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SUBSTANTIVE HEARING: MR SHAFQAT ZAMAN (01-19220) Thursday 25 October 2007 DAY THREE

[Hearing resumed at 9.36 am] Ms Jeyasingham: Ms Rollason, you were questioning Professor Parrish? Thank you.

Professor Stephen Parrish Examined by Ms Rollason (continued) Q. Thank you. Good morning, Professor Parrish. Picking up where we left things yesterday evening, do you have a copy of the Registrant's bundle, including your report there? I think I do. At page 23 onwards. Correct. I have just a very few further questions for Professor Parrish. Could I ask you to look at page 30 and the question put to you for your opinion at paragraph 3.5? The question you were asked was, "In your view, is there any requirement under the Rules relating to Injury or Disease of the eye which require an optometrist to conduct a sight test when faced with a person who appears to be suffering from injury or disease of the eye?" I think we made some reference to those Rules yesterday; they are appended to your report at Appendix 1. They are indeed. Could you just explain for us the context of those Rules and what the requirement is in terms of a sight test? Yes. My understanding is that there is no actual statutory requirement to conduct a sight test. There certainly is a duty to refer to a medical practitioner if an optometrist feels that a patient is suffering from injury or disease of the eye, but I am unaware of any actual legislation which says you have to precede that with a sight test. What is the context of the Rules you refer to? What do they deal with? The GOC Rules of referral? They define how an optometrist ­ or when an optometrist ­ should carry out an onward referral.

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You give your opinion that you are unaware of that requirement and that the optometrist should do what is in the best interests of the patient and it will be dependent on many factors ­ such as the time since the last eye examination, availability of an appointment, and the nature of the problem giving rise for concern? That is correct. And you would confirm that opinion as at today? Absolutely. In your knowledge of the circumstances of Mr Zaman's case, is it your view that he complied with that duty? Yes, it is. As we discussed, there were several options open to Mr Zaman at the time, but I think the option that he chose was fulfilling that obligation. He has a duty to refer to a medical practitioner, and he did so. Thank you. In relation to the circumstances at Mr Zaman's practice on the day in question, on his account Patient A presented without an appointment and, in his mind or view, he lacked the time do the test that he thought he would wish to do in the circumstances and he had a concern in his mind, a worry, about what Patient A was presenting with. Therefore, on Mr Zaman's account, what was achievable on that day itself was limited. What would your comment be on whether his decision to refer without any further examination of the patient was in a range of reasonable decisions for the management of that patient? Yes. I think if it was not possible to conduct any further examination, then by referring a patient onwardly, requesting an urgent specialist opinion, was the correct thing to do in this patient's best interest. You have actually pre-empted my next question, which is: what would your opinion be about the best interests of the patient in those circumstances? I think it has been established that, had it been possible to do a range of tests at the time that might have been a preferred option. But given that, from Mr Zaman's account, was not an option, then I think the patient's best interests were definitely served by the immediate onward referral; especially as I think in this case it would appear that Patient A was about to go off on holiday. So getting the patient back at a subsequent point was probably not a viable option. Then it was a very sensible course of action and certainly, I think, was within the spirit of the Rules. Thank you. Can I take you back to your report then and to review your overall conclusion about this matter? You have stated here that it is best practice to provide as much information as possible when making onward referral to a medical practitioner and you agree that, if data is being used from a previous time, it should be made clear in the referral letter. You then go on to say, "The failure to do so in this case was unfortunate but" ­ in your opinion ­ "does not in itself constitute impaired fitness to practise and had no bearing on the eventual clinical outcome".

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I am not going to ask you to comment further on the issue of impairment of fitness to practise, Professor Parrish. That is probably going to be a matter in the decision of the Panel, should we reach that stage. Other than that issue, does that accord with your opinion as at today, having heard evidence in this matter? It does. And likewise, do you confirm the rest of that paragraph of your final conclusion? I do confirm that, yes. Professor Parrish, thank you very much. There may well be further questions for you. Professor Parrish cross examined by Mr Alder

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Thank you. Professor Parrish. I have one or two points for clarification, if I may? Your evidence this morning was that there would be a range of possible options available to Mr Zaman, but a preferred option would have been to have performed some examinations. Is that right? Correct. The preferred option. You say that would have been preferred ­ I may be putting the cart before the horse in the way in which you phrase this, so please to confirm it to me if I have not understood ­ that referral would have been an option available if it was not possible to perform further examination. Correct. We heard from Mr Zaman yesterday that there was the potential for some time being available to perform some examinations, if not a complete sight test ­ that is not the allegation ­ but there was some time available to him, to perform at least some examinations? Is that your recollection of his evidence? Yes, indeed. You referred then to the preferred option of performing some tests. Why is that the preferred option? My preferred option was not to perform some tests but my preferred option would be if time had allowed, to perform a full sight test. The point I made yesterday is that I feel if you are taking selected parts ­ just refraction or just a visual acuity ­ in many ways that is a slightly dangerous place to be, because you are getting just a snapshot and a very small part of the overall clinical picture. So I think like I said yesterday, and also the way the general ophthalmic service is structured in England, there is no facility for doing parts. So my preferred option would have been a complete and full eye examination, had time allowed and that was always going to be, probably, in the patient's best interests. But I do not think, from what we heard yesterday from Mr Zaman, that that sort of time was available.

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You focus in this case very specifically on one type of examination, a refraction examination, of which part is a visual acuity measurement. Is that a correct understanding? A full eye examination is, by definition, refraction. Implicit in that, one checks the visual acuity. But also, there is a statutory obligation to examine the internal and external structure of the eye. This is a complete eye examination. The particulars of the allegation, though, the issue of the measurement of the visual acuity and the performance of a refraction examination, are very much the starting point though, aren't they? You would measure both of those as part of a full eye examination, most certainly. Would it be right that those are very much the starting points of your examination? That actually, the results of those examinations then lead an optometrist down to perhaps additional tests that would be performed or relevant or indicated by the results? I am not sure they would necessarily be the starting point. There are other things that you would do before you measure the visual acuity. And there are a body of optometrists that do other internal and external tests before they did the refraction, so I am not sure they would be the starting point. They would be components thereof. If your referral of a patient was to flag an issue as to reduced visual acuity, the performance of a visual acuity measurement would give you that clinical certainty. Would that be right? I think that is how you phrase it in your report. Yes. What I was saying was the more information you have about a patient, obviously, the greater clinical certainty you have, whatever that is. But the point that I think I made quite clearly yesterday is that we have to be very careful about taking these isolated measurements, because they only increase your clinical certainty if you view them as part of a more holistic approach. As I said yesterday, you could have perfectly normal visual acuity ­ that is, you could read the letter chart ­ but it does not mean the eye is normal. So I think it has to be looked at ­ and that is why I think it is very important that one considers the whole eye examination, rather than selected pieces of it. If you, as an optometrist ­ and this is purely hypothetical ­ had undertaken a visual acuity examination of a patient; say, in the circumstances Patient A presents on 7 March, you perform a visual acuity measurement, that eye gives you results of concern, or no results of concern because you compare back to your previous record card. You then look at the clock and think, `Well, I haven't got time to do any more'. You could still refer the patient on. But there would be a need there to write in your referral the steps you had taken and the measurements you had been able to achieve at that point. Would that be a reasonable course? If other tests had been carried out and then you were making a subsequent referral, it would be appropriate to include those details in that referral, I would agree.

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Or likewise, if you were not able to undertake specific examinations, it is reasonable that that could form part of your referral note as well? Yes. I think, as I said, in this particular case it would have been appropriate to have made a note that the tests were carried out in the February appointment rather than the March appointment. I just very briefly want to touch on the evidence you gave this morning. You referred to it not being an option, or potentially not, for this patient to be rebooked because she was going on holiday. Of course, Mr Zaman did not know that at the point at which he spoke to the patient, did he? There is no evidence ­ certainly none from the patient ­ that she had told Mr Zaman that she was going on holiday. So, I think Mr Zaman, on the day, was faced with the decision of what to do. And I think he felt the patient's best interests were going to be served by making this referral as soon as possible. Now, Mr Zaman may have known that he had not got an appointment free for a day, two days ­ I don't know. But I suspect that what happened is that he felt that on that day, with due regard to the circumstances, the patient's best interests were served by onward referral at that point. And I think that was probably a perfectly reasonable course of action and typical of what a reasonable body of optometrists may well have considered doing. To get to that point, an optometrist would need to ask questions of their patient, about their availability, looking at the appointments diary, taking all of that additional information before choosing whether that is an appropriate option to take or not. Yes. Unless he has sufficient clinical certainty that he was going to make an onward referral anyway and therefore had decided that he was going to do that as a matter of some urgency, irrespective of doing further eye examination. You used the phrase this morning, `the facility under the NHS regulations' for presumably the eligibility for sight tests. Fees, presumably? Is that the situation? Yes. We were discussing yesterday, if we consider the appointment in March is unrelated to the appointment in February ­ that is, the patient has now come complaining of a different set of symptoms ­ then I think it is appropriate that Mr Zaman, if he wished to do a full sight test or could have done a full sight test, could legitimately have done that under the National Health Service. That is provisionally there if there are symptoms or signs causing concern. But, having gone down that route, I think he would have to do then a full sight test, as defined in the legislation. He could not just do selected parts of it. And yes, he would then be able to claim a fee for the time he spent in doing that, if indeed he chose to go down that route. But the facility you talk of merely goes to a payment, a cost route, for the optometrist, so they can have their fee paid by the NHS, as opposed to explaining to a patient and having a private consultation.

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Yes. In any event, if private or otherwise, if Mr Zaman was doing a sight test, under the meaning of the Opticians Act, then it would have to be a sight test as defined by those Rules, which would, therefore, include all the components that we spoke of earlier. You referred to the patient presenting with a different set of symptoms and that that, in your view, creates a different `chapter' (I think was the phrase you used yesterday) ­ a different examination ­ between February and March. On the basis of your impartiality as an expert, on the basis of the evidence presented by the patient, this was a situation where she was exhibiting ongoing symptoms ­ nothing had changed but her vision had not improved over that time ­ then presumably the chapter from February remains open? It is the same cycle? Yes. It is a slightly grey area as to whether then you could legitimately do another sight test under the Health Service or was this in fact some follow-on from the existing sight test which may have rolled on from there. And a body of optometrists would possibly be divided on how they dealt with that. We went particularly through your CV yesterday and I think you conceded the point that you have not sat `in secondary care', I think was the way it was phrased ­ No. I have worked in the hospital eye service but not in terms of ­ In terms of considering referrals. So you can bring no expertise to bear upon what standards are applied to referral letters, what tests, diagnoses, professional acumen, is applied to the clinical data on those referrals, can you? In terms of grading their urgency, then the only knowledge I have is from my own referrals that I make and the feedback that one gets from the hospital consultants. You have not had to sit in a situation where you have to ­ to use the word ­ `triage' or prioritise those referrals. Absolutely not. Okay. Presumably with this reasonable body of optometrists or within their training process ­ I note you are involved in the training of optometrists ­ there would be an understanding of the need, the very real, logistical needs, of the NHS, in terms of prioritisation of care and that is, effectively, why you have these different types of referral routes, presumably? Yes. There are, for the conditions which are likely to be met by optometrists on the high street, fairly clear indicators as to the degree of urgency with which certain conditions would be referred. The only way, of course, for that prioritisation, that route, to be made once the referral is received is based purely upon the referral letter itself and the clinical data contained within that. Correct.

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Which presumably is why it follows that the referral letter should be as full as possible? Correct. It should be as clear as possible. Correct. And it should contain accurate information. Correct. On the February assessment ­ you will need to assist me ­ you refer to their being a stability of this patient's vision ­

Ms Jeyasingham: I think, Mr Alder, that the allegations are about 7 March and we have heard quite a lot about the 16 February assessment, so can you keep your questioning really to things that are relevant to 7 March? Mr Alder: Yes, of course, Madam. My question ­ and perhaps if I address it to you first you can confirm whether it is relevant or not ­ is as to where the stability comes from as to this patient's vision. I understand it is Professor Parrish's view that there had been a stability of vision over a period of time, two or three years, and I am just wanting to confirm that that view has come from the patient's previous prescription section of the results of 16 February 2006. I am then going to suggest to Professor Parrish that actually, that impacts upon the decisions taken in March, because we have got a sudden vision loss then, between the two tests. Ms Jeyasingham: Okay. Mr Alder: That was the thrust of my questioning on that point. If I can ask you to turn with me to page 3 of the Council's bundle? You may have it in the Registrant's bundle as well. Purely from my experience, Professor Parrish, we have the current prescription of 16 February in the bottom left hand corner? A. Correct. Q. A. Q. And we have, in the top right hand corner, a prescription which, as I understand it, is the patient's current ­ at that time, her current ­ spectacles? Correct. So if this is right, we can extrapolate between the two and say, `Well, her current spectacles she had worn for, say, two or three years' and that prescription is fairly similar to the prescription which was found and determined by Mr Zaman in February 2006. That is correct. And that is the basis, is it then, for the conclusion that there had been stable vision or thereabouts ­ I do not think I said it was stable vision but a stable prescription.

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Stable prescription, yes. We then go to March 2006. The patient presents, on Mr Zaman's evidence, as presenting with reduced visual acuity, having difficulties with vision in her left eye at near and distance. Given that that must have occurred between February and March and we have a previous stable prescription, that would be of some significant concern would it, to a reasonably competent optometrist? Yes. And would trigger in their minds, I would suggest, the need for some examination or fuller examination or understanding of the reasons behind that sudden vision loss? Yes. I think it would certainly trigger the need, as we found, either to do a further examination or, as we said, if time did not allow to do the alternative, which was immediate onward referral. That would form within your view I think you put it, an exploration of the reasons for that visual deterioration? If you carried out further examinations, yes, then you would be looking for reasons for that deterioration. And that would be a step you would take? That would be your preferred option as an optometrist in practice? Absolutely. If I had the time, that would be the preferred course of action. Dr Spry was concerned ­ I am summarising ­ that a patient presenting, based upon the patient's evidence, with an ongoing symptomology that had not been explained, would also lead an optometrist to want to explore the basis for that unresolved symptomology. Would you agree with him on that? I would. Again, for the same reason, an optometrist could, as a preferred option, consider it appropriate to perform examinations again to understand the basis behind that symptomology. They certainly could. I just touch on a phrase you use throughout your report, Professor Parrish, when you refer to their being `no effect on the visual outcome'. I think that is tempered with quite a significant degree of hindsight, is it not? You are able to say this patient had a macular hole, therefore we can trace back through the records to see that actually the way in which things panned out would not have had an effect. Would that be a fair summary? Yes. Also, I think the point I was making is that whether or not any further investigation took place on the day in March, then the outcome would have been the same, because the referral was made as an urgent referral to an ophthalmologist. So I do not think in this particular case it would make any difference, because that referral was made. At that point in time, 7 March 2006, you do not have that benefit of hindsight. You are presented with a patient ­ on Mr Zaman's evidence of a patient presenting following a previously stable prescription for some years ­ with a

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sudden, unexplained visual loss in the left eye. There are a number of potential pathologies at that point which would be at the forefront of an optometrist's mind, aren't there? There could be several pathologies, certainly. Such as? There could be anything. There could be different forms of maculopathy. There could be other causes of painless visual loss, other forms of retinal disease. And at that point in time, an optometrist would not know which potential pathology there could be? They would not. So there could, actually, have been ­ depending on what this condition was ­ a very significant outcome for her vision. There could have been. There could have been. And that could have been significantly affected by the referral pathway undertaken and instigated by the optometrist? Yes. And I think if further examination as we said was not possible, then the decision would come down to the symptoms that the patient presented with and I think Mr Zaman alluded to that yesterday. With regard to the symptoms that he had for Patient A ­ Unexplained visual loss in her left eye occurring in a very short space of time? That is right. In which case, he made an urgent referral and I think that was still a sensible option in the patient's best interests. It might not have been the preferred option but given the circumstances, I think it was a sensible option. My point is, Professor Parrish, that you cannot conclude as a matter looking forward from 7 March, that there would not have been an impact on the visual outcome. Absolutely. I would agree with you. If I could ask you to turn to the referral and so everybody is aware, it is on page 4 of the Council's bundle? You have quite clearly reviewed this referral and you have commented on it in your evidence and in your report. It is accepted that the prescription details from the current sight test is recorded as 7 March 2006. In fact, the details provided are taken from the 16 February examination. It is recorded that there was no pathology found on examination, as is recorded in the note, but there was no such examination for such pathology on 7 March. We have some confusion and Mr Zaman was unable to help us with the detail as to why he wrote all of what he wrote at this point. There is a reference made to reduced visual acuity. Those, given the date, all imply ­ those points requiring attention all imply ­ that the test was performed on this patient on 7 March 2006. Would you agree with that? I do.

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So, if you were receiving this referral, you would assume that there had been an examination on 7 March 2006, would you? I would. That a lady had attended with reduced visual acuity, that there had been an assessment of that visual acuity using pinhole but that showed no improvement, that it was unsure of the causes of reduced visual acuity ­ sorry, it is all recorded so you need to answer ­ Yes. Okay. And that there was an examination performed to try to identify a type of pathology. It says `no pathology on examination'. Would that be a reasonable conclusion? Yes. All of those aspects of this referral are wrong, aren't they? That implication is wrong. The date is certainly misleading. The date is misleading and misleads the rest of the information on the form. Would that be right? In so much as the date is wrong, yes. But it leads the rest of the information to be misleading purely in terms of what is written. No intention is alleged by any of this but it is potentially misleading. Yes. To that extent, it is inaccurate, would you agree with that? In that it implies that it is done on 7 March, certainly. Your view yesterday was that the referral was, to use your phrase, `fit for purpose'. Given that your conclusions this morning are that this information is misleading and inaccurate, do you accept that the referral itself is inadequate? Well, as I said yesterday, it was adequate in so much that when, I think it was Dr Walter Abelman, received the letter, he made an appropriate interpretation of it and made the appropriate onward referral. Interestingly, in Dr Abelman's onward referral, he makes no reference to the date, to the visual acuity or to the prescription. He has merely referred onwardly, based on his own observations, and the points requiring attention. So when I say it is fit for purpose, it actually did the job and, as we said yesterday, it probably was not the best referral letter but it certainly did the job. And on that basis, if you say, `Was it adequate?' then I think clearly it was adequate, because it did the job. But it certainly was not perfect, I would agree with you. You forget, of course, that the patient sat with Dr Abelman, explained her symptoms to him and discussed with him the referral options available. She took the mantle of the referral on herself. That was not assisted, I suggest, to you, by this document. Do you agree with that, or not? I know we do not have Dr Abelman, so it is very difficult to answer that.

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No, but I think it would be normal practice for a patient to take a referral letter to their medical practitioner and to discuss it with them. That is why the letter was given to the patient, as distinct from posted to the GP. So that discussion is a normal event. I do not think it is unique to Patient A. Do you commonly, when you are training the optometrists, students, other opticians, condone to them the use of inaccurate information on clinical documentation such as this? No, of course not; not at all. You would condone, though, this as being an adequate referral letter, of the standard that you would expect? I am saying that it actually fulfilled the purpose for which it was intended, on this occasion. As a piece of clinical documentation, is this an adequate reflection of what happened during that consultation, Professor Parrish? I think the biggest problem with this letter clearly comes back to the date, and the date is unquestionably misleading. But the date has an effect, doesn't it? The date itself actually has an effect and leads, as your conclusion was this morning, to conclude that the information is misleading. It is potentially misleading, though I think in this case it was not misleading, because clearly, Dr Abelman made the right decisions in the right time frame and in fact, does not even allude to the date or the top part of the form ­ Those are Dr Abelman's conclusions having met with the patient. He is not available to give evidence, so that is pure speculation, isn't it? Yes. You said yesterday, and I assume this was training of students or optometrists, when discussing referrals and what information to provide that you should make the main point the main point. I think that is something now that is generally accepted with optometric circles, certainly. It may be that I am just too legalistic about it, but could we include in that a caveat? Would you expect, when training your students, that when they make the main point the main point, that actually should include the necessity of clarity and accuracy? Yes. I think it should be as clear and as accurate as it is appropriate to make. But I would point out, particularly perhaps for the lay members, that we have to bear in mind that this letter was written whilst this patient was in the practice. There was a timeframe to this. It was not a `sit down, consider it, run up a draft, have a look at it'. It was done in a fairly short timeframe. And I think we heard yesterday that the patient was described as possibly agitated or concerned because they had not had a satisfactory explanation to their potential problem. And from my own experience of doing this, you are therefore writing these letters under some pressure. It is not a situation where

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you have a secretary who can type it up, you can look at a draft, maybe alter it. This is something that is done, probably, I would guess, in two, three, four minutes. So in that regard, by definition, it has got to be to the point, it has got to be brief and this does get to the point, albeit it can be said it is not perhaps as full as it might have been. Q. A. Q. A. Q. But there has been time, has there not, to review the previous record card ­ that is where the information is drawn from ­ Yes. To check the GP's details ­ Yes. To record all of this information. How long would it really have taken, Professor Parrish, to have included a line which said something in terms of, `Have not tested patient today'? That would take no time. Absolutely. If indeed that had been thought of at the time, I am sure Mr Zaman or anybody else would have included that. But as I say, I think we have to bear in mind this was written under some pressure and with the benefit of hindsight, yes, I agree, it would have been nice to have had that statement in. But in the context in which it was written then I still think, having seen lots of referral letters over the years, this does make the point that is required, namely an urgent referral. But that issue about the date ­ I do not wish to keep going over the same ground, but this issue about whether the test was performed on that date or not ­ is actually the most fundamental section that you should have had on this referral. That is right, isn't it? It should have said, `I haven't tested the patient today'. Yes. And I think the point that was made yesterday, 99 per cent of these referrals that we make are made on the day of the sight test with the patient sat there and I think intuitively, one just puts on the date that is on that particular day and I can see how the error can be made. But it is no more than that. I am intrigued with your overall conclusion. I am intrigued by your use of the phrase `unfortunate' and I wonder if I can explore that briefly with you? Let me read the whole section: "It is my opinion that it is always best practice to provide as much information as possible when making onward referral to a medical practitioner and if data is being used from a previous time it should be made clear in the referral letter. The failure to do so in this case was unfortunate". Fortune does not actually play a part in clinical practice, does it, Professor Parrish? Or certainly should not do? Do you agree with that? In the perfect world, I would agree with that.

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In the perfect world? So has this patient been fortunate that she only suffered from a Grade 3 macular hole, as opposed to a retinal detachment? Is that good fortune, Professor Parrish? I could not comment. You comment that in a perfect world, fortune does not play a part. I think in a perfect world, nobody would make an error but, as we saw in this room yesterday, twice the date was given wrongly here. People do make mistakes. I think that was an unfortunate error. I do not think that was anything more than that. It has potential consequences for patients. It does indeed. And Mr Zaman said yesterday that he sees 15 patients a day. That is 300 a month. That is 3,500 a year and he has been qualified for seven years. That is 21,000 people. I would suggest anybody who does anything 21,000 times will make a mistake. I think that is for all of us and that is a fair point to make. I am grateful. Thank you, Professor Parrish. Thank you, Madam.

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Ms Jeyasingham: Thank you. Mr Lamb ­ any questions? Mr Lamb: It may be that Miss Rollason has some re-examination? Ms Rollason: I do not, Sir, thank you. Mr Lamb: I have no questions, thank you. Mrs Huka: Professor Parrish, could I just ask you whether, in your expert opinion, it could actually be deemed that the test on 16 February and the subsequent test on 7 March could be one test? A. I think opinion may well be divided on that. I think there are some optometrists who would, perhaps, see it as a continuation. There are optometrists who would say, `Well, the first test was satisfactorily concluded on that day, therefore, 19 days later this is now a separate issue and therefore, justifiable to claim a separate NHS sight test fee, that is, a new sight test'. And I think opinion may well be divided. And it may also have some geographical basis. Different areas and different PCTs may have a slightly different interpretation of that, I would imagine. So I do not think there is a clear cut answer to that question. Ms Jeyasingham: Mrs Norgett? Mrs Norgett: I have no questions, thank you. Ms Jeyasingham: Lady Wall? [No questions] Mr Charlesworth: I have a couple of questions. Just on a point of law, if you turn to Section 5, your report there, you reproduce the General Council's Rules of referral. Point 4 I will read out, if I may?

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"In referring a person to a registered medical practitioner, a registered optician shall take the following steps: (a) he shall advise the person to consult such a practitioner; (b) he shall wherever practicable furnish a registered medical practitioner named by the person with a written report of the findings indicating the grounds for thinking the person may be suffering from injury or disease of the eye; and (c) where action appears urgent, he shall also take such measures as are open to him to inform a registered medical practitioner immediately". I wonder if you could take us through those three points and just let us know what you think the actions of the reasonable optometrist would be on each of those, and whether Mr Zaman has met them. In terms of advising the person to consult, clearly that would be verbal advice that would be given at the time and I think we heard from Mr Zaman yesterday, on his account he said that he advised the patient to take the letter he had given to the medical practitioner. So I think if we take Mr Zaman's account, then that advice was given and the urgency was appropriate. If we take the second point, (b), then clearly, Mr Zaman did provide a written report of the findings, subject to the date that we have discussed, and why he thought the person might be suffering from injury and, on the evidence he had, I think he has made that point fairly succinctly. But, as we said before, because he was not able to perform other tests, the actual reason perhaps was not apparent and that is made clear in the letter. Where the action appears urgent, I think this required an urgent referral but I do not think it was an emergency referral and that probably means for a situation where if it is urgent as in emergency, it would be sent perhaps straight to an Accident and Emergency Unit and a letter would also be sent to the patient's medical practitioner informing him of the action that had been taken. But that I do not think applies here; this was not an emergency referral. So that would not be applicable. Q. So, even though we have been talking about an urgent referral and section (c) here says, `Where action appears urgent', in your opinion that is a slightly different thing? Well, yes. Because this is saying you can do whatever is appropriate and inform the medical practitioner immediately and I do not think this was an immediacy. I think immediate would be something like a patient having a retinal detachment who was sent to Casualty this morning and you would inform the GP of the action that you had taken, because I think the word `immediate' appears in that. This was not an immediacy. I think there is a difference here between `urgent' and `immediate' and I think this is how one has to interpret that. Thank you. That then leads on to my next question, because we have heard ­ or we know ­ that Patient A had a macular hole. We have also heard

A.

A.

Q.

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A.

conjecture that it might have been a retinal detachment. Is there any way, in your view, that an optometrist would be able to talk to a patient and tell the difference between a macular hole and a retinal detachment, without examining them any further? I think the symptoms would be, almost certainly, quite different. The symptoms of retinal detachment would definitely be different to the symptoms of a macular hole. A macular hole, as we went on to discover later on, is when people describe a problem with their central vision and often distortion in the vision. A retinal detachment, probably, would present with flashing lights in the vision, floaters in the vision. People describe it as a curtain coming across their vision. They would be different symptoms, I think it is fair to say, and I think with careful questioning you probably could differentiate one from the other quite easily. So it is possible for an optometrist to get some idea of the disease from the symptoms, but how advisable would it be to make a referral just on that without any further ­ I think as we said before, if that is all you have time to do, then there is little choice but, as I said before, if time is available there is no question. A full eye examination to support that would undoubtedly be the best course of action. Okay. I just have one more question which relates to the accuracy of the referral. We know and we accept that the date on there is incorrect ­ I don't think anyone is disputing that ­ but there has been from Dr Spry a description of triaging and how important it is to have information on there that will let the hospital decide whether it is urgent, rather than the optometrist decide whether it is urgent. Yes. Now, I am aware that Dr Spry's experience is particularly with glaucoma and glaucoma is a more common disease than a macular hole. I would just like your opinion on would it be easier to write a full and complete record or account of somebody that had been examined for glaucoma than it would be for somebody who has got some sort of unknown disease because they had just come in complaining of loss of vision in one eye? In the sense that if somebody has glaucoma and you have optic nerve head changes, visual field changes, intraocular pressure changes, then you probably have more specific information which would lead you to that conclusion. I think in this case, where the pathology is unknown because it is unknown the letter has to have a certain amount of vagary about it. It cannot be as specific. Does that sort of answer your question? I think it does. I think really I am just trying to ascertain whether, because you said you were not really aware of this triaging system ­ As a practising optometrist over many years, maybe it is just the area in which I work but I am unaware of the referrals being ­ if somebody asked for an urgent referral, then I am unaware of that ever being overridden, I have to say. Maybe, but I am unaware of it after 29 years.

Q.

A.

Q.

A. Q.

A.

Q. A.

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Q. A.

I am just wondering if you think that that might be something that happens in glaucoma that does not happen in other issues. I have to say I did wonder that but I have no evidence for that. But I was surprised by what Dr Spry had said. Okay. Thank you. I do not have any more questions.

Q.

Ms Jeyasingham: Any further questions for this witness? Ms Rollason: None from me, Madam. Mr Alder: [No further questions] Ms Jeyasingham: Thank you very much, Professor Parrish. Ms Rollason: Madam that completes the evidence on behalf of Mr Zaman. Ms Jeyasingham: Mr Alder, is there any further rebuttal evidence that you want to call on? No? Then we move on to submissions. Ms Rollason: Madam, before we do that, may I raise a question that we have about the stage we are at under the Rules? Not being perhaps as familiar as Mr Alder is with the process before this Council, the Rules are not entirely detailed as to the process in terms of decision-making stages which will be followed. I wonder if the Panel, or the Legal Adviser, will confirm what the next decision you will make will be. Mr Lamb: Yes. Has everybody got the book? Ms Rollason: I don't have the book. I have a copy of the Rules, yes. Mr Lamb: If you turn to page 101. Ms Rollason: I have a copy of the Rules, Sir. Perhaps if we can refer to the Rule numbers, that will be helpful. Thank you. [Receives copy of Rule Book] Mr Lamb: Page 101. Okay? Registrant's case. Ms Rollason: Yes. Mr Lamb: The invitation has gone out to call evidence in rebuttal. Ms Rollason: Yes. Mr Lamb: Submissions: following the presentation of evidence, including any evidence in rebuttal, the Presenting Officer ­ Mr Alder ­ shall be entitled to address the Fitness to Practise Committee. Following any address made by the Presenting Officer, the Registrant shall be entitled to address the Fitness to Practise Committee ­ you get the last word. The Fitness to Practise I think we have heard 46, presentation of the

16

Committee shall then determine their findings as to fact, and as to whether or not the allegation is proven. So that would be the conclusion, as I understand it, of the first stage, which is: these are the facts; we find those proven. Then we go on to mitigation. Ms Rollason: I think my query, Sir, relates to elaborating on the various issues the Panel has to decide: the factual allegations, clearly; the issue of whether the facts amount to deficient professional performance and then the issue of impairment. And would the Panel be proposing to take those in three separate stages, or in one global stage? Mr Lamb: If they embarked on their deliberations without an apparent - to me awareness of those distinctions, I would chip in and say, let's perhaps take it in three stages. Mr Alder: I wonder if I could assist. I am just conscious, perhaps from my own position as well as Mrs Rollason's, that it will affect the submissions that would be made at this stage. From my experience before these Committees, the procedure that the Committee has adopted would be to consider the issues as to fact and deficiency as one stage then reconvene to announce the decision, give the reasons for that decision, followed by submissions as to impairment if that stage were reached. It clearly just affects the submissions which could be addressed to the Committee. There may be some logic, some merit, to breaking down into that particular procedure, but that is entirely a matter for the Committee and of course, any legal advice also you may have and any comment from Mrs Rollason. Mr Lamb: Have you two formulated some issues that you want the Committee to consider? Have you had a discussion about where you are going in your submissions at this stage? Ms Rollason: No. Mr Lamb: Would it be convenient for you to sit down and say, `Right, members of the Committee, we are addressing this issue, this issue and this issue. This is how we want to do it'? Yes. Mr Alder: It may, Sir. Ordinarily, submission at this stage, from the Council, merely say, `Well, you've heard the evidence, it's fresh in your minds, these were the issues I flagged in opening', rather than identifying specific issues. But if it was felt to be helpful then of course, I am more than happy to ­ Ms Rollason: I think what concerns me is knowing which parts of those three elements to address at this point. It is my experience that certainly, the stage of impairment be taken as a separate and later stage, enabling the parties to make submissions directly specifically to that. Mr Lamb: Let's try to get from the general to the specific ­

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Mr Alder: It may be just a decision for the Committee as to the procedure it wishes to follow at this stage ­ Mr Lamb: Helpful suggestion. If we go to the allegations for the moment, (1) and (2) are admitted. Ms Rollason: They are, Sir. Mr Lamb: There is an issue about inadequacy. The inadequacy is spelled out in the three numbered subparagraphs ­ Ms Rollason: Yes. Mr Lamb: There is really only one issue that arises out of that, isn't there inadequacy? Ms Rollason: Yes, that is the overall allegation in head 3. Mr Lamb: What else do the Committee have to decide? Ms Rollason: Yes, Sir, I agree. Mr Alder: Of course there may be some submissions in respect of the deficiency of that, which would be additional submissions to make, depending at which stage it was called. Mr Lamb: Would you like the Committee to decide on the question of inadequacy, come back to you and say, `Right, we find that this referral letter was inadequate. Now, where do we go from here?' Is that how you would like it? Ms Rollason: Sir, I think that my position would be it is a matter for the Committee to determine which state is ­ I simply ask to know so that I can know how to address my submissions. Mr Lamb: Okay. Madam, the decision-making process is entirely a matter for you. A suggestion which occurs to me is that you hear both sides on the issue of inadequacy. You make your ruling as to that, come back in and say, `Right, as a matter of fact, we find ­ or do not find ­ that this referral was inadequate' and then we will move on to the issue of deficiency in practice. That is the suggestion that I make. Whether you adopt it or not is entirely a matter for you. You can take both at the same time if you want to, in which event, you will hear from counsel on both issues. Ms Jeyasingham: No. I think we will take it stage by stage. That seems a logical way to go ahead. Mr Lamb: Right, so you will both get two words if you find it is inadequacy. Ms Rollason: Thank you, that is helpful.

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Mr Alder: Then very briefly, closing in respect of the submissions as to adequacy, of course, there may be some additional submissions to make as to deficiency, as an issue for the Committee distinctly, as to, for example, the admitted facts in (1) and (2) and to whether the Council, as alleged, say they amount to deficient professional performance. In respect of head (3), the Council have alleged that the referral is inadequate. We have said so on very clear grounds, as are set out clearly now in the expanded allegation. You have heard a quite significant length of evidence as to the nature of the referral but I would ask you to consider very clearly the evidence of Dr Spry, who sits as one who considers these referrals. He is able to confirm that actually to him, the information provided in this document was not helpful. It was misleading; it was inaccurate and would have led to their being a question over the prioritisation of this particular patient. You heard this morning from Professor Parrish, once he was answering my questions, that actually to him, the information was misleading. The issue has focused very specifically on the date given as being inaccurate ­ 7 March 2007 ­ as being a prescription detail from a current sight test. We know ­ it is the evidence that has come out through this hearing ­ that there were no examinations performed on this patient on that day. There was no clarification of the information which was provided in the points requiring attention. Some focus has been given to the time it would have taken to have included a line which says, `I have not tested the patient'. That would have provided sufficient certainty for those who were considering this referral afterwards to have applied some certainty to their onward referral process. Madam, it has very clearly put the grounds on which the referral is said to be inadequate. It is obviously a matter in one sense for your decision and consideration of the referral itself. But given that the clinical document which you have in front of you and the importance this document plays in the referral process ­ the importance of it to this particular patient and her onward management ­ it would be a brave decision, I suggest, to conclude that inaccurate and potentially misleading information on a clinical form is not found to be inadequate. Madam, the evidence before you is obviously presented by Professor Parrish. It is presented to an expert extent by Dr Spry. Those are both expert evidence that you will be able to take into account. That evidence is fresh in your mind. I propose not to recount it in great detail with you and those are my brief submissions as to the adequacy which the Council allege, in this particular referral, which says quite clearly that this, given the inaccuracies, is an inadequate referral. Mr Lamb: Mr Alder, help me please with a question of interpretation of the allegation. Paragraph 3, the opening two lines: we know in this case that it was a two stage referral: optometrist-GP, GP-ophthalmologist. On one interpretation of those opening two lines, the allegation concerns itself only with the first stage and does not get to the Spry stage. Mr Alder: Sorry ­ so your question is?

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Mr Lamb: What is the interpretation of those two lines? Dr Spry talks about what happens triaging at a hospital but on one interpretation, these two lines do not concern themselves with what goes on at a hospital. Mr Alder: The relevance of Dr Spry's evidence to the extent of a practitioner, a clinician, with optometric experience, beyond that of a GP receiving this information in this referral, concludes that it is inadequate because of the lack of information in there. And it leads to potentially confusion and concern as to the necessary route and prioritisation for this referral. Does that assist you or answer your question? That is the relevance to my suggestion of Dr Spry's evidence. He is one experienced in receiving referrals and of drawing conclusions from the information presented within them. Ms Rollason: Thank you, Sir. It has been helpfully clarified that at this point the Committee is considering purely the factual allegations and the fact which remains in dispute is head 3. You will receive advice from your learned Legal Assessor in a moment but I would respectfully remind the Panel that, in terms of the facts in this matter, the burden of proving the allegation is upon the Presenting Officer for the General Optical Council, not upon Mr Zaman. And the standard of proof I understand to be applied in these proceedings is the criminal standard, so that you will be advised that you must be satisfied so that you are sure, before you can find that allegation proved. Of course, that is the high standard of proof. I ask you to consider the precise terms of the allegation that the Council has decided to bring against Mr Zaman. There is an allegation as a matter of fact that Mr Zaman's referral of Patient A was inadequate. So in a sense, that issue of inadequacy is brought into the factual allegation and you have to find inadequacy proved beyond a reasonable doubt, as well as the bases set out in the three heads. I do draw your attention to the point just raised by the learned Legal Assessor, in terms of precisely the terms of the global allegation in head 3, that it was the issue of Mr Zaman's referral of Patient A to her general practitioner that is your consideration and I certainly ask you to have close attention to that. The Council has particularised how it says the referral was inadequate in the three sub particulars, and it is those particulars which, in my submission, you must address your mind to. You may have heard other issues which you might think are relevant to referral, but that is how the Council has decided to put its allegation of inadequacy. It may be, Madam, that you take the view, having heard the evidence of the two factual witnesses, Mr Zaman and Miss A, and the experts for the respective parties, that this comes down to quite a narrow issue. I think it has become apparent in Mr Zaman's evidence that he accepts the factual bases of (1), (2) and (3) sub heads. What he does not accept is the overall conclusions reached and the criticisms. I would summarise Mr Zaman's case in this way: that he accepts that referral was not perfect. It was not, as you have heard from Professor Parrish's view, it would not be, the ideal standard. But the question you are asked to consider is was it adequate? You heard Professor Parrish's evidence today that in his view it was adequate. It was fit

20

for purpose. `It did the job', as he put it. And that is evidenced by the action the GP took when he received that referral. It is a pragmatic view, Madam, but you are asked about the issue of adequacy, not perfection. I think that when you come to consider the differences between Professor Parrish and Dr Spry, that is coloured by their different perspectives. Dr Spry is principally, and has for some years, been working in the secondary setting as a hospital optometrist, which he has clearly acknowledged and his experience of referrals is at the other end of the process. Given the wording of the global allegation in head 3, he is at a further stage on from that which you are asked to consider. In contrast, Professor Parrish's background is still very much in the field of the primary care setting; he works regularly in that setting, in a similar type of setting to that which Mr Zaman practises in. He, I would suggest you can conclude, has a better appreciation of the realities of the primary care setting, the real issues which face an optometrist in a high street practice ­ issues such as those Mr Zaman raised about the appointments system, the availability of time, what is achievable in that practice. Indeed, Dr Spry himself acknowledged, when it was put to him, that there are pragmatic factors on the ground and it is a question of what is achievable in the circumstances and that ­ turning specifically to the facts here ­ it was, in his view, in a range of reasonable actions for Mr Zaman to refer the patient without further examination in the circumstances that it was not possible to conduct the tests that Mr Zaman wished to conduct. I need to mention the question of the date of the referral again, on which a lot of discussion has focused. Again, Mr Zaman has openly and frankly acknowledged that that date was incorrect and, in a sense, impacts upon the information in the referral. But I do ask you to accept his evidence that there was no intention to mislead, there was no deceit involved in this; it was an error, a lack of clarity. The information in that referral related in part back to the previous visit on 16 February and again, I ask you to consider in the particular circumstances this was not a previous visit and sight test months before or a year before, as much as two years before it might have been in the circumstances a sight test. It was a recent matter and to that extent, that is a fact I ask you to bear in mind. I just say finally a word about how I would suggest you should treat the expert evidence because, clearly, you do have a point of conflict between the two and this Committee must, of course, consider the expert evidence but it is not bound by it and it is a matter for you to apply your own judgment upon that issue. Madam, that completes what I wish to say at this point thank you. Ms Jeyasingham: Thank you. Mr Lamb: Madam, you are now going to embark on the determination of the issue of adequacy, which arises out of paragraph 3 of the allegation. If you decide that the referral was inadequate, we will come on at a later stage to decide

21

whether or not that denotes deficiency in fitness to practise. So one issue: adequacy of the referral. Burden of proof: on the Council; it needs no further elaboration from me. Standard of proof: you heard, in the course of counsel's submissions references to the word `sure' and also reference to the phrase `beyond reasonable doubt'; they are synonymous. The question of adequacy ­ the word `inadequate' is a word of ordinary common English, with which you are all familiar; it is a word which you will interpret in its application to the facts of this case in the light of your own commonsense and in the light of the factual evidence which you have received from Patient A and the Registrant and in the light of the expert evidence on the field of optometry which has been given by Dr Spry and Professor Parrish. They have illuminated that world insofar as it was not known to you. I put to Mr Alder that there is perhaps a question mark over the precise meaning of the introductory words of paragraph 3 of the allegation. The phrase `to her general practitioner', as used there, it strikes me, are capable of at least two possible interpretations. They could be adjectival; they could be merely descriptive of the piece of paper. One might, for example, substitute the phrase `which he put in an envelope and gave to Patient A' in order to denote this piece of paper. Alternatively, `to her general practitioner' could look at the purpose of the referral, the first stage of the two stage referral process here. It is a matter for you; you may come up with your own interpretations of what that means there What I would suggest to you ­ and I will take correction on this at the end ­ is that if there is any ambiguity in your minds, you should resolve the ambiguity in favour of the registrant and take that interpretation, which it is the more difficult for the Council to prove. Unless there is anything else, or particular points, on which you would like my advice, Madam that is all I was proposing to say. And I will take corrections now. Ms Rollason: I have none. Mr Alder: Sir, no correction. I am conscious that the focus of the submissions at this stage are on the adequacy that denotes very clearly the particular of head 3. But of course, admissions have been made in respect of particulars (1) and (2). Those are still requiring determinations as to fact by the Committee. Mr Lamb: Admitted. Mr Alder: But there is no provision in the Rules, as I understand it, for those to be accepted as read by the Committee.

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Mr Lamb: Thank you for reminding me. You are quite right. Mr Alder: So the Committee still need to make a determination. Mr Lamb: There is no dispute about those matters, (1) and (2). Mr Alder: Thank you. Sir, it may go too far and you can stop me; I am conscious of the advice you have given to the Committee as to the phrasing of allegation at head 3, the referral of Patient A to her practitioner. That, Sir, is taken in small part from the terms given at the top of the referral letter itself. Thank you. Mr Lamb: But resolution of ambiguity? Mr Alder: No, of course, Sir, absolutely. Ms Jeyasingham: Thank you. Can you clear the room, please? [Hearing adjourned at 10.44 am] [Hearing resumed at 12.48 pm] Ms Jeyasingham: I am going to read out the determination in findings in relation to the particulars of the allegation. Determination The Committee found particulars (1) and (2) of the allegation admitted and proven as a matter of fact. The Committee has accepted the suggestion that it would be convenient to resolve the issue of adequacy of the referral before considering any question about the deficiency, if any, of Mr Zaman's professional performance. The Committee has carefully considered the submissions made by the legal representatives and has accepted legal advice from the Legal Advisor. The Committee is not satisfied that the referral of Patient A was inadequate in the respects particularised in the sub paragraphs (i) to (iii) of paragraph 3 of the allegation. The Committee's primary reasons for the finding of adequacy are as follows: 1. The referral did contain data resulting from an examination on 16 February 2006 and did not make that clear. Nevertheless that did not prevent the referral from achieving the intended result, examination by an ophthalmologist. 2. No re-examination was carried out because, as Mr Zaman explained, it was not possible on that occasion. Referral was within a range of acceptable options open to a reasonably competent optometrist. The referral conveyed the necessary urgency to the GP.

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3. The giving of the date of 7 March 2006 was an oversight, as Mr Zaman admitted. The misdating did not preclude the GP from fulfilling his part in the referral process. The Committee accepts the factual basis of paragraph 3, subsections (i) to (iii) of the allegation but does not find that, in this case, it amounts to inadequacy. Mr Alder, how do you want to proceed? Mr Alder: Madam, I think we would, therefore, proceed to the determination by you as to the issue of deficient professional performance. I have very brief submissions for you on that point. Of course, the issue as to deficient professional performance is a matter entirely for you; it is a matter for your professional judgment. It has been accepted that there was no measurement of the visual acuity of the patient, nor a performance of the refraction examination. Madam, it has been suggested on behalf of the counsels that, notwithstanding your conclusions about the adequacy of the referral, that information could have been sought and should have been sought, because it would have assisted and provided clinical data which could have utilised in the referral pathway. I am very conscious of the decision you have made about the adequacy of the referral in the grounds set out in the allegation. My suggestion and submission to you, Madam, is that ­ given it is a matter for your professional judgment as to the deficiency, as alleged by the Council, who are entitled to go on if you accept the evidence of Dr Paul Spry to some extent, but I appreciate not entirely, but to some extent, the agreement with Professor Parrish in the expert report that he provided ­ it may have been a preferred option for examinations of this nature to have been undertaken. Of course, one instance of failing to measure the visual acuity of his patient and failing to perform the refraction examination of this patient on 7 March 2006 is sufficient for you to find deficient professional performance. One instance is sufficient. You will balance that, of course ­ I am well aware ­ in the overall context of the case. The test for you to apply is that of the reasonably competent practitioner at this stage. My submission is that the evidence and opinion of Dr Paul Spry is persuasive and the onward referral of her information made available to subsequent practitioners, there would have been real benefit to this patient in seeking this information at this time. As Professor Parrish put it, `there would have been clinical certainty in at least seeking this particular information'. As I suggested in opening, the Council have not set out every potential test which should, the Council believe, may have been undertaken on 7 March. They are starting points. The Council is unsure, and there is no evidence, as to what particular potential pathology this patient presented to Mr Zaman with on 7 March 2006. In undertaking the referral pathway that he did, I appreciate your determinations on adequacy, but in determining that particular referral pathway without clinical knowledge, without assessing at least those two very basic, fundamental examinations of her sight, he was to some extent making

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a referral in the dark. He had no diagnosis, no signs and the evidence of both the patient and Mr Zaman, the only symptoms which she presented to him with was of a sudden, unexplained vision loss in her left eye. Those were Mr Zaman's recollection of her symptoms. Given those matters, in not performing the examination of the visual acuity, not performing the refraction examination as the starting point, were to, to some extent, place this particular patient at risk. You will have heard my discussion with Professor Parrish about the issue as to visual outcomes. That is very much to deal with this matter with hindsight which is, Madam, perhaps an inappropriate way to deal with it. You must consider what was available to Mr Zaman on 7 March 2006 and the steps which he had taken at that point. Madam, I am conscious that it is a matter for your professional judgment. They are only very brief submissions as you would anticipate. Of course, your determination today as to the standards of conduct expected of a reasonably competent optometrist will, of course, include your consideration of your wider duties to the public and to the profession and the message that you will send to both of those ­ the public and the profession ­ as to what standards are expected of a reasonably competent practitioner. In this case, I suggest that Mr Zaman should have, as a preferred option, undertaken the measurement of visual acuity, the measurement of the refraction of this patient. That would have provided specific, clinical certainty and was, most importantly, in this particular patient's best interests. Only with that information as a starting point, could there have been an informed decision about the correct referral pathway to take. Madam, I hope those matters have addressed the issues and they are my very brief submissions. Ms Jeyasingham: I think we need to think about the next stage of this and considering the discussions that the Committee have already had and also the fact that we have heard all the evidence in this hearing so far, I am just going to ask the Legal Adviser, maybe the best way of going ahead is for us to consider those matters and to clear the room and then come back with our final statement. Ms Rollason: Madam, I would clearly ask for a chance to make submissions on behalf of Mr Zaman at this point ­ Mr Lamb: If we get there. Ms Rollason: Indeed; very well. On that basis, subject to having the opportunity ­ Mr Alder: I apologise. It is clearly my error. I am not quite sure what we are aiming at. Are we looking at the procedure we will take forward or my submissions as to deficient professional performance? Mr Lamb: The next stage is to determine deficiency, if any, of practice. Committee has that very much in mind. The

25

Mr Alder: Sir, on that basis, my concern would therefore have been, on behalf of Ms Rollason, that she would welcome, perhaps, the opportunity to make submissions. Mr Lamb: The Committee will not make any findings without hearing from Ms Rollason. Mr Alder: Very well. [Hearing adjourned at 12.56 pm] [Hearing resumed at 2.12 pm] Mr Lamb: Ms Rollason, we have taken a slightly high procedural route through this and you look surprised, understandably. Let me ask you this hypothetical question: if the Committee has concluded that your client's fitness to practise was not impaired and intends to acquit him on all counts, would you insist that they should hear from you further? Ms Rollason: No, Sir. Ms Jeyasingham: Then I will continue. Determination Mr Zaman carried out a full eye examination of Patient A on 16 February 2006. Both expert witnesses agreed that an adequate eye examination was performed on that date. Patient A re-presented with symptoms on 7 March 2006 and Mr Zaman made the decision to refer her to an ophthalmologist via her GP urgently. In the absence of time to complete a full eye examination, referral is an acceptable option open to a reasonably competent optometrist. It therefore follows that the fact that Mr Zaman did not perform the specific procedures, a visual acuity measurement and refraction, cannot constitute a deficiency in his professional performance. I also want to add: The Committee is entitled to assume that the allegations given to them and read out at the beginning of the hearing are the same allegations upon which both representatives base their case. This was not the case as we discovered partway through the hearing. We request that the GOC investigate how this occurred. Furthermore, for future reference, the Committee expects the allegations brought by the GOC to have due regard to published Rules and guidelines. Mr Lamb: Ms Rollason, now a real question. Ms Rollason: Yes.

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Mr Lamb: In front of you is the handbook. Flagged is page 101. There you will find Rule number 51. Are you familiar with it? Ms Rollason: I had looked at it, Sir, yes. Mr Lamb: Does your client ask for ­ require - want a declaration of fitness to practise? Ms Rollason: May I just take one moment to confirm? [Aside] Sir, thank you for bringing that to our attention and yes, my client would ask for that declaration by the Panel. Ms Jeyasingham: Pursuant to Rule 51, the Committee declares that Mr Zaman is fit to practise as a registered optometrist. Ms Rollason: Thank you. Mr Zaman: The last hours have been very difficult for me and my uncle passed away on Monday. I would like to say that the way you have conducted yourselves has been very dignified and professional towards me over the last two days. Ms Rollason: Thank you, Mr Zaman. [Hearing concluded at 2.16pm]

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