Fitness to PractiSe Panel
3 to 11 march 2011
7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ
Name of Respondent Doctor: Dr Adolf POELLMANN
Registered Qualifications:State Exam Med 1979 Ludwig-Maximillians Universität München
Area of Registered Address:Germany
Reference Number: 4621629
Type of Case: New case of impairment by reason of: misconduct; deficient professional performance
Panel Members:Dr R Ferguson, Chairman (Medical)
Dr G Chung (Medical)
Mrs S Hollingworth (Lay)
Legal Assessor: Mr Robin Ince
Specialist Performance Adviser: Mr Jeffrey Hillman
Secretary to the Panel:Ms Jackie Kramer
Representation:
GMC: Mr Nigel Grundy, Counsel, instructed by GMC Legal
Doctor: Not present and not represented
allegation
That being registered under the Medical Act 1983 (as amended):
Patient A
1.a. On or about 11 March 2008 Patient A consulted you about you performing bilateral upper lid blepharoplasties [“the Operation”], Found proved
b.During the consultation with Patient A you did not
i.perform an adequate examination, Found proved
ii.obtain an adequate history, Found proved
iii.make a correct assessment of her condition, Found proved
ivadvise her upon the correct operation to be performed to treat her condition, Found proved
v.obtain appropriate informed consent for the operation, Found proved
vi.make and/or keep an adequate record, Found proved
viitake pre-operative photographs, Found proved
viii.advise Patient A not to take medications such as aspirin
prior to the operation;Found proved
2.a.On 25 March 2008 you performed the Operation upon Patient A
at the Cosmetic Medical Centre, Douglas, Isle of Man (“the Centre”), Found proved
b.The Centre was not adequately equipped for the performance of the Operation, Found proved
c.Before performing the Operation you did not mark
i. the lid creases, Found proved
ii.the amount of skin to be excised, Found proved
d.When making the initial incision in the left eyelid you told Patient A for the first time that you would remove some fatty tissue or words to that effect, Found proved
e.You did not address adequately the left orbital haemorrhage suffered by Patient A, Found proved
f.You did not make symmetrical incisions in the left and right
eyelids, Found proved
g.You did not perform the Operation in an appropriate manner, Found proved
h.You did not make and/or keep an adequate record; Found proved
3.Following the Operation you did not
a.provide adequate aftercare, Found proved
b.make and/or keep an adequate record of your aftercare;Found proved
4.Your actions or omissions at paragraphs 1b, 2b to 2h inclusive, 3a and
3b above were
a.not in Patient A’s best interests, Found proved
b.below the standard to be expected for a Consultant Ophthalmologist; Found proved
Performance Assessment
5.A General Medical Council (“GMC”) assessment of the standard of
your professional performance (“Assessment”) took place on
a.11 May 2009 (tests of competence), Found proved
b.1 to 3 June 2009 (peer review), andFound proved
c.24 August 2009 (additional notes review); Found proved
6.In the Assessment, your professional performance was unacceptable in
the following areas
a.assessment of patients’ condition, Found proved
b.providing or arranging investigations, Found proved
c.providing or arranging treatment, Found proved
d.record keeping, Found proved
e.treatment in emergencies, Found proved
f.working within law and regulations, Found provedand
g.communication with patients, listening to patients, respecting
their views and providing comprehensible information; Found proved
7.In the Assessment, your professional performance was a cause for
concern in the area of respect for patients, politeness, respect and confidentiality including respecting patients’ rights to decline treatment or for a second opinion; Found proved
8.In the tests of competence phase of the Assessment you undertook
a.an applied knowledge test in which
i.you scored 50%, compared with a minimum acceptable
score of 66%, Found proved
ii.you demonstrated that your knowledge base in general ophthalmology is unacceptable, Found proved
b. an Observed Structured Examination (OSE) consisting of 12 stations in which
i.your performance in four of the stations was unacceptable, Found proved
ii. your performance on one of the stations was a cause for
concern, Found proved
c. a Communication Skills Observed Structured Clinical Examination (“OSCE”) in which your overall score was 62.5
i.compared with a maximum possible score of 120, Found proved
ii.which was well below all the scores of the referencegroup, Found proved
d.a Clinical OSCE consisting of 6 patients in which your performance in relation to all 6 patients was unacceptable.Found proved
And that by reason of the matters set out above your fitness to practise is impaired because of:
a. your misconduct, Found provedand/or
b. your deficient professional performance.Found proved
Determination on facts
“Mr Grundy
Dr Poellmann is neither present nor represented at these proceedings. You submitted that, in accordance with Rules 15(3) and 40(1) of The General Medical Council (Fitness to Practise) Rules Order of Council 2004, notice of these proceedings had been properly served upon Dr Poellmann.
The Panel has noted that the Notice of Hearing, dated 28 January 2011 was sent to DrPoellmann’s registered address by Special Delivery. The FedEx special delivery service informed the GMC that it had delivered the Notice of Hearing at Dr Poellmann’s registered address on 3 February 2011, although no signature was available. Furthermore, the Notice of Hearing was emailed to Dr Poellmann’s two email addresses on 27 January 2011. A delivery status notification email indicated that the emails had been successfully delivered.
The Panel was satisfied that notice of these proceedings has been properly served upon Dr Poellmann in accordance with the provisions of Rules 15(3) and 40(1).
The Panel went on to consider, under Rule 31 of The General Medical Council (Fitness to Practise) Rules Order of Council 2004, whether to proceed with this hearing in Dr Poellmann’s absence. In doing so, the Panel considered your submissions and the advice of the Legal Assessor.
You also referred the Panel to the checklist of matters relevant to the exercise of the Panel’s discretion set out in the case of R v Jones [2003] 1.AC.1.
The Legal Assessor advised the Panel that it had a discretion to proceed with the hearing in the doctor’s absence, though this discretion is to be exercised with great caution and with the overall fairness of the proceedings in mind.
In determining whether to proceed in Dr Poellmann’s absence, the Panel was conscious of its duty to ensure that the hearing would be fair to him.
The Panel noted that Dr Poellmann emailed the GMC on 14 February 2011 stating that he was no longer interested in being registered with the GMC and that he did not intend to return to the UK.
The Panel concluded that Dr Poellmann has intentionally absented himself from this hearing; given the content of Dr Poellmann’s email of 14 February 2011, it also concluded thatthere is little likelihood of Dr Poellmann attending a future hearing.
The Panel also considered the risk of reaching an improper conclusion on the merits of the case in the absence of any oral evidence or submissions from the doctor, and the risk of wrongly drawing adverse inferences from the doctor’s absence. The Panel has taken into account the delay that would be caused by an adjournment and the detrimental effect this could have on the memory of the witnesses and on their convenience. The Panel was of the opinion that it was in the public interest to hear the case without further delay and that, as a professional and experienced panel, it would ensure that these proceedings were conducted in a fair and proportionate manner.
Accordingly, the Panel determined to exercise its discretion and proceed with this hearing in the absence of Dr Poellmann in accordance with Rule 31 of the Rules. In reaching this decision, it balanced the need for fairness to the doctor, including his right to be present, with the public interest in proceeding with this case. The Panel wishes to emphasise that it has not drawn any adverse conclusions from Dr Poellmann’s absence.
The Panel has given consideration to all the evidence adduced in this case, including the oral evidence of Patient A; the oral evidence of each of the four assessors who took part in the assessment of Dr Poellmann’s professional performance (and of their report dated 6 February 2010); and the reports dated 20 June 2009 and 20 January 2010 and oral evidence of Mr B , Consultant Ophthalmologist, the GMC’s expert witness, who in turn had considered the expert report obtained by Patient A of Mr C, a Consultant Ophthalmic and Oculoplastic surgeon, dated 7 October 2008. The Panel considered each of the witnesses to have been consistent, compelling and fair in giving their evidence.
The Panel also noted a number of items of correspondence from Dr Poellmann in relation to his treatment of Patient A and in response to the outcome of the assessment of his professional performance. The Panel has given limited weight to this evidence as it has not been tested by cross examination or panel questions. On balance, the Panel preferred the evidence of the live witnesses who attended this hearing, to Dr Poellmann’s written evidence and further, has accepted the findings of the report of the Assessors dated 6 February 2010 which have not been challenged by Dr Poellmann in any of his correspondence with the GMC that has been produced in evidence before the Panel.
The Panel also considered the submissions made by you on behalf of the GMC and the advice of the Specialist Performance Advisor to the Panel, Mr Hillman.
In relation to the burden and standard of proof, the Panel accepted the Legal Assessor’s advice that the burden of proof rests on the GMC and that the standard of proof to be applied is the civil standard, namely on the balance of probabilities. The balance of probabilities means that a Panel is satisfied on the evidence that an event is more likely to have occurred than not.
The Panel has considered each allegation separately. Accordingly, it has made the following findings on the facts:
Patient A
Paragraph 1a:
“On or about 11 March 2008 Patient A consulted you about you performing bilateral upper lid blepharoplasties [“the Operation”]”
Has been found proved.
Patient A told the Panel that she had attended a consultation with Dr Poellmann, related to her forthcoming blepharoplasty surgery, approximately two weeks prior to the operation itself, which took place on 25 March 2008.
The Panel also noted that Dr Poellmann’s medical notes indicate that such a consultation took place although the record of the consultation was undated.
Paragraph 1bi:
“During the consultation with Patient A you did notperform an adequate examination”
Has been found proved.
Patient A told the Panel that her consultation with Dr Poellmann took approximately 15 minutes. She stated that he leant across his desk and lifted her eyebrows. That was the total extent of the physical examination.
Mr B told the Panel that he would expect a reasonably competent Consultant Ophthalmologist to have undertaken a full pre-operative assessment of the patient which should have included an examination of:
- Pupils;
- RAPD severity;
- Lid laxity;
- Blepharitis;
- Brows (elevation and ptosis);
- Lateral canthal rhytids;
- Measurements of PA, LF and SC;
- Myaesthenetic signs;
- Dermatochalasis;
- Measurements of upper lid skin show and height;
- Bell’s phenomenon;
- Blink;
- Lag on downgaze;
- Orbicularis function;
- Ocular motility; and
- Upper lid fat prolapse.
There is no note within the medical record prepared by Dr Poellmann, nor any other evidence, that he undertook those examinations. The examination he performed upon Patient A was described by Mr B as ‘totally inadequate’.
Paragraph 1bii:
“obtain an adequate history”
Has been found proved.
Patient A told the Panel that Dr Poellmann asked for details of her name, address and telephone number. He may also have asked for her date of birth. She told the Panel that he asked whether she was ‘healthy’ but otherwise did not ask her about her medical history, nor whether she was taking any medication. There is no note in the medical record prepared by Dr Poellmann to indicate that he took an adequate history from Patient A during the consultation.
Paragraph 1biii:
“make a correct assessment of her condition”
Has been found proved.
In his report dated 20 January 2010, Mr B stated:
“Having reviewed exhibit BLJ1 [a photograph of Patient A taken shortly before the operation] I now believe Dr Poellmann made an incorrect assessment of [Patient A’s] condition at his initial consultation and performed the wrong operation on [Patient A]. In the first photograph of BLJ1 the lid crease of the left upper lid can be seen and there is also an amount of ‘show’ (that is distance between the lid margin and the lid crease). This would be unusual in a patient suffering purely from dermatochalasis (excess skin) as in this condition the lid crease is obscured by the excess skin and the amount of show is minimal. It is therefore my opinion that [Patient A] was primarily suffering from ptosis rather than dermatochalasis (in other words suffering from a drooping of the eyelids caused by an abnormality in the levator muscle complex rather than by weight of excess skin).”
Paragraph 1biv:
“advise her upon the correct operation to be performed to treat her condition”
Has been found proved.
The Panel again noted the evidence of Mr B, as referred to at paragraph 1biii.
Paragraph 1bv:
“obtain appropriate informed consent for the operation”
Has been found proved.
The Panel noted a consent form signed by Patient A and dated 25 March 2008, the day of the operation. Patient A confirmed that she had signed that consent form on the day of the consultation, but had signed it giving the proposed date of the operation. She told the Panel that, when she signed the form it was blank and had not been otherwise written upon and that no one, apart from Dr Poellmann, had been present at the time of signing.
The copy of the consent form put before the Panel in evidence has been annotated. It was designed for a different procedure from the operation which was performed on Patient A by Dr Poellmann, and has been amended by hand to refer to a blepharoplasty procedure. Moreover, someone had written that a theatre nurse had been present when Patient A had given her consent, which was not correct.
The Panel also noted a number of information sheets related to blepharoplasty surgery produced by the ‘Isle of Man Eye Centre’; these sheets refer to the risks associated with that surgery. Patient A was clear she did not receive those information sheets until after she had made a complaint about the operation. If she had seen them prior to surgery, she would have been concerned, particularly as the sheet stated that thyroid problems such as hypothyroidism, a condition from which Patient A has suffered for many years, can make the surgery more risky.
In relation to whether appropriate consent had been obtained by Dr Poellmann from Patient A, Mr B stated in his report dated January 2010:
“[Patient A] did sign a consent form and states that this was signed at her initial consultation with Dr Poellmann. The consent form is not correctly dated and is preprinted for the procedure of sclerotherapy. [Patient A] states that she was told about the possibility of bruising, swelling and double vision. She was not informed, nor is it annotated on the consent form, about the risk of visual loss from severe orbital haemorrhage. The latter was particularly relevant if Dr Poellmann was considering removing orbital fat as part of the blepharoplasty procedure. She was not given a copy of the consent form to take home. It is my opinion that although some aspects of informed consent were covered it was not complete.”
The Panel was satisfied that Dr Poellmann did not obtain appropriate informed consent from Patient A for the procedure.
Paragraph 1bvi:
“make and/or keep an adequate record”
Has been found proved.
Patient A told the Panel that Dr Poellmann’s note of her consultation with him was made on a card, approximately the size of a postcard. The Panel has noted that the card is undated and contains only scanty details. In comparison to the record made by Mr C following his consultation with Patient A, Dr Poellmann’s record is extremely brief.
In his report dated 20 January 2010, Mr B described the record thus:
“This record contains no mention of the patient[‘]s general health, nor drug treatment, There is no assessment and record of the palpebral aperture, the height of the eyelid creases, the levator function nor the position of the brows. As such it is a totally inadequate record.”
Paragraph 1bvii:
“take pre-operative photographs”
Has been found proved.
Patient A was clear in her evidence before the Panel that Dr Poellmann took no pre-operative photographs. No such photographs have ever been produced by him in evidence.
Paragraph 1bviii:
“advise Patient A not to take medications such as aspirinprior to the operation”
Has been found proved.
Patient A was clear that Dr Poellmann had not advised her to avoid medications such as aspirin prior to the operation. Mr B told the Panel that he would advise a patient not to take aspirin for 14 days prior to any such procedure as the eyelids are very vascular. The Panel noted that in his letter to the GMC dated 6 April 2009, Dr Poellmann stated that: