laprascopic right hemicolectomy.

It was Dr Q’s evidence that she had sent Dr Ramos to the ward to carry out a pre-operative assessment on Patient A. When she arrived 15 minutes later she found Dr Ramos carrying out her pre-operative assessment without the patient’s notes, and writing the patient’s replies on the printed operating list. Dr Q told the Panel that she went to get the patient records and handed them to Dr Ramos.

Dr Ramos stated in her written response to the Trust, dated 8 December 2011, that she could not remember the incident.

The Panel has considered the anaesthetic assessment which is contained within Patient A’s clinical records. The sections on the printed chart relating to physiological observations, physical examination and investigations have been left blank. Furthermore, there is no mention that the patient was a Jehovah’s witness and that she had refused a blood transfusion. Although that fact had been recorded at a pre-operative assessment clinic on 2 February 2011, Dr Ramos failed to include this information on the anaesthetic record.

Dr V’s expert opinion was that the purpose of a pre-operative anaesthetic assessment is to identify patients who are at a particularly high risk. She further stated that that it was imperative that Dr Ramos transferred all the relevant information to the anaesthetic record so that the information would be available to all other clinicians involved in Patient A’s care.

Paragraph 3b: ‘You failed to undertake an adequate pre-operative

anaesthetic assessment of Patient A in that you did not have

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Patient A’s clinical notes during your pre-operative assessment consultation with Patient A.’


Dr Q told the Panel that she found Dr Ramos carrying out her pre-operative assessment without the patient’s medical notes, and writing the patient’s replies on the printed operating list, although the notes were easily available on the ward desk.

Dr V’s expert opinion was that a review of the patient’s medical notes for past medical and anaesthetic history is an essential part of the pre-operative assessment.

PATIENT B

Paragraph 4: ‘On 17 March 2011 Patient B returned to theatre for revision

surgery having had a caesarean section on 16 March 2011 following which there had been continuing blood loss from the abdominal drain.’


The Panel took account of Patient B’s medical records which note that the patient had returned on 17 March 2011 for revision surgery following a caesarean section on 16 March 2011.

Paragraph 5a: ‘On 17 March 2011 you inappropriately administered

thiopentone to Patient B during an emergency laparotomy for postpartum bleeding contrary to current safe UK anaesthesia practice.’


Dr L told the Panel that Dr Ramos had given the patient two 60mg doses of thiopentone, an anaesthetic induction agent, which can cause respiratory depression and loss of laryngeal reflexes.

Dr Ramos, in her written response to the Trust, appears to deal with the caesarean section undertaken on 16 March 2011 and not the revision surgery on 17 March 2011.

Dr V’s expert opinion was that it was not appropriate for Dr Ramos to administer thiopentone to this patient at all, unless she intended to give a full general anaesthetic. Furthermore it was not appropriate to administer thiopentone in a volume which induced unconsciousness, as this was tantamount to giving a general anaesthetic to the patient without the necessary safeguards to protect the airways from obstruction. She stated that this was contrary to current UK safe practice.

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The Panel considers that administering thiopentone in that manner was inappropriate and accordingly finds this proved. Paragraph 5b:

‘On 17 March 2011 you administered thiopentone to Patient B when there was no anaesthetic assistant present.’

Has been found not proved

The Panel has seen no documentary or witness evidence to support this allegation.

Paragraph 5c: ‘On 17 March 2011 you failed to intubate Patient B.’Has been found proved

It was Dr L’s evidence that this patient was unconscious and not intubated.

The Panel has heard that the induction of general anaesthesia carries a significant risk of aspiration of gastric contents in pregnant women and for a period after delivery, especially after operative delivery. If general anaesthesia is planned, steps must be taken to protect against this.

Dr V’s expert opinion was that it was inappropriate for Dr Ramos not to intubate an unconscious patient. In this situation, the airway and the lungs were at risk.

The Panel accepted the evidence of Dr V.

PATIENT C

Paragraph 6a:‘On 15 August 2011 whilst working with Dr L to perform a

rapid sequence induction on Patient C you inappropriately injected Patient C with 250mg thiopentone as a bolus.’


Patient C was an elderly patient. Dr L told the Panel that she thought the airway might be difficult so she wanted to manage it carefully. Dr L asked Dr Ramos to give the patient 125mg of thiopentone. She expressed her surprise when Dr Ramos administered 250mg. That dose is confirmed in the patient’s medical records.

It was Dr L’s evidence that Dr Ramos injected the thiopentone as a bolus, i.e. it was given rapidly and not titrated to effect.

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Dr V told the Panel that the recommended dose for a patient would be 180-360mg, or less in an elderly patient, having emergency anaesthesia and suffering from a number of co-morbidities. She did not criticise the use of thiopentone or the dose given but the manner in which it was given. She was of the opinion that to inject it as a bolus was inappropriate because it could result in a very rapid decline in respiration.

Paragraph 6b: ‘On 15 August 2011 whilst working with Dr L to perform a

rapid sequence induction on Patient C you injected Patient C with 250 mg of thiopentone in disregard to the instruction of Dr L.’


The Panel accepted Dr L’s evidence that she told Dr Ramos to give the patient 125mg of thiopentone. Dr L further stated that when administering the thiopentone, Dr Ramos did not stop at 125mg as initially told, but carried on until 250mg of thiopentone was administered.

Having had regard to the drug chart, the Panel can be satisfied that Dr Ramos did administer 250mg of thiopentone to the patient instead of 125mg.

Paragraph 6c: ‘On 15 August 2011 whilst working with Dr L to perform a

rapid sequence induction on Patient C you did not know the concentration of thiopentone.’


It was Dr L’s evidence that when she asked Dr Ramos for an explanation for her actions she replied that she did not know the concentration of the drug she was giving.

The Panel has heard that thiopentone is a mainstay of anaesthetic practice and was a commonly used drug at the Hospital.

In her written response to the Trust, Dr Ramos requested more information about the patient. However, she did indicate that thiopentone was a drug she had used frequently over many years and knew very well.

The Panel accepted the evidence of Dr L that Dr Ramos did not know the concentration of thiopentone.

Paragraph 6d: ‘On 15 August 2011 whilst working with Dr L to perform a

rapid sequence induction on Patient C you in the alternative to 6(c) above, were not able to remember the concentration of thiopentone.’

Has been found not proved

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As a consequence of the Panel’s findings in 6(c) above, the Panel finds 6(d) not proved as this allegation is posited as an alternative.

PATIENT D

Paragraph 7: ‘Patient D was booked on the trauma list on 19 July 2011 for laparoscopic appendicectomy; Has been found proved

Patient D’s medical records and Dr M’s statement both show that this patient was booked on the trauma list on 19 July 2011 for laparoscopic appendicectomy.

Paragraph 8: ‘You were undertaking the trauma list with Dr M.’Has been found proved

The trauma list confirms that Dr Ramos was undertaking the trauma list with Dr M.

Paragraph 9:‘In respect of Patient D you failed to

a. carry out a rapid sequence induction correctly, Has been found proved

b. intubate Patient D’s trachea,Has been found proved

c. recognise that you had intubated Patient D’s oesophagus. ‘Has been found proved

Patient D was a 40 year old female patient who presented in the Accident and Emergency Department on the evening of 18 July 2011 with abdominal pain. She was booked on the trauma list on 19 July 2011 for laparoscopic appendicectomy.

Dr W gave his account of the incident and referred to the near contemporaneous note he provided to the Trust, dated 22 July 2011. He told the Panel that following the induction of anaesthesia Dr Ramos made a number of attempts to intubate the trachea, using the laryngoscope and bougie technique. Dr M criticised Dr Ramos’ practice - in particular that she could not say whether the endotracheal tube was in the trachea or the oesophagus, she did not check the monitor screen during the incident and she did not have a ‘Plan B’ to deal with a failure to carry out a rapid sequence induction.

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Dr Ramos’ written response is in conflict with Dr M’s account. She accepted some of the criticisms made but recalled that it was easy to ventilate the patient and that she wished to give gentle manual ventilation whilst checking the monitor. She also referred to a possible plan if a further attempt at intubation was unsuccessful and to the drugs she would have given the patient. She said that she knew that on both occasions the tube was not in the trachea but in the oesophagus. On balance, the Panel prefers the evidence of Dr M which was written as an expression of concern to consultant colleagues, three days after the material events on 22 July 2011, over the account of Dr Ramos which was given on 8 December 2011.

Dr V explained to the Panel that, whilst acknowledging that this was not an easy patient to intubate, rapid sequence induction is one of the basic anaesthetic techniques. She was critical of Dr Ramos for not knowing whether or not she intubated the trachea and for apparently having no suitable alternative plan of action in the face of a failed rapid sequence induction.

PATIENTS E & F

Paragraph 10: ‘Patient E was listed for left knee arthroscopy on 4 August

2011 and Patient F was listed for right total knee replacement on 25 August 2011.’


The Panel took account of Patient E’s medical records. The Panel found that the date of surgery from the anaesthetic record indicates that the procedure was in fact listed for 3 August 2011.

The Panel also took account of Patient F’s medical records which confirms that the patient was listed for this procedure on 25 August 2011.

Paragraph 11: ‘In respect of each date you failed to check the anaesthetic

machines.’Has been found proved

The Panel has noted the evidence of Dr N and the two emails exhibited to his witness statement dated 4 August 2011 and 25 August 2011 and sent to Dr CC that on the relevant dates the anaesthetic machines had not been checked.

Paragraph 12: ‘On 4 August 2011 when asked by Dr N to check the

anaesthetic machines in the anaesthetic room and theatre you indicated that the machines were in order when in

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fact the sevoflurane vaporiser on the anaesthetic machine in theatre was completely empty.’


The Panel accepted the evidence of Dr N who stated in his 4 August 2011 email to Dr CC that when he asked Dr Ramos to check the anaesthetic machines, she had not checked either the machine in the theatre room or the machine in the anaesthetic room on 4 August 2011. In an email of 25 August 2011, Dr N said that Dr Ramos had “…failed to see that Sevo vaporiser was completely empty…”

In her written response Dr Ramos detailed the checks she made on both 4 August and 25 August 2011 and acknowledged that the sevoflurane vaporiser in theatre was empty on 4 August 2011 and that on 25 August 2011, the vaporiser was half full in theatre.

The Panel is satisfied that based on the evidence of Dr N and Dr Ramos’ own admission that on 4 August 2011, the sevoflurane vaporiser in the anaesthetic machine in theatre was empty.

Paragraph 13: ‘On 25 August 2011 you indicated to Dr N that all the anaesthetic machines had been checked and were in order when in fact the sevoflurane vaporiser was completely empty.’Has been found proved

The Panel accepted the evidence of Dr N in his email of 25 August 2011 who stated that:

“… she has confidently told me all the checks have been done and everything is good to go. Unfortunately she failed to see that the Sevo vapouriser was completely empty, this was a tad disappointing as this is what she missed a couple of weeks ago.”

PATIENT G

Paragraph 14: ‘On 8 August 2011 Patient G (aged 5) was admitted for

reduction and internal fixation of a fracture of his/her left elbow.’Has been found proved

The Panel took account of Patient G’s medical records which note that on 8 August 2011, the patient was admitted for reduction and internal fixation procedure.

Paragraph 15: ‘You were working on the trauma list with Dr O.’

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On the basis of Dr O’s witness statement, the Panel can be satisfied that Dr Ramos was working on the trauma list with Dr O.

Paragraph 16a: ‘In respect of Patient G you disregarded the explicit instruction of Dr O to

i. cannulate Patient G, Has been found not proved

The Panel accepted the evidence of Dr O that she had given Dr Ramos explicit instructions to cannulate patient G.

In her written response, Dr Ramos confirms that she did indeed receive instructions from Dr O to cannulate the patient. Since Dr Ramos proceeded to cannulate Patient G, she cannot be said to have disregarded Dr O’s instruction to do so.

ii. await Dr O’s return before inducing anaesthesia.Has been found proved

The evidence given by Dr O makes it clear that she asked Dr Ramos to await her return before inducing anaesthesia. This is confirmed in the witness statement of Mr Y, Operating Department Practitioner (ODP). Dr Ramos’ written response is that while Dr O was helping someone in theatre she decided to use gas instead as the child had become anxious. On the basis of that admission, the Panel is satisfied that Dr Ramos did not await Dr O’s return before inducing anaesthesia as instructed.

Paragraph 16b: ‘In respect of Patient G you repeatedly and

unsuccessfully tried to cannulate a vein.’Has been found proved

The Panel accepted the written evidence of Ms X, who stated that:

“… I can’t recall how many times Dr Ramos had tried to get the cannula in …”

Paragraph 16c: ‘In respect of Patient G you

i. asked and/or allowed Patient G’s mother to hold the anaesthetic mask whilst administering 7% sevoflurane and whilst you and your assistant were otherwise occupied.’Has been found proved

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The Panel noted the written evidence of Ms X that Dr Ramos told Patient G’s mother to put the face mask over the child’s face. It also noted the written evidence of Mr Y, ODP who stated that he came into theatre, saw what was happening and immediately took over from the mother.

Dr Ramos, in her written response, explained that the child had become anxious and was crying. She also accepted that she did ask the child’s mother to hold the face mask over the child’s face. However, she stated that this was for a second, whilst she tried to hold the child, she then went to the head of the bed and took the face mask.

Dr V’s expert opinion was that it was not appropriate for Dr Ramos to allow Patient G’s mother to do this. She stated that airway maintenance is a specialist skill requiring training and expertise, particularly in small children, who can ‘go off’ very quickly.

In the light of the evidence of Ms X and Mr Y and of Dr Ramos’ own admission, the Panel is satisfied that Dr Ramos asked and/or allowed Patient G’s mother to hold the mask.

PATIENT H

Paragraph 17: ‘Patient H was admitted for insertion of wire and removal of a

breast lump on 26 August 2011.’Has been found proved

The Panel took account of Patient H’s medical records which note that the patient was admitted on 26 August 2011 for this procedure.

Paragraph 18: ‘On 26 August 2011 whilst working on a list with Consultant

Anaesthetist Dr P you

a. disregarded Dr P’s instruction not to anaesthetise Patient H until Dr P returned,Has been found proved

Patient H was a 51 year old woman. Dr P was the anaesthetist responsible for the list and she was working with Dr Ramos and Dr R, a Foundation Year (FY1) doctor who had done approximately three weeks of anaesthetic observation. In Dr P’s written evidence, she had told Dr Ramos not to start the case until she had returned. When she returned she found Dr Ramos putting the patient to sleep and Dr R ventilating the lungs.

Dr V’s was of the opinion that disregarding the instruction of a consultant anaesthetist was not appropriate.

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b. in breach of current guidelines induced anaesthesia in Patient H without an anaesthetic assistant present,Has been found proved

The Panel accepts Dr P’s account that there was no ODP present. The guidelines as identified by Dr V, state that to induce anaesthesia without an anaesthetic assistant present is neither in line with the current guidelines nor was it appropriate.

c. delegated airway management to Dr R without close supervision and assistance;Has been found proved

The Panel has considered Dr R’s witness statement in which she stated that Dr Ramos had delegated airway management to her. Dr R stated that Dr Ramos was aware of her inexperience.

Dr V’s expert opinion was that it was not appropriate for Dr Ramos to delegate airway management to Dr R without close supervision and assistance.

PATIENT J

Paragraph 19: ‘Patient J (a child) was listed for extractions of upper left and

right incisor teeth on 15 September 2011.’Has been found proved

The Panel took account of Patient J’s medical records which note that the patient was listed for this procedure on 15 September 2011.

Paragraph 20: ‘On 15 September 2011 whilst working on the oral surgery list

with Dr Q you

a. informed Dr A that you had checked the anaesthetic machines in both the anaesthetic rooms and theatre when you had not,Has been found proved

In Dr Q’s written statement to the Panel, she had asked Dr Ramos whether she had checked the anaesthetic machine. Dr Ramos admitted that she had not carried out the mandatory checks on the machines which she had previously been instructed to do.

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There is no evidence before the Panel to demonstrate that Dr Ramos did check the machines, but based on her admission, recorded by Dr Q, that she had not checked the machine in theatre, the Panel can be satisfied Dr Ramos did not check both machines.

b. failed to identify a leak in the anaesthetic machine;


The Panel has had the benefit of hearing Dr Q’s evidence in which she told the Panel that Dr Ramos did not pick up the leak in the anaesthetic machine.

In a written response from Dr Ramos, she states that the leak happened after the check had taken place. Although Dr Ramos’ account was not explored with Dr Q in evidence, the Panel found Dr Q to be a credible witness and accepted her written and oral evidence. Therefore, on the balance of probabilities, the Panel is satisfied that it is more likely than not that Dr Ramos failed to identify a leak in the anaesthetic machine.

Paragraph 21: ‘During the transfer of Patient J to recovery you failed to

notice that Patient Ja. was not breathing properly,


b. had become hypoxic.’Has been found proved

Dr Q told the Panel that following the procedure she asked Dr Ramos to take the patient to recovery. It was Dr Q’s evidence that Dr Ramos was reversing the bed out of the anaesthetic room and was at the head of the bed. She therefore had the responsibility to check the oxygen bag. Dr Q placed herself at the side of the child. Her main criticism was Dr Ramos’ reaction; when asked whether the child was breathing, she was dismissive and when the concerns were raised she did not acknowledge she had missed something.

There is a disparity in Dr Ramos’ written account and the evidence of Dr Q. Dr Ramos claims that Dr Q was at the head of the child. Dr Ramos also criticised Dr Q’s handling of the patient as she did not put the patient in the recovery position or use a swab to pack the bleeding in the patient’s mouth. In her opinion as a consequence the blood flowed back into the patient’s throat and he became hypoxic.

Dr Q’s evidence was that there was no reason to put the child in the recovery position as a laryngeal airway was in place and a swab does not always stop the blood flow.

The Panel is satisfied by the written and oral evidence of Dr Q that Dr Ramos did fail to notice that Patient J was not breathing properly and had

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become hypoxic. The evidence of Dr Q is supported by the evidence of Ms AA.

PATIENT K

Paragraph 22: ‘Patient K underwent an elective caesarean section on 31

December 2010 under combined spinal epidural anaesthesia (CSE) where you were the anaesthetist.’


The Panel took account of Patient K’s medical records which note that the patient underwent the procedure on 31 December 2010 and that Dr Ramos was the anaesthetist on that day.

Paragraph 23: ‘On 4 January 2011 you performed a blood patch on Patient K in breach of current guidelines in that you failed to involve a consultant or senior colleague.’Has been found proved

The Panel has been informed that a blood patch is a surgical procedure used to close one or many holes in the dura of the spinal cord, usually caused as a result of a previous epidural procedure.

Dr L told the Panel that she provided Dr Ramos with the Hospital guidance regarding ‘Accidental Dural Tap’ and how to manage the situation on the very morning of the incident. The guidelines require that a consultant anaesthetist is informed before carrying out a blood patch to aid follow-up and advice. The guidance also provides that a patient should be reviewed with a senior colleague before doing a blood patch.

It was Dr L’s evidence that Dr Ramos had the necessary information to enable her to follow the Trust guidelines. However, later that day, Dr L was informed that Dr Ramos had carried out a blood patch on Patient K without consulting with a senior colleague.

Dr Ramos has not provided a written response in relation to Patient K.

Dr V was of the opinion that it was not appropriate for Dr Ramos to perform a blood patch on Patient K without senior involvement given that she had been provided with the Trust’s guidelines by Dr L. Furthermore, there were two consultant anaesthetists present on the ward that day and Dr V was of the opinion that Dr Ramos should have informed one of them.

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The Panel considers that having been given a copy of the Trust’s guidelines which clearly state that a senior colleague is required to be informed before carrying out a blood patch, Dr Ramos’ failure to inform her supervising consultant was a clear breach of those guidelines.

Paragraph 24: ‘Your record of the history in respect of Patient K was inadequate in that you failed to record

a. the method of anaesthesia,Has been found proved

b. information about whether the headache interfered with sleep and whether it occurred after mobilisation,Has been found proved

c. information about neck and shoulder pain,Has been found proved

d. a physical examination.’Has been found not proved

These findings are based on Dr Ramos’ clinical note dated 4 January 2011. The Panel notes that the method of anaesthesia, whether the headache interfered with sleep and whether it occurred after mobilisation, are not recorded. Neither is there any information about neck and shoulder pain. It accepts the expert opinion of Dr V that the failure to do so could be construed as inadequate.

In respect of paragraph 24(d), to the extent that the patient’s temperature and blood pressure had been recorded, the Panel has concluded that a physical examination had been carried out.

Paragraph 25: ‘By letters dated 28 January 2013 and 14 March 2013 you were invited to undergo a performance assessment.’Has been found proved

The Panel has been provided with the letters sent by the GMC to Dr Ramos dated 28 January 2013 and 14 March 2013.

Paragraph 26: ‘You failed to submit to such performance assessment.’


The Panel took account of the witness statement by Mr BB, Investigation Officer who stated in his written evidence that:

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“I did not receive any further response from Dr Ramos in relation to the performance assessment or otherwise. I can see no evidence in the case file on GMC’s case management system, Siebel, that Dr Ramos agreed to undergo a performance assessment, or that she corresponded with the GMC any further in relation to the performance assessment and I am not otherwise aware of any such further correspondence having been received by the GMC.”

In the light of Mr BB’s evidence, the Panel can be satisfied that Dr Ramos failed to submit to undergo a performance assessment.

Determination on impaired fitness to practise

Ms Felix: Having announced its findings on the factual allegations, the Panel has now considered whether Dr Ramos’ fitness to practise is impaired by reason of deficient professional performance. The Panel has taken into account all of the evidence before it. It has noted the submissions made by you on behalf of the General Medical Council (GMC) and the comments made by Dr Ramos in her correspondence with the GMC and in her responses to the Hillingdon NHS Trust internal inquiry.

GMC Submissions

You submitted that the matters before the Panel do not relate to a single incident of negligent treatment but rather to a pattern of failings occurring over a relatively lengthy time, relating to ten patients. You submitted that the pattern of poor practice related to:

a failure to check anaesthetic machines a failure to follow instructions inadequate assessment a failure to carry out basic procedures a dangerous delegation of responsibility

some of which were serious failings, particularly in relation to Patient G and Patient J.

You submitted that the matters before the Panel constitute a fair sample of Dr Ramos’ work.

You referred to Dr V’s expert report and oral evidence and submitted that the Panel should take account of her opinion when assessing whether there is deficient professional performance. You reminded the Panel of Dr V’s opinion that ‘she [Dr Ramos] is not safe enough’ and of the criticisms she made regarding Dr Ramos’ practice relating to a lack of knowledge, her attitude, a lack of insight and an inability to assess risk. You submitted that the Panel can properly find deficient professional performance.

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In relation to whether Dr Ramos’ fitness to practise is impaired you asked the Panel to bear in mind the opinions expressed by the consultants, who had worked with Dr Ramos. Regarding possible remediation Dr Ramos had been given the opportunity to re-train, under supervision, but this had no impact upon her. You highlighted that the Panel has no evidence regarding any steps Dr Ramos might have taken to remedy the concerns raised.

You submitted that the findings of fact are such that the Panel can conclude that Dr Ramos’ failings are so serious that she continues to present a risk to patients. Referring to the over-arching public interest you invited the Panel to conclude that Dr Ramos’ fitness to practise is impaired by reason of her deficient professional performance.

Legal Advice

The Panel accepted the advice of the Legal Assessor that the Panel must first decide whether there has been deficient professional performance and then, if so, is it such that the doctor’s fitness to practise is currently impaired.

The Legal Assessor drew the Panel’s attention to relevant case law, setting out the approach it should adopt when considering deficient professional performance and impairment.

He also advised the Panel to consider the context of the allegations made in respect of Dr Ramos’ level of experience as a speciality doctor in anaesthesia.

Panel’s Decision

In reaching its decision the Panel has exercised its own judgement. It has borne in mind that its primary duty is to consider the public interest, which includes amongst other things the protection of patients, the maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour. As advised, the Panel has approached the question of impairment in two stages.

Deficient Professional Performance

The Panel’s findings on facts refer to instances of:

inadequate pre-operative assessment inappropriate selection of anaesthetic techniques technical failings in rapid sequence induction (RSI) and dangerous

execution of the technique a potentially dangerous technique in the administration of an

anaesthetic induction agent ignorance as to the use of commonly used anaesthetic agents a failure to fully check anaesthetic equipment

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a disregard for instructions given by senior colleagues inappropriate delegation of tasks, particularly in relation to Patient G

when Dr Ramos delegated holding the anaesthetic mask to the patient’s mother

inadequate supervision of and delegation to an inexperienced junior member of staff

not recognising hypoventilation and hypoxia in a child ignoring Trust guidelines as to when to involve senior colleagues

The Panel considers that the wide ranging nature of these deficiencies, which are based on its findings in relation to ten unconnected clinical situations spanning a period of nine months, indicate a pattern of performance which raises significant concerns regarding Dr Ramos’ overall competence as an anaesthetist.

The Panel considers that the facts found proved in relation to these ten patients indicate significant departures from the standards expected of a reasonably competent speciality doctor in anaesthetics. It is particularly concerned that had colleagues not stepped in to assist Dr Ramos, when required, there could have been serious consequences for some of the patients.

Whilst the Panel accepts that Dr Ramos did not train in the UK and that there may be some differences in practice it is concerned that Dr Ramos had difficulty in carrying out the most basic of procedures. The Panel considers that the range of failings and in some cases the repetition of these failings demonstrate an unacceptable pattern of behaviour.

The Panel has noted that Dr Ramos’ colleagues from the Hillingdon Hospital, who had close knowledge of her clinical performance, all expressed serious concerns regarding her clinical knowledge and skills.

The Panel has been informed that as a result of the 17 March 2011 incident, relating to Patient B, Dr Ramos was removed from the obstetrics on-call rota immediately as it was considered that she was not safe to work unsupervised. She was offered remedial training and supervision. The training was competency based and she was assessed on the skills expected of a trainee in the early part of training. However, it appears that Dr Ramos was unwilling or unable to fully engage with the process as she did not provide Dr T, College Tutor, with completed and signed assessment forms.

Dr V explained that the difference between a safe and unsafe anaesthetist is that a safe anaesthetist has the ability to understand what can go wrong, is endlessly vigilant and has a willingness to react immediately. She told the Panel that attention to detail keeps patients safe and that although things do not often go wrong when they do it could be catastrophic. In Dr V’s opinion Dr Ramos ‘is not safe enough’. The Panel

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fully accepts Dr V’s opinion that Dr Ramos poses a risk to patient safety, she has an inability to analyse risk and put in place plans to manage and she does not undertake the fundamental role of an anaesthetist.

Dr V was of the opinion that the overall standard of care provided by Dr Ramos was variably below and seriously below the standard expected of a reasonably competent specialist doctor in anaesthesia.

On the basis of its findings the Panel is in no doubt that Dr Ramos’ professional performance was seriously deficient at the material time and that she was performing well below the standard expected.

Impairment

In determining whether Dr Ramos’ fitness to practice is currently impaired the Panel has considered whether her performance is remediable and whether it has been remedied.

The Panel accepts that the deficiencies identified are in principle remediable. However, the Panel has no evidence that Dr Ramos has attempted to remedy the deficiencies in her performance. Dr Ramos was given an opportunity to remediate but did not appear to fully engage in re-training and the evidence before the Panel is that her performance did not improve.

The Panel is concerned that Dr Ramos has continuously demonstrated that her practice is unsafe and that she lacks vigilance and caution. In the Panel’s view the way in which Dr Ramos has practised anaesthesia posed a risk to patient safety. Given her failure to submit to a GMC Performance Assessment and in the absence of any evidence as to her current practice or employment the Panel must conclude that that risk remains.

In all the circumstances the Panel has determined that Dr Ramos’ fitness to practise is impaired by reason of her deficient professional performance.

Determination on sanction

Ms Felix: Having determined that Dr Ramos’ fitness to practise is impaired by reason of her deficient professional performance, the Panel has considered the submissions you have made, on behalf of the GMC, regarding the appropriate sanction, if any, that should be imposed on Dr Ramos’ registration.

You drew the Panel’s attention to relevant paragraphs of the GMC’s ‘Indicative Sanctions Guidance’ (ISG). These state that the purpose of sanctions is not to be punitive but are designed to protect the wider public

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interest. The principle of proportionality should apply and aggravating and mitigating factors should be considered.

You submitted that Dr Ramos’ written responses to the Hillingdon Hospital Inquiry did not suggest that she had any understanding of her situation. You asked the Panel to note that she had been given the opportunity to retrain and did not avail herself of that opportunity.

You referred to the relevant paragraphs of ‘Good Medical Practice’ (2006), including the requirement for doctors to keep their professional knowledge and skills up to date. You submitted that the facts found proved are not supportive of her compliance with the principles set out in GMP.

You submitted that the concerns regarding Dr Ramos’ practice are wide-ranging, her practice is dangerous, that she lacks insight and that there is no evidence of remediation. As such Dr Ramos continues to pose a significant risk to patient safety.

You also submitted that Dr Ramos has demonstrated a reluctance to engage with GMC procedures which denotes a pattern of behaviour which is fundamentally incompatible with continued registration. You submitted that, given the seriousness of the findings made against Dr Ramos, erasure is the proportionate response in order to protect patient safety and maintain public confidence in the profession.

The Panel is aware that the decision as to the appropriate sanction, if any, to impose on Dr Ramos’ registration is a matter for this Panel exercising its independent judgment. It has taken account of the guidance in the current ISG.

In considering whether it is necessary for the protection of members of the public, in the public interest or in Dr Ramos’ own interests to make a direction in relation to her registration, the Panel has balanced the public interest against Dr Ramos’ own interests and has taken into account the principle of proportionality. The Panel recognises that the purpose of sanctions is not to be punitive, although they may have a punitive effect.

The Panel has borne in mind its duty to protect the public, to maintain public confidence in the medical profession, and to uphold proper standards of conduct and behaviour as set out in the GMC’s document “Good Medical Practice”.

No Action

The Panel first considered whether to conclude Dr Ramos’ case and take no further action but determined that, given the serious concerns regarding her deficient professional performance, concluding the case with no further action would be insufficient to protect patients nor would it be in the wider public interest.

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Conditions

The Panel next considered whether it would be appropriate to impose a period of conditions on Dr Ramos’ registration. It has borne in mind that any conditions must be appropriate, proportionate, workable and measurable.

It considered paragraph 62 of the ISG which indicates the circumstances in which conditions might be appropriate. These include identifiable areas of the doctor’s practice in need of assessment or retraining and potential and willingness to respond positively to retraining. It has also considered whether Dr Ramos’ wide-ranging deficiencies are remediable.

The Panel accepts that the deficiencies in Dr Ramos’ clinical practice are in principle amenable to remediation/retraining but it has little confidence that Dr Ramos would be open to retraining. In reaching this view the Panel has taken into account that the responses made by her to the Trust inquiry display scant evidence of insight. She did not fully engage with the Hospital retraining offered to her and she failed to submit to a performance assessment as invited to do by the GMC. In all the circumstances the Panel is not satisfied that Dr Ramos has the potential and willingness to benefit from and co-operate with any remedial measures which would have to be imposed in respect of conditional registration. It has therefore determined that conditions would not be a sufficient, appropriate or a proportionate response.

Suspension

In considering whether suspension would be the appropriate action in respect of Dr Ramos’ registration, paragraph 70 of ISG is apposite:

‘Suspension is also likely to be appropriate in a case of deficient performance in which the doctor currently poses a risk of harm to patients but where there is evidence that he/she has gained insight into the deficiencies and has the potential to be rehabilitated if prepared to undergo a rehabilitation programme. In such cases, to protect patients and the public interest, the panel might wish to impose a period of suspension, direct a review hearing and to indicate in broad terms the type of remedial action which, if undertaken during the period of suspension, may help the panel’s evaluation at any subsequent review hearing.’

The Panel also had regard to the non-exhaustive list of factors set out at paragraph 75 which indicate when suspension might be appropriate:

‘This sanction may therefore be appropriate when some or all of the following factors are apparent (this list is not exhaustive):

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- In cases involving deficient performance where there is a risk to patient safety if the doctor’s registration were not suspended and where the doctor demonstrates potential for remediation or retraining.

- No evidence of harmful, deep-seated personality or attitudinal problems.

- Panel is satisfied doctor has insight and does not pose a significant risk of repeating behaviour.’

The Panel has had regard to ‘Good Medical Practice’ and considers that there are a number of examples of departures from the standards expected:

Recognising and working within the limits of your competence (paragraph 3a),

Keeping clear, accurate and legible records (paragraph 3f), Taking advice from colleagues when appropriate (paragraph 3i), Keeping knowledge and skills up-to-date (paragraph 12), Delegation (paragraph 54)

All of these are areas which would fall within the ambit of a retraining programme.

However, the Panel has not been provided with any direct evidence of any insight nor of Dr Ramos’ willingness to address the deficiencies identified in her practice. On the contrary it appears that Dr Ramos has a lack of insight into the need for her to re-train in order to practice safely in the UK. In her responses to the Hillingdon Hospital Inquiry Dr Ramos accepted that some things went wrong but she also denied other matters and took contrary views to the consultants with whom she had worked.

The Panel has grave concerns about the safety of Dr Ramos’ practice given the evidence of the consultant anaesthetist witnesses who worked with her. This was also confirmed in the expert opinion of Dr V who stated that ‘she is not safe enough’. It heard evidence of an attitudinal problem as Dr Ramos had demonstrated an unwillingness to take criticism, accept advice or react positively and modify her practice when required. Some of the witnesses referred to Dr Ramos repeatedly stating, when challenged, that this was ‘how she practised in Spain’.

In a statement, dated 29 November 2013, Dr T, Consultant Anaesthetist and College Tutor at the Hospital, referred to a meeting with Dr Ramos in April 2011. She noted the following in respect of discussions with Dr Ramos about the 17 March 2011 incident:

‘As it turned out, during the meeting it became quite evident that Dr Ramos did not think she had done anything wrong. She was very

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angry and said that her actions during the 17 March incident were how she worked in Spain and there was nothing wrong with them. This was even more concerning to me – she seemed to have a lack of insight.’

Dr T noted the following in respect of the training that Dr Ramos was asked to undertake:

‘I made it clear to Dr Ramos that Dr N and I would be looking at the evidence of her assessments and making a decision as to whether

she could go back on the on-call rota. I did not receive anything back from Dr Ramos. She simply did not provide me with any evidence of having completed the assessments…’

In oral evidence Dr T stated that she thought Dr Ramos was ‘untrainable’.

The Panel is disappointed that Dr Ramos has not provided any evidence regarding her past or current practice or supportive testimonials. The Panel can only make a decision upon the evidence it has before it and it has no evidence about Dr Ramos’ current practice, future intentions and whether she would engage with the GMC.

Having regard to all the circumstances of the case, and in particular Dr Ramos’ lack of any potential for retraining, lack of awareness of the need for such and scant insight as referred to in paragraphs 70 and 75 of ISG, the Panel has determined that it would be neither appropriate nor sufficient to suspend Dr Ramos’ registration.

Erasure

The Panel has therefore determined that Dr Ramos’ name should be erased from the Medical Register. This case demonstrates in particular the following elements, as set out in paragraph 82 of the ISG:

‘- A risk of doing serious harm to others (patients or otherwise), either deliberately or through incompetence and particularly where there is a continuing risk to patients,

- A reckless disregard for the principles of Good Medical Practice and/or patient safety,

- Persistent lack of insight into seriousness of actions or consequences.’

In all the circumstances the Panel is satisfied that erasure is the proportionate and appropriate sanction

The effect of the foregoing direction is that, unless Dr Ramos exercises her right of appeal, her name will be erased from the Medical Register 28

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days from the date on which written notice of this decision is deemed to have been served upon her.

Determination on immediate sanction

Ms Felix: Having determined that Dr Ramos’ name be erased from the Medical Register the Panel has now considered, in accordance with Section 38 of the Medical Act 1983 as amended, whether to impose an immediate order on her registration.

You submitted, on behalf of the GMC, that an immediate order is appropriate in this case given the Panel’s findings.

The Panel is aware that it may impose an immediate order where it is satisfied that it is necessary for the protection of members of the public, or is in the public interest or is in the best interests of the practitioner.

The Panel has determined that, given the serious and wide-ranging deficiencies in Dr Ramos’ practise and its opinion that she continues to pose a risk to patient safety, it is necessary for the protection of members of the public and in the public interest to suspend Dr Ramos’ registration forthwith.

The substantive direction for erasure, as already announced, will take effect 28 days from when written notification is deemed to have been served upon Dr Ramos, unless an appeal is lodged in the interim. The order of immediate suspension takes effect when notice is deemed to have been served on Dr Ramos and will remain in force until the substantive direction takes effect, or until such time as the outcome of any appeal is decided.

The interim order currently imposed on Dr Ramos registration will be revoked when notice of the immediate suspension is deemed to have been served.

That concludes this case.

Confirmed

26 March 2014 Mr N Fyfe, Chairman

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