DANIEL RAVINDRA SUNDAR VEERAVALLI v GENERAL MEDICAL COUNCIL

A section 40 appeal is an appellate rehearing, not merely supervisory review. The High Court may substitute its own decision, while giving appropriate respect to a specialist tribunal’s primary factual findings and professional expertise.

Informed consent remains necessary even where a proposed management plan is clinically reasonable, particularly where the treatment carries significant risks and alternatives exist. Serious failures in consent, communication and clinical assessment may amount to misconduct. Current impairment may properly be found where the practitioner has shown insufficient insight into personal failings, remediation is inadequate and repetition cannot be regarded as highly unlikely.

The appellant, a consultant obstetrician and gynaecologist, appealed under section 40 of the Medical Act 1983 against a Medical Practitioners Tribunal decision finding misconduct, current impairment of fitness to practise and imposing 12-month conditions on his registration.

The proceedings concerned his management of a patient undergoing a difficult vaginal breech delivery. The Tribunal found failures including recommending syntocinon without direct clinical review, failing to obtain informed consent for its continuation, misinterpreting the cardiotocographic trace and failing to formulate a safe management plan. It did not find that those failings caused the baby’s death.

The central issues were whether the Tribunal’s factual findings, misconduct and impairment determinations were wrong or procedurally unjust, and whether the appeal should result in intervention under section 40.

1. Appeal dismissed. The Tribunal’s decision was neither wrong nor unjust because of serious procedural or other irregularity.
2. Under section 40, the High Court exercises an appellate jurisdiction by way of rehearing. It is entitled to substitute its own decision, but the rehearing is not unrestricted. Under paragraph 19.1 of PD 52D, the court will generally respect primary findings made by the tribunal which heard the witnesses. The court must correct material errors of fact or law and exercise its own secondary judgment; it must not abdicate that responsibility. The approach in Meadow v General Medical Council [2007] QB 462, Raschid v General Medical Council [2007] 1 WLR 1460, Ghosh v General Medical Council [2001] 1 WLR 1915, Sastry v General Medical Council [2021] EWCA Civ 623 and Gupta v General Medical Council [2001] UKPC 61 was applied.
3. The Tribunal was entitled to accept the consistent evidence of the appellant’s colleagues, to find that he had recommended syntocinon without first reviewing the patient, and to distinguish that finding from a finding that he had directed that it be commenced without later review or consent.
4. The Tribunal was entitled to conclude that, when the appellant saw the patient after syntocinon had commenced, he had a duty to discuss continuation, explain its benefits and risks, take account of her views and obtain verbal consent. A clinically reasonable plan to continue the infusion and review it shortly afterwards did not remove the separate requirement for consent, particularly where the procedure was risky and alternatives were available.
5. The Tribunal was entitled to rely on the recorded baseline heart rate as reflecting the appellant’s understanding at the relevant time. Its finding that he failed adequately to interpret the CTG and formulate a safe management plan was not inconsistent with its separate finding that persistent fetal tachycardia for approximately one hour had not been proved.
6. The Tribunal applied the correct test for serious professional misconduct. The appellant’s failures in consent, communication, CTG assessment and management planning were capable of amounting to a serious departure from expected professional standards. Its conclusion was not improperly dependent on the tragic outcome or on criticisms not found proved, and was independently open on the evidence.
7. The Tribunal was also entitled to find current impairment. It distinguished generic responsibility as consultant from insight into personal failings, considered remediation and the absence of repetition, and concluded that repetition could not be regarded as highly unlikely. The need to protect the public and maintain professional standards and public confidence justified the impairment finding.

1. High Court (Administrative Court) — The appeal under section 40 of the Medical Act 1983 was dismissed.
2. Medical Practitioners Tribunal — On 3 September 2021, the Tribunal found the appellant’s fitness to practise impaired by misconduct and imposed conditions on his registration for 12 months.