I have been asked to provide a comment on the current ongoing case of the GMC v Dr H Webberley. The Tribunal hearing is being held at the Medical Practitioners Tribunal Service (MPTS).
Firstly, this blog is an opinion on matters as they proceed, and I have no part in the case. I am merely viewing aspects from the outside, like many others. I am preparing this in a non-professional capacity, but I do have some experience at giving expert evidence at tribunal over many years.
I am getting updates from ‘live Tweets’ from the hearing provided from the Tribunal service and will see if I can get a press update as well. I am also thankful to @truesolicitor and others for their updates on this case. We are aware of other live feeds but are also aware that these are not as accurate and the reporting is, let’s say, skewed. ‘live tweets’ are taken from them being in the room and hearing and seeing proceedings. Apart from being there, it’s the best we can get.
I am trying to remain faithful to the feeds and comments made, but to report the facts and give a background to the proceedings and how the trial system works.
In this case, and current tribunal hearing, Dr Webberley (Dr W) is accused of practising medicine outside the rules and regulations of the General Medical Council (GMC) during the period March -November 2016, A failure to hold a proper safeguarding policy, and (2018) a failure to be registered as a practice in Wales. But there is more to it than that.
This update is from day 23
Day 23 is brought to you by trying to sound convincing but it’s not working.
(Thursday) [week 6] of the public hearing.
Intended start at 10:00am.
Note: We are advised that connection of the feed that Live Tweets, who are providing the reporting of this case from the hearing, are delayed at the start of some sessions.
As such some of the discussion and questions are being missed by them and aren’t being reported on. The extent of this detail will only become evident once the full transcripts are published.
In general, this is unlikely to affect the pathway of this case, from an understanding point of view, but some aspects are being missed, by them, and consequently those reporting on this case.
Dr Klink is back today to finish his evidence mainly about Patient C. There will be some further examination from SJ on matters relating to his cross examination by IS
After a delayed start and some missed feed, IS continues his questioning of Dr Klink. (He is from the Netherlands; you may recall and is very fond of MDT’s in any form.
As the start of the feed is missing, some of the early questions are missed.
IS continues asking Dr Klink about the concerns of the patient, the difficulty of the patient’s experience and the fact that Dr W is trying her hardest to help the situation.
Dr Klink confirms this aspect and acknowledges the input of the Tavi (and PGB) isn’t necessarily the best at the time.
These are pure gatekeeping and integral and institutional issues withing the NHS. These are from 2016. NONE have been addressed in any way since. Even Dr Klink indicates that matters may be improving, or should be improved, but with little progress.
Dr Klink indicates that he giving his evidence is supposed to engender discussion, debate, and bring about changes. It might but might not. This is a pure ‘them and us’ case. It’s about stopping and messing with those trying to move away from the established order.
Dr Klink is aware of the sensitivity of this case particularly surrounding the patient of younger ages, and how this area is being stifled by ‘outside’ interests. He is aware of the Cass review (now) and hopes that might help.
Dr Klink states “I think it’s feasible & responsible to give early medical intervention to trans youth, with the right medical supervision. I’m advocating for good medical practice in your country.”
Surely, that is EXACTLY what Dr W was trying to do, whilst those efforts were being (not so) quietly strangled by the medical “establishment”.
What is unlikely to happen is anything of the sort if the GMC ‘win’ this case. They will close ranks and make it even harder. Who suffers? The patients directly affected by the efforts that Dr W and others around the world are trying to bring about.
IS runs through the record of Pt C and what was asked for, received and medication considered. He readily accepts (again) that this is good practice.
Dr Klink, again, considers that physical examination of patients, in puberty is ‘important’ in many cases. IS is trying to suggest it isn’t. But Dr Klink stands fast on this point.
IS ends his cross-examination questions of Dr Klink.
What have learned?
That Dr Klink agrees (still) more often than not with the practice and procedure, when shown the notes and records, with how Dr W dealt with the patients. He hasn’t ever really said any is wrong or ‘dangerous’ but there are some areas of indifference perhaps.
Remember these three patients are those selected by PBG and/or others and used by the GMC for this case. PGB and /or others had complained to the GMC about the handling of these cases.
SJ takes over and re-examines Dr Klink on some matters that have arisen from his cross-examination. This is normal procedure, but not always needed. SJ is trying to ensure the panel have his side on some aspects and feels that reinforcement of those point would be useful.
SJ starts on Dr Klink’s favourite subject….MDTs.
However, the ‘flexibility’ of the approach again rises to the surface and Dr Klink also asserts that some methods provided by Dr HW are acceptable and appropriate.
Whilst Dr Klink is a fan of MDTs, he can’t confirm with any certainty that they are useful all of the time, when they are essential and when they are not suitable.[1] So that suggests a flexible approach, based on circumstance and the direct needs of an individual patient.
There is discussion surrounding age, height, and stage of puberty.
Dr Klink suggests that age 14 is the minimum[2] age for giving hormone therapy and that this is the age that ability to give patient led consent and understanding is placed.
He the counteracts this by saying that he has allowed patients at 13yrs 9 months to give ‘informed’ consent.
He also says that in some cases other factors can make this even lower and that a lower age is used around the world in some other centres.
He cannot state there are any studies that show an approach like this is detrimental, if (and only if) the GP/specialist has the appropriate level of skill and training. Remember Dr HW is not a novice at this, she is experienced and understands each patient’s needs. Remember also that NONE of the patients have complained about her care. Or being rushed through the system, treated badly, or given wrong advice. This case is driven directly from those with in the Tavi, via the GMC.
It’s what the Panel make of this that will decide this case. On the face of it, the evidence that she acted outside the level of expectation is weak. The GMS+C witness have all stated that flexibility is important and there isn’t a one size fits all. The established approach isn’t necessarily the right approach all the time.
The session goes to a break for a while. Again, the re start of the session is (again) fed out late to the Live Tweets/observers.[3]
SJ is trying to get Dr Klink to accept that the cut off should be 16 and maybe 14 but not lower. Dr Klink (a GMC witness) isn’t agreeing to this. He also refers to Dr Shaumer’s report (Dr HW witness) that treatment at age 12 is possible but does want to see how and why. He isn’t accepting it is wrong, just he wouldn’t do it.
SJ tries to asset on Dr Klink that the intervention of Dr HW in the matter whilst Pt B was being treated by PGB was, in fact Dr HW’s fault. That’s a bit rich as Pt B went to Dr HW for advice and guidance having been, or to be kicked out of the Tavi system.
SJ then corrects this, admitting his mistake, and saying the question relates to Pt A, not Pt B.
SJ struggles a little in getting the right bundles to refer to admitting one says one thing but means another.
SJ then refers to Dyslexia in patients and does this affect GD and treatment. Dr Klink explains that treatment of Dyslexia should be considered, maybe more than GD and would require a different approach.
What did we learn?
That Dr Klink hasn’t really changed his opinion much and hasn’t really fired any punches that would knock down the Blue boxer. He also doesn’t like the NHS way of doing things, but oddly, they are not on trial here.
The panel now ask questions of the witness to clarify any points they have.
These centre around clarification of ‘cross sex hormones in trans/natal patients. There is no evidence of a difference and that each patient needs to be considered on their own circumstances. Normal medical practice.
The panel again ask Dr Klink to confirm the dose of hormones given to Pt A was correct. He agrees and explains how and why. This is against the evidence of PGB, who said it wasn’t correct. Dr Klink has confirmed his agreement[4] with Dr HW on many occasions. This is an important threshold for Dr HW.
There were questions about how it should be administered, they type of drug (whether powder/gel etc) and the risks in each. Dr Klink is not fully agreeing with Dr HW’s approach in the main. But no indication it was wrong or harmful.
Dr Klink also indicates that practice is moving forward in Holland and that medical intervention is getting earlier than it was. i.e., younger ages.
Surely this shows what Dr HW did, was ahead of her time. It would seem mad to strike out a Dr who undertook procedures that were considered unacceptable at the time (2016) [should that be their judgement] but show clear evidence that those same procedures are now being adopted in other centres in one way or another.
The evidence from Dr K is complete.
What next?
Dr Dean (Dr D) is back for his cross examination, having been given the questions in advance. This continues the session from yesterday (Wednesday).
IS starts his cross examination for the session. He establishes the following from Dr D:
1) Dr D qualified as a GP in 1981
2) Dr D became a principle in 1987
3) He was a sole practitioner at first, the job shared with his wife
4) He has NEVER seen a child patient with GD in his 10-12 years of GP practice
5) He DID see some adults, a few at first then, as it became known he was “understanding” numbers grew.
6) Hormone treatment was given but under London or Exeter clinics (at the time)
7) His treatment was “as formal” as a shared care plan more ad hoc “treating and monitoring”
8) It WASN’T an MDT
9) He then became HEAD of a GIC based on little more than ‘interest’ and some experience.
10) He did SOME personal study, but basically was given the nod by a fellow professional and eased into the role. NO FORMAL TRAINING.
11) He is unqualified and NOT an Endo.
12) He is only self-taught.
13) He has NEVER treated a patient under 17 for GD
14) He was clinical lead at ‘The Laurels in 2000. This with a Psychotherapist (NOT a Pead Endo).
15) At that point he had NEVER worked in or at a GIC before.
What have we learned?
That this “expert” is only self-taught has no formal qualifications other that being a GP and has never worked in a GIC or treated under 17s with GD.
He sounds just the person to be giving full and detailed expert evidence on a Dr in this case. Especially when the accusation is a ‘lack of qualification and suitable experience.
Patients A-C
IS moves on the THREE reports Dr D has prepared, all of the same date and dealing with the patient records of patients A-C
What did IS establish from Dr D?
1) That as Dr D has no experience in treating child GD, he “can’t respond to this” [ the points requested of him by the GMC] but does INDEED respond to those points. Mainly on his ‘experience’ but gives no indication of his Duty, as an expert to do so. That is quite a big blooper as an expert. He is giving an expert opinion on something he thinks he knows about.
2) That Dr D had input into the GMC guidance known as BAGIS.
3) There was “very little” training available in 2016 AND there was considered to be “a degree of hostility” towards trans healthcare doctors who were, he said “interlopers in the field”.
4) That Dr D “didn’t feel entirely welcome” although some changes were beginning to occur by 2013.
5) That the “suspicion” lay with those “working outside the NHS” (Dr HW perhaps!!- the feline has left the receptacle)
6) That in his evidence to the women equalities commission, the NHS didn’t look good in how it treated patient and operating the service.
7) There is inconsistency in interpretation of policy across the various GICs. Being pulled apart rather than working together.
8) Even in 2015/16, patients were being treated as though GD was a mental health issue (which it is NOT)
9) Dr D can’t comment on Endo Guidelines, as he isn’t qualified.
10) He WAS a member of WPATHWPATH World Professional Association for Transgender Health https://www.wpath.org, but it has lapsed!! (A Dr treating people via those guidelines who hasn’t paid his subscription!!)
11) He wrote his report into the [5] treatment of Patient A based on the 2019 guidelines because “he didn’t have” the earlier guidelines! (Did he not ask? Could he not get an archive copy? He is an expert isn’t he?)
12) IS reads out extracts of the 2015 guidance TO THE EXPERT!
13) Dr D can’t find all the evidence he has been given
14) Dr D “accepts” that if the 2016 guidance suggests that GPs don’t require “specialist skills” after a patient has been diagnosed with GD by a specialist, they can issue bridging prescriptions.
15) Dr D accepts the treating patients with GD on the SAME medication as CIS patients “particularly specialist” (Dr D clarifies this is for blockers.)
16) IS points out that DR D uses (and relies on) guidance that didn’t exist in 2016. ( that is an error by SJ tbh. He should have spotted that and had it corrected or reasons as to why given.)
17) Dr D hasn’t worked on matters relating to the ‘induction’ of puberty.
18) Dr D accepts that abrupt withdrawal of treatment “can result in harm.”
19) Dr D has had links with US colleagues regarding trans healthcare, and they seem far better at it than we are.
With that, the Chair ends the session until tomorrow for Dr Dean.
What did we learn?
That Dr Dean can time travel and get Dr HW to meet rules that didn’t exist when the alleged offences took place
Dr D uses guidance to suit what he needs it to suit even when it isn’t suitable.
He is GMC expert and yet has shown the case to be even more crumbly than it was before he started.
Day 24 is brought to you by the GMC can time travel, yes really!
(Friday) [week 6] of the public hearing.
Intended start at 10:30am.
Note: We are advised that connection of the feed that Live Tweets, who are providing the reporting of this case from the hearing, are STILL being delayed at the start of some sessions. As such some of the discussion and questions are being missed by them and aren’t being reported on. The extent of this detail will only become evident once the full transcripts are published. In general, this is unlikely to affect the pathway of this case, from an understanding point of view, but some aspects are being missed, by them, and consequently those reporting on this case.
Dr D is back today to finish his evidence (hopefully) as he is poorly.
We are expecting Dr Kierans (Dr KS[1] ) from KOI to be questioned.
Dr Dean (Dr D) is back for his cross examination, having been given the questions in advance. This continues the session from yesterday (Wednesday).
IS starts his cross examination for the session. Due to the delayed feed entry, some questions are missing, and responses aren’t known.
From the questions known, IS establishes the following from Dr D:
1) Dr D Acknowledges HIS training wasn’t “fit for purpose in 2018, Things had moved on” (This is AFTER the alleged claims were made about Dr HW)
2) Expectations “were changing” regarding training for a GD specialist.
3) Dr D was asked and gave opinions to the GMC on training and Guidance.
4) There was [2] NO FORMAL qualification in GD anywhere in the world! This, in itself, is an utter failure of medical practice around the globe)
5) An “agreement to create training was achieved in 2017, but nothing came of it (as yet)
6) Dr D contributed to some GMC guidance [3] in 2016
7) Dr D was asked to work with others to write (or contribute to) WPATH version 8[4] , but was unable to do so at the time.
8) He has visited centres in the US and was impressed by the level (and speed) of care provided. (those of a nervous disposition ought to look away now!)
9) The centres catered for EVERY aspect and need of the LGBT community.
10) Patients were assessed after TWO appointments with a nurse and one with a specialist GD GP and a treatment plan agreed. 80% after 2 visits.
11) A holistic approach was being taken.
12) An online and face to face approach
13) That the centres were dealing with “very young patients”.
14) That 16 and above is considered competent (medically) to make life decisions.
15) Dr D doesn’t know the youngest age of people that were treated by the New York centre.[5] Nothing is implied.
16) MH expertise and other care and help can be “drawn in in (his word) amazingly in TWO WEEKS” (my emphasis).
17) They had a good MDT set up. It was a “well run” and “effective” service. (if it wasn’t for you meddling politicians, we would have gotten away with this)
18) Dr D suggested such a model to the NHS. (Well, what happened to that then??)
19) Dr D incorrectly states that a pause on patients (now) is occurring due to Tave-v-Bell. This is incorrect as a patient above 16 has capacity AND has NOTHING to do with this case! As that was from 2016. Water muddying from the witness NOT stopped by SJ
20) When IS askes Dr D to look at a document on the study of effects of T in trans youth doesn’t affect final adult height[6] Dr D responds, “…it makes me think my knowledge is incomplete” (A current GIC Head and expert in a trans healthcare case NOT up to date with trans medicine? )
21) The Expert acknowledges his report is incorrect as the guidance now shown to him changes his view.
22) Dr D hasn’t been provided with ALL the documents needed to respond to the ADVANCE questions AGAIN!
Due to a technical error, there is a break. SJ breathing a sigh of relief I expect.
IS continues
1) Dr D notes the delays in getting patients seen (but doesn’t apologise)
2) IS points out Dr D says that DR HW isn’t qualified to carry out an assessment without relevant training under WPATH v 7. He responds with “not necessarily”. Is he back tracking?
3) Even with aspects pointed out to him, Dr D is a bit woolly with his responses on who can provide what service at lower age groups.
4) He agrees that where Dr HW HAD documents and information about a patient from the Tavi, she could rely on those.
5) Dr D carries out physical examinations on GD children. Always needed?
6) The “abrupt withdrawal” of treatment (once commenced) can cause harm.
7) Dr D suggests a capacity from should accompany a consent form for under 17’s
8) Dr D accepts that “most young people do have capacity” but “ its outside his area of expertise”.
9) That the records from Dr HW that should have been provided to the expert weren’t when he wrote is report. (But he implies the manner in which the records are presented (written no on screen) is somehow Dr HW’s fault and not the GMCs.
Dr D stands down (for now) he will be back on Monday afternoon.
What did we learn?
That there is a huge amount of inconsistency in all the protocols and that the GMC are STILL relying on information, cases and procedures that didn’t exist at the time of the allegations.
Not sure that Dr D is competent to be an expert and not one on trans child healthcare.
What next?
Dr Kierans (Dr KS) from the NI trans healthcare service (KOI) is due later.
Before that, there is a bit more handbags and squabbling between the QCs. SJ is again bickering that defence evidence is late or not presented yet (remember his process is faultless thus far!!).
IS seemed to have the upper hand on this one and accused the GMC team of “gatekeeping” evidence before passing it on.
The panel chair is starting to get a little bit anxious about this now.
The squabble centres around what benefit there is for the evidence from Dr KS as it from Northern Ireland. Also, that Dr Bouman’s report isn’t finished (yet) and is needed so Dr KS can finish her evidence based on it.
SJ starts the examination of his witness and her evidence.
First question: “Your first report, dated 19th July 2021….”(yes 2021).
19th July is 47 days ago. (a little under 7 weeks) THIS Hearing started on 26th July. (7 days after).
In that time the defence team are supposed to have received, seen and prepared a response to that report (those reports) and considered that content in ALL the other witness statements being prepared. YET SJ moans on about it being late! At the same time, the GMC KEEP introducing yet more new evidence at short notice and expect immediate Reponses on it.
This hearing should not have started at least until all evidence is disclosed and cases made and put by both sides.
SJ gets Dr KS to confirm certain aspects. These are those He feels are important to their case
1) Dr KS is a member of BAGIS as a result of hours of clinical practice worked.
2) That in the KOI the “clinical Nurse” is part of their MDT (Autism and family therapy)
3) That whilst GD isn’t an MH condition, all patients for KOI MUST come via CAMHS
4) The KOI “explore Gender identity “ rather than treat
5) A Pead Endo may be involved if “it is felt necessary”
6) Patients MUST be mentally stable before treatment starts. If they are suicidal, get them to explore why before treatment to “help them” better understand their condition. (in the hope it goes away?)
7) Assessment of capacity is carried out “over time” to see how the patient feels.
8) That the signing of the consent form is ALWAYS done in person (Covid or no Covid)
9) That the KOI use Bell-v-Tavi to restrict PBs (NOTE: this wasn’t a thing in 2016)
10) That a diagnosis of ADHD, could be (another) way to delay treatment until that issue is resolved.
11) That as Dr HW “was intending to act outside clinical practice at that time” should have linked with the professionals previously dealing with the patient” (I think we have established that she did, many times. Other GMC witness es have acknowledged that.)
What have we learned?
It is a published fact that the KOI have a poor record of treatment against a list of poor treatments from other centres.
That there seems to be A LOT of gatekeeping going on. Any excuse for a delay seems to be taken. This against the background, that mother nature doesn’t delay puberty until the specialists are ready.
This compared with the centres that Dr D visited in the US, its chalk and cheese. Mainly due to political interference and politics at play. It could work better, if it was allowed to, but it isn’t.
Cross examination
IS begins his cross examination of her evidence.
There is a break for a short while.
Yet again, the feed connection is delayed, and questions are missing.
IS continues
The chair ends that session
What have we learned?
The KOI seems a bit of a mess, more or less that the other GICs. They seem a little more expert but have some very long lead times and high-pressure gatekeeping protocols.
There’s is no apology for this, just it’s what happens. There’s no given reason other than its protocol.
What next?
The day ends with yet more bickering between the QCs about what is allowed by whom and when.
The chair is getting disgruntled now.
It is agreed (to a point) that Dr Bouman MUST have his report to the tribunal by Tuesday. This will allow Dr KS to see it and be able to be questioned on its content in relation to her report next Friday.
That session will END the GMC case of giving evidence.
Before that Dr D is back Monday afternoon and may be Thursday.
Summary
The GMC case has the red boxer rocking unsteadily having taken a series of powerful blows not only from IS but from its own side.
Normally, the prosecution case is put robustly, and the defence has an uphill struggle to overturn that and prove it wrong.
In this case, it seems the GMC case is determined to prove itself wrong before we get to any meaningful defence.
This is not just the result of one expert, but many, all saying much the same thing.
I wonder if experts that could wield lethal blows don’t want to, because they don’t see an issue.
It is presumed the panel will allow the defence to put all its case and be cross examined. They could easily call a halt part way through, having heard enough.
Whether they do or can, is another question.
Of course, SJ may do more of a hatchet job on the defence case than expected, but I somehow, very much doubt it. Too much damage has already been done.
Not only that, but one would also have to think, having seen the level of evidence thus far, that if some of the ‘experts’ were in the dock and the same charges were put to them, there would be much more of a case against them.
The NHS protocols and in house divisions have been severely exposed over this and is bleeding quite badly.
What next?
Back Monday (day 24) at the later time of 14:30
To be continued…../
Nicola
