The Codes of Professional Conduct for both veterinary surgeons and veterinary nurses stress the need for effective communication with clients and ensuring that informed consent is obtained and documented before treatments or procedures are carried out.
At its January meeting RCVS Standards Committee approved changes to chapter 11 (‘Communication and consent’) of the supporting guidance to the Codes to provide further advice to the professions on matters that should be discussed with clients to ensure informed consent is gained, provide clarification on who can gain consent for a procedure and give some additional guidance on consent forms.
Nick Oldham, Standards and Advisory Manager at the RCVS, said: "We hope that this updated guidance is more accessible, readable and will aid members of the profession in developing a more comprehensive approach to gaining informed consent for treatments and procedures and therefore reduce the risk of miscommunication and misunderstanding which can lead to concerns being raised by clients.
"For example, we have updated our guidance to encourage veterinary surgeons to consider discussing a number of additional factors with a client before obtaining consent. This includes the nature, purpose and benefits of any treatment or procedures, the likely outcomes including potential risks, financial estimates, informing the client when other treatments may have available and checking that the client understands what they are agreeing to rather than assuming the client understands both the potential financial outlay and possible side effects.
"Furthermore, there is now additional guidance for veterinary surgeons on who should be seeking consent. While ordinarily it is expected that the veterinary surgeon undertaking the procedure or providing treatment is responsible for obtaining the client’s consent we know that this is not always practical.
"Therefore we clarify that the responsibility of obtaining consent can be delegated to another veterinary surgeon and, failing that, a registered veterinary nurse or student veterinary nurse could obtain consent provided that they are suitably trained, have sufficient knowledge of the proposed procedure or treatment and understand the risks involved.
"The RCVS Standards and Advice Team is also in the process of producing a series of fictional case studies based on informed consent issues encountered by the College’s Preliminary Investigation Committee which we hope will further help the profession."
The updated supporting guidance can be found in full at www.rcvs.org.uk/consent
The Code of Professional Conduct and its supporting guidance can also be downloaded as an app for smartphones and tablets at www.rcvs.org.uk/codeapp
Members of the profession seeking confidential advice on matters relating to professional conduct can contact the Standards and Advice Team on 020 7202 0789 or advice@rcvs.org.uk
Mr Lomax was found guilty of causing death by careless driving at Shrewsbury Crown Court in July 2019 and was subsequently sentenced to a 12-month community order, 300 hours’ unpaid work, 15-months’ driving disqualification and ordered to pay £1,000 in prosecution costs and victim surcharge of £85.
Mr Lomax declared his conviction to the RCVS in April 2020 as part of his declaration upon renewing his registration, following which the RCVS started its concerns investigation process leading to his appearance before the Disciplinary Committee last Monday.
At the outset of the hearing Mr Lomax admitted the charge against him, which was also accepted by the Committee based on its receipt of the certificate of conviction from Shrewsbury Crown Court.
The Committee then considered whether the conviction rendered Mr Lomax unfit to practise. The RCVS submitted that the nature of the conviction and the devastating consequences of Mr Lomax's conduct, which caused the death of a 64-year-old woman, rendered him unfit to practise.
The College also submitted that his conduct would be considered to have fallen far short of the standard expected of a member of the profession, that it had devastating consequences, and that the conviction would have an impact on the reputation of the profession and the public’s confidence in it.
Mr Lomax’s counsel, who represented him during the hearing, submitted that he did not accept his conduct rendered him unfit to practise as a veterinary surgeon, although Mr Lomax did accept that the impact of his conduct was devastating.
Mr Lomax’s counsel submitted that there was a significant difference between his conduct and its consequences, as evidenced by the fact he was charged with careless driving rather than dangerous driving meaning that, though his standard of driving had fallen below that expected of a competent and careful driver, it did not fall far below. Nor was there a suggestion that Mr Lomax had carried out a deliberate act, was carrying out any dangerous manoeuvres or was otherwise impaired.
Dr Martin Whiting, chairing the Committee and speaking on its behalf, said: “There is no doubt that the consequences of Mr Lomax’s conduct were serious and tragic for the [victim’s] family.
"The Judge at the Crown Court referred to their loss in detail and it no doubt played a significant part in the sentence he passed, as reflected by his comments.
"The Committee was cognisant, however, of the different role it had to perform.
"A criminal conviction marks a breach of criminal law, whereas a finding of unfitness marks a breach of professional standards.
"When looking at the conviction, the Committee focused on the actual conduct of Mr Lomax and the concomitant level of culpability, rather than the consequences. Whilst it would be artificial, insensitive and inappropriate to ignore the consequences, the Committee was concerned with the conduct.”
He added: “The Committee did not consider that Mr Lomax’s conduct was liable to have a seriously detrimental effect on the reputation of the profession and concluded that the public, in full knowledge of the circumstances of this particular case, would not expect a finding that the conviction renders him unfit to practise as a veterinary surgeon.
"Rather, the public would recognise that whilst the consequences were appalling for the [victim’s] family, in terms of Mr Lomax’s culpability this was a momentary piece of poor driving rather than anything more blameworthy. At its height it was careless driving for three or so seconds.
"In the Committee’s view Mr Lomax’s careless behaviour fell below, but not far below, the standard expected of a veterinary surgeon and did not amount to disgraceful conduct in a professional respect.”
The full findings of the Disciplinary Committee can be found at www.rcvs.org.uk/disciplinary
The consultation invited members of the professions to explain how they currently understand and interpret Schedule 3 in practice, how it could be clarified and how it might be amended to bolster the veterinary nursing profession.
11,625 people responded to the consultation, the highest number that has ever responded to an RCVS consultation. 6,873 were veterinary nurses (around 35% of the profession and including 1,665 student veterinary nurses) and 4,752 were veterinary surgeons (around 21% of the profession).
The report on the consultation, which is published today by the Institute for Employment Studies, found that 92% of veterinary nurses and 71% of veterinary surgeons think veterinary nurses should be able to undertake additional areas of work.
However, neither vets nor nurses seem to have an especially good understanding of the current scope of Schedule 3 and how it applies in practice, rating their personal understanding at 5.6 and 6.7 out of 10 respectively.
When asked what prevented the full utilisation of veterinary nurses, the majority of both vet and vet nurse respondents highlighted a lack of understanding of what tasks can be delegated under Schedule 3, with around 60% of veterinary surgeons also admitting that they are not good at delegating.
61% of veterinary nurses and 50% of veterinary surgeons thought that the RCVS gives sufficient support and advice about Schedule 3, though the relatively poor level of understanding amongst veterinary surgeons in particular suggests more needs to be done.
In corresponding comments both veterinary nurses and veterinary surgeons said they would like more clarity, especially around 'grey areas' such as the meaning of the term 'minor surgery', as well as further communication from the College about Schedule 3 and for more training for veterinary nurses to ensure they have the competence and the confidence to carry out delegated procedures.
Liz Cox, Chair of RCVS Veterinary Nurses Council, said: "Thank you to all those who responded to the consultation in such large numbers and who shared their views on this topic. The consultation grew out of the government’s suggestion that we review Schedule 3 as a means of bolstering the VN profession, and from the VN Futures project last year, when Schedule 3 was identified as an area where there could be some additional work to clarify the rules around delegation to veterinary nurses.
"There was a clear consensus that veterinary nurses could do more in their role and under Schedule 3 and so we will be feeding the findings back to the RCVS Legislation Working Party, which will be looking, in the round, at possible changes to the framework of veterinary legislation, including how it applies to veterinary nurses and other paraprofessionals.
"In terms of the understanding of Schedule 3 and how it applies in practice it is clear that we need to do some further work to clarify the rules and develop guidance to assist both veterinary nurses and veterinary surgeons in exercising their professional judgement in respect to delegation, for example, through case studies and other examples."
Looking at the tasks currently performed by veterinary nurses, the survey found the five most commonly performed are: clinical cleaning (92%), administration of medicines by subcutaneous injection (91%), administration of medication (90%), monitoring of anaesthesia (86.5%) and administration of medicines by intramuscular injection (86%).
The consultation also found that the majority of veterinary nurses are involved in clinics aimed at educating animal owners on various different aspects of animal health and welfare. The most common include puppy/kitten care (66.5% of respondents), nutrition (65% of respondents), general check-ups (62.5% of respondents) and dental care clinics (57% of respondents).
Post-survey interviews with 10 veterinary nurses and 10 veterinary surgeons found a number of recurring themes, including: limited career paths for veterinary nurses; poor pay for VNs relative to their training and complexity of work; lack of recognition and appreciation for the VN role; enthusiasm for advanced practitioner and specialist status for VNs; and difficulty recruiting experienced VNs.
The College says the results of the consultation will now be considered by the RCVS Schedule 3 and Legislation Working Parties, which are reviewing the efficacy of the current Veterinary Surgeons Act and whether changes need to be made to bring the legislative framework for the profession up-to-date, including consideration of the part played by allied professions like veterinary nurses in the veterinary team.
The full report can be downloaded here.
The College first became aware that confidential information had been leaked earlier this year after the Veterinary Record made the decision to publish details.
The College says it then provided a number of informal opportunities for the person leaking the information to come forward and discuss the reasons for their actions, but nobody stepped forward.
A Council member then made a formal complaint about the leak, which triggered the complaints policy set out in the College’s Code of Conduct for Council Members and instigated the investigation.
The investigation was run independently of the RCVS by an external specialist consultancy, and coordinated by a legal assessor.
Initially, the investigators were asked to focus on a single leak, but following a number of further leaks over ensuing months, it became necessary to widen the scope and depth of the investigation.
The investigators’ report concluded that there had been several separate and deliberate leaks of confidential information by a current or former Council member over an extended period.
However, they were not able to identify who specifically was responsible for the leaks, and because nobody admitted it, no further action under the complaints policy of the Code of Conduct for Council Members was appropriate.
The investigators concluded that the leaks were not the result of poor understanding of College or Council processes, but a deliberate decision to provide confidential information to third parties.
Council members have therefore agreed to review existing training requirements and mechanisms for handling confidential information and to explore in more detail the potential motivation of the person or people who leaked the information, together with the underlying culture of Council that might have influenced their behaviour.
RCVS President Mandisa Greene, said: “There is no denying this is a sad day for the College, and for RCVS Council in particular. As Council members of our professions’ regulatory body, we must maintain the very highest standards of probity and integrity if we are to maintain the trust and confidence of our professional colleagues. In the same way, we must subject ourselves to the same level of scrutiny and investigation if these values and behaviours are ever called into question.
“That someone chose to breach the trust placed in them by their peers is extremely disappointing, especially when they were given every opportunity to come forward to discuss their concerns, and avoid the College having to launch a formal investigation.
"Our default position during Council meetings is to hold as many discussions as possible in public session to ensure Council’s decisions are as open and transparent as possible – something that we will continue to increase as much as possible. Like any organisation, however, there may be a small number of issues that need to be discussed in closed session – for example, those still at concept stage prior to any decision being made public or put out for consultation, or those containing personal or commercially sensitive data.
"I sincerely hope that all of us on Council can learn from this unfortunate and unnecessary episode. We must rebuild and maintain sufficient confidence in each other, and in our processes, that, even if we disagree on certain matters, it is always best to do so in a direct, upfront and honest manner."
The Statutory Membership Examination must be taken by all individuals educated outside of the UK whose veterinary qualification is not recognised by the RCVS. Passing the exam allows them to join the UK Register, and practice as a veterinary surgeon in the UK.
The exam has existed in its current format for over 30 years, and the review was implemented to ensure the examination remains fit for purpose, and sits in line with international best-practice and the College’s current Day-one Competences.
The College says the review was also designed to make sure it is using the most appropriate means of assessment methods, to best prepare candidates for success, and to ensure candidates can work in the UK to the best of their ability.
The written examination will now consist of two parts; a clinical Multiple Choice Question (MCQ) paper (in a single best answer clinical vignette format) and an open book examination, which will be used to ascertain the candidate’s knowledge of the RCVS Code of Professional Conduct.
The Clinical, Practical Examination will now exist in the form of a multi-dimensional Objective Structured Clinical Examination (OSCE). This examination is set to measure a range of clinical, technical and professional skills including clinical reasoning, communication, professionalism, and ethical awareness. Following a tender process, Glasgow Veterinary School has been awarded the contract to host the OSCE examination for five years from 2019 to 2023.
RCVS Examinations Manager, Victoria Hedges, said: "The review of the Statutory Membership Examination has provided us with the opportunity to ensure that we continue to test the skills and knowledge needed to work effectively in a veterinary practice in the UK in a robust manner, and bring it in line with the final year examinations delivered at UK vet schools. In designing the examination, the RCVS has considered international best practice, in addition to approaches to regulatory examinations within both the veterinary and medical sectors."
A comprehensive handbook regarding this new examination will be available on the Statutory Membership Examination section of the RCVS website (www.rcvs.org.uk/statutory-membership-exam) shortly.
If you have any questions, please get in contact with Examinations Manager, Victoria Hedges: v.hedges@rcvs.org.uk
Mr Kashiv first appeared before the Committee in December 2016 in relation to four charges against him regarding his inadequate treatment of a Scottish Terrier called Tanzy which was ultimately euthanased due to renal failure.
The first charge related to Mr Kashiv’s original consultation with the owner in March 2015 and his failure to investigate for renal disease; his failure to discuss with the owner investigations to assess metastatic spread; failure to discuss with the owner alternative options to surgery such as palliative care or euthanasia and failure to explain to the owner key factors with regards to the surgery he had suggested to her, including its nature and extent, the risks involved, the fact another vet would be performing the surgery, and what to expect post-operatively.
The second charge related to the fact that, having admitted the dog as an in-patient at the practice, he failed to conduct further investigations regarding her poor condition; provide any or any adequate pain relief, or fail to record the same; failed to discuss with the owner the dog’s poor prognosis and failed to discuss with the owner the option of euthanasia.
The third charge related to the fact that Mr Kashiv discharged the animal back into her owner’s care when she was not in a fit state for discharge. The fourth and final charge related to the fact that Mr Kashiv failed to keep sufficient clear, detailed and accurate clinical records for his treatment of the dog.
At his original hearing in December 2016, the Committee found the four charges proven and also found that charges 1 to 3 amounted to serious professional misconduct. However, the Committee decided to postpone the judgement for two years, whilst recommending that Mr Kashiv agree to undertake a structured programme to improve his clinical practice, including putting together a personal development plan, having a mentor, accepting regular practice visits and undertaking additional continuing professional development (CPD).
The resumed hearing took place on Tuesday 18 December 2018, during which the Committee heard evidence from Dr Writer-Davies MRCVS (the veterinary surgeon appointed to review Mr Kashiv’s practice and report back to the Disciplinary Committee over the two year period), Mrs Somers MRCVS, (his appointed mentor), and Mr Kashiv himself.
Dr Writer-Davies told the Committee that she had no concerns about Mr Kashiv’s abilities regarding patient safety and that, in her view, he now meets the standards of a reasonably competent veterinary surgeon. She cited the fact he had gained in confidence when communicating with clients, had undertaken a considerable amount of CPD focused on the areas of concern identified in the case, that she had observed more detailed record keeping from him and that a veterinary nurse had been appointed to assist in running Mr Kashiv’s practice.
The evidence from Mrs Somers also found that Mr Kashiv’s knowledge was in line with that expected of a reasonably competent veterinary surgeon and that she had observed a good quality of care for pets and their owners from him.
Mr Kashiv also gave evidence, which the Committee said demonstrated considerable insight into his previous conduct and a good attitude towards self-reflective practice. The Committee also felt that the testimonials provided by Mr Kashiv showed him to be a kind and caring veterinary surgeon.
Stuart Drummond, chairing the Committee and speaking on its behalf, said: "The Committee considers that, having successfully completed the undertakings, Mr Kashiv is now a safe practitioner. The last two years has allowed Mr Kashiv to develop his skills particularly in the area of communication.
"However, the Committee has not lost sight of the fact that this was a serious case and that there was substantial harm caused to Tanzy.
"The Committee considers that in the intervening two years Mr Kashiv has gained considerable insight, developed better communication skills and remains open to improving his practice. It therefore imposes a reprimand on Mr Kashiv. The Committee considers that a reprimand is the appropriate and proportionate sanction to uphold proper professional standards and to maintain public confidence in the veterinary profession."
ITV's Tonight programme broadcast last night portrayed a veterinary profession in which overcharging is commonplace.
Researchers for the programme took three healthy animals (a cat, a dog and a rabbit) to a number of different vets, telling them that the animals were off their food. The advice they were given varied. In the case of the rabbit from no treatment necessary, to dental work under general anaesthetic.
TV vet Marc Abraham then looked at each animal and told viewers that the correct advice in each case would have been the least expensive.
The programme also highlighted the substantial savings that pet owners can make by buying drugs online, and questioned whether the penalty meted out to a vet that had committed malpractice was sufficient (the vet had been struck off for 14 months, where presenter Jonathan Maitland argued it should have been for life).
Veterinary business consultant Mark Moran said: "So often, vets rely to a large degree on what owners are telling them, and the degree to which they insist the animal is ill, or off its food, will affect the advice and treatment given. Marc Abraham had the luxury of being presented three animals that he knew to be perfectly fit and well."
However he agreed wholeheartedly with the response from RCVS President Jill Nute this morning, that the thing both vets and pet owners need to learn from the programme is "the importance of communicating with each other".
Mark said: "It's a question of managing people's expectations. There'll always be a variance in the advice being given, but being up-front and open will help mitigate the risk of being accused of overcharging".
Click here to watch the programme. Click here to read the reactions to Marc Abrahams' blog
Mrs Mullen faced four charges against her.
The first was that she failed to provide information to her clients about her practice OOH provision.
She was also charged with discharging a Labrador, called Cleo, that was unfit to be discharged following spay surgery, with an inadequate abdominal dressing and inadequate information given to the dog's owners regarding complications from surgery, the risk of post-operative haemorrhage and arrangements for out-of-hours care, as well as failing to make adequate clinical records.
The third charge alleged that she had failed to obtain informed consent for anaesthesia/ surgery performed on an English Bulldog, called Boycie, from his owners, failed to ensure the dog had adequate monitoring whilst recovering from anaesthesia, failed to offer an adequate range of overnight care for the dog, left the dog alone overnight when it was not in a fit condition to be left, failed to provide information to its owners on post-operative care at home and out-of-hours emergency arrangements, and failed to make adequate clinical records relating to its treatment.
Finally, she was charged with failing to have Professional Indemnity Insurance (PII) or equivalent arrangements in place or failing to provide details of it, failing to respond to requests regarding her continuing professional development records and failing to respond adequately to reasonable requests from the College for details and documents regarding her treatment of the two dogs.
Mrs Mullen indicated to the RCVS before the hearing that she would not be engaging with the disciplinary process.
The Disciplinary Committee therefore granted the RCVS permission to proceed in her absence on the basis that Mrs Mullen had made it clear that her absence from proceedings was deliberate and voluntary, that there was no indication she would attend any future hearing if it was adjourned and that the charges were of sufficient seriousness that it was in the interests of animal welfare to proceed with them.
The Committee heard evidence from a number of witnesses including the animals’ owners, an expert veterinary witness and College staff.
In the evidence, the Committee heard that the Labrador had died while undergoing treatment at another veterinary practice from complications arising from blood loss following Mrs Mullen’s surgery.
The Committee also heard that the English Bulldog had suffered brain damage and had lost its sight due to post-operative hypoxia, although it had otherwise recovered.
Having heard all the evidence, the Committee found all the charges against Mrs Mullen proven.
The Committee then went on to consider whether the proven charges amounted to serious professional misconduct.
In doing so it considered the aggravating factors, including that there was actual injury to animals, that the misconduct was sustained and repeated over a period of time, that the conduct directly contravened advice issued by the RCVS, and the blatant disregard of the RCVS’s regulatory role.
It also considered that Mrs Mullen had previously been suspended from the Register by the Disciplinary Committee for two months in April 2017 for failing to have Professional Indemnity Insurance arrangements in place.
It considered that there were no mitigating factors in the case and accordingly found serious professional misconduct in relation to all the proven charges.
The Committee then considered what the most appropriate sanction would be.
Judith Way, chairing the Committee and speaking on its behalf, said: “Animal welfare lies at the heart of the veterinary profession.
"The Committee considers that [Mrs Mullen’s] treatment of Cleo and Boycie constitutes a breach of this fundamental tenet of the profession.
"Other serious findings of disgraceful conduct against [Mrs Mullen] are her failure to provide informed consent, failure to provide details about out-of-hours cover, failure to have in place Professional Indemnity Insurance (PII), continuing professional development (CPD), and failure to respond to the College’s request for information.”
The Committee considered that the conduct was so serious that the only means of protecting animal health and welfare and public confidence in the profession was to direct the Registrar to remove Mrs Mullen’s name from the Register of Veterinary Surgeons.
Judith added: “The Committee considers that [Mrs Mullen] has displayed a persistent lack of insight into the seriousness of her actions or their consequences.
"The Committee considers that [Mrs Mullen’s] conduct raises serious clinical concerns, shows disregard of obligations in relation to out-of-hours care, indicates deficiencies in making decisions, demonstrates an obstructive attitude to her regulator and creates a potential risk to patients.
"She has not engaged with the regulator, she has not demonstrated insight into her misconduct, has learned nothing from her previous suspension in relation to PII, and has done nothing to remediate her disgraceful conduct.
"There is no evidence that [Mrs Mullen} has complied with any of her obligations in relation to CPD."
“In the view of the Committee, if [Mrs Mullen] were permitted to remain on the Register, there would be a serious risk of harm to animals. She has demonstrated a reckless disregard for the obligations of a registered veterinary surgeon.”
Mrs Mullen has 28 days from being informed of the Committee’s decision to lodge an appeal with the Privy Council.
The motion was introduced by Kate Richards MRCVS, Chair of the RCVS Standards committee, who explained that it'd been driven by three things, namely: the Vet Futures Initiative, the RCVS Strategic Plan signed off by Council in 2017 and the RCVS telemedicine consultation that took place earlier this year.
The latter of these showed that 69% of vets opposed the idea of prescribing without a physical exam, which rather beggars the question why it's being discussed at all. However, as Kate explained, when asked whether certain types of products could be remotely prescribed, the answer was more equivocal: 52% of vets said "yes".
Kate also explained that over the last two years, there had been a number of good quality discussions at Standards Committee and Council, but that decision-making had been "hampered by a paucity of evidence on the opportunities, risks and benefits of telemedicine to animals and the public".
The full wording of motion was: "Council is invited to consider the recommendation of Standards Committee to conduct a limited and time-bound trial to assess the benefits and risks of allowing the remote prescription of POM-V (excluding opiates, sedatives and potentially also critically important antibiotics) where there has been no physical examination."
However, in order for the trial to take place, it would be necessary to make a temporary change to the Supporting Guidance of the Code of Professional Conduct concerning the definition of "Under his care" (Ed's note. C'mon RCVS, isn’t that a bit anachronistic? Both your CEO and your President are now "her". "Under Care" would do it.), adding the words in italics to para 4.1: "A veterinary surgeon cannot usually have an animal under his or her care if there has been no physical examination; consequently a veterinary surgeon should not treat an animal or prescribe POM-V medicines via the Internet alone, other than in circumstance where a telemedicine service is a part of the RCVS telemedicine trial".
In the best interests of animal welfare
Amanda Boag (MRCVS, Vets Now, RCVS President) then reminded everyone that: "RCVS Council needs to act in the best interest of animal welfare and the public, and whilst sustainability of veterinary services is important, it isn't our role to promote anything novel or to protect traditional models."
Really? Strikes me that the sustainability of veterinary services isn’t just "important", it's an essential part of ensuring good animal welfare. Surely, therefore, it most certainly is the role of Council to protect traditional business models or, for that matter, to promote novel methods if (and I stress "if") doing so protects or enhances animal welfare.
Don’t confuse telemedicine with remote prescribing
Jo Dyer (MRCVS, small animal locum, Devon) opened by pointing out that this is not about telemedicine per se. Telemedicine has been going on since the invention of the telephone in the late 1800s, supplemented over the last 20 years or so by photography and video sent over the internet. Telemedicine does not, in and of itself, require a change in regulation.
What this is about, she explained, is the much narrower act of remote prescribing without physically examining the animal, something which would require the profession to redefine "under his care", which in turn "makes up the foundation of what forms the relationship with the owner and the animal in order that we can safeguard the use of medicines, safeguard the animals under our care and safeguard our clients."
No evidence remote prescribing increases access to veterinary services
Jo argued that the only reason Council should be considering the prescription of medicines without a physical examination would be if it were in the interests of animal welfare. And yet, she said, there is no evidence to support this idea.
Some have suggested that it could increase access to veterinary care. However, Jo said she had been unable to find any evidence to support this idea either. Not just in the veterinary profession, but in the medical profession in the Western and the developing world.
Jo also noted that the trial proposal was to use commercial organisations which have a financial interest in a positive outcome, which would render the results biased and unreliable.
She then raised the issue of antimicrobial resistance, highlighting the use of cytology and culture sensitivity to make sure the right antibiotics are used. Remote prescribing, she said, would be a retrograde step, even if only non-critical antibiotics could be prescribed remotely.
Spawning a new class of limited service provider
Next she highlighted the impact of the trial on 24-7 cover. Under the proposal, "Those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."
As Jo pointed out, this would by definition mean that any veterinary surgeon, not just those practising telemedicine, could set themselves up as a limited service provider and refer all cases they didn’t want to see (whether OOH or not) to a local practice. This, she argued, should only happen after a proper debate, and not be just the unintended side-effect of regulation change to allow remote prescribing.
In fact, there is evidence that this is exactly what is happening in human medicine. Only the following evening, the BBC aired Diagnosis on Demand: The Computer Will See You Now, a documentary about telemedicine and artificial intelligence in human medicine. It should be required watching for all RCVS Councillors.
The programme makers visited GP at Hand, a telemedicine business based on the Lillie Road in Fulham, London that has been formed in partnership with Babylon. Coincidentally just up the road from where I used to live, it's a pretty nondescript sort of a place, but now home to the fastest-growing GP surgery in the UK. Since late 2017, it has amassed a staggering 30,000 clients from across London, virtually none of whom will ever visit the place. The problem is that GP at Hand has skimmed away fee-paying clients from across the capital that had in effect been helping to subsidise local care elsewhere.
More information needed for such an important decision
Jo concluded by saying that a decision of this magnitude, particularly when it seems to go against the wishes of the majority of the profession, demands checks to ensure no conflicts of interest, legal advice and wider consultation with organisations such as the VMD, Defra, the BVA and its subdivisions and the VDS. Therefore, she would propose a new motion to delay the decision until more information is made available.
Chris Barker (MRCVS, small animal practice, Cumbria) was up next. He felt that the RCVS consultation was very effective and gave a good picture of what veterinary surgeons see as the risks inherent in remote prescribing. However, he felt that the analysis has been marshalled to suit an agenda and minimises the concerns of general practitioners.
Fragmentation and multiple consultants leading to a loss of responsibility
The trial, he said, will lead to fragmentation of veterinary provision and send the message to the public that it is quite OK to go to more than one vet for advice and treatment, and that will lead to confusion and the loss of individual responsibility for the veterinary care of an animal that exists today.
An inspection with no history: not a proper examination.
Chris argued that the act of prescribing demands a physical examination, but that a video consultation could only ever be an inspection. He also highlighted the importance of patient histories and argued that the immediacy of telemedicine simply doesn’t allow a practitioner to get the patient history from another vet.
Chris also argued that the profession is not structured to allow for clients to consult multiple veterinary service providers simultaneously: once a client leaves his practice, he has a duty under GDPR to expunge much of their records, and he for one didn’t much care for the idea of re-registering a client at 2:00am.
Some of the issues Chris raised may of course be solved by technology in the foreseeable future. GDPR already calls for data portability, presumably it will not be long before owners expect the same data portability for their animals' clinical histories.
Who wants clients who only ever call when telemedicine has failed?
Still, his overall point was an important one: whether or not there will be vets out there who are happy to pick up and see failed telemedicine cases at 3:00am in the morning from people who are not clients of their practice and who don’t otherwise contribute financially to the business.
90% of vets say remote prescription is high risk or inappropriate
Lastly, Chris drew attention to a question in the RCVS consultation which asked respondents what risk they thought there would be in a remote consultation when the consulting vet did not know the owner, did not know the animal and does not know the situation in which the animal is kept: "90% of responding veterinary professionals either chose it as high risk or simply not appropriate at all. I know of no better body of people than practitioners in Britain to understand the welfare and the risk to the welfare of animals."
The risk of misdiagnosis
Martin Peaty (MRCVS, equine practitioner, Wiltshire) spoke next, highlighting the risk he saw to animal welfare from misdiagnosis. He drew attention to concerns raised by the Quality Care Commission in human medicine, in particular that there is no access to the long term medical records of the patient, and the risk of misdiagnosis: "And that’s in human patients who can fluently articulate their symptoms", he said, "I think we should be much more cautious in exercising care before allowing remote diagnosis and prescription."
Martin's point seemed especially apposite in the light of an article which appeared in The Times two days later: 'NHS app 'no match for trip to the GP', in which Professor Helen Stokes-Lampard, chairwoman of the Royal College of GPs expressed concerns about online consultation systems, particularly for vulnerable groups, such as children.
Remote prescribing demands that vets sacrifice principles
Martin also outlined the three principles which underpin current practice: physically examining the animal, considering its history and providing 24 hour care, the latter in part in case of a reaction to a prescribed medicine.
"These proposals ask us to sacrifice these principles for telemedicine businesses whilst for good reason they remain in place for other veterinary practices. I think that is hypocritical. I think it is wrong."
Not enough follow-up
Sue Paterson (MRCVS, a referral specialist who offers a dermatology telemedicine service to the profession and the public, Merseyside) jumped in next. She was unashamedly enthusiastic about the benefits of telemedicine, in particular how it allows practitioners to engage with the public and make veterinary advice more accessible, not to mention because: "I am sick to death of people coming into consults when they have been on Facebook or they’ve been on to talk to Dr Google."
However, despite her enthusiasm and despite finding that users of her service do not want antibiotics, just advice, help and reassurance from people they trust, Sue was still against the idea of remote prescription: "I don’t want to prescribe because I can't follow those cases up, because I can’t maintain the level of client care that I think is really important, so for me, I would not want to see this change to the code."
We won’t know what we missed, or the consequences of what we missed
Caroline Allen (MRCVS, charity veterinary director, London) said the biggest issue for her is that without a physical examination, she won’t ever know what she missed (the heart murmur, the goitre, the subtle muscle wastage), or for that matter, the animal welfare consequences of what she missed.
As others had done, Caroline highlighted the importance of getting a weight every time and how difficult it is for clients to measure accurately.
Lastly, she made the thought-provoking point that allowing the remote prescription of drugs without a physical examination would risk legitimising Dr Google in the eyes of the public. After all, if no veterinary physical exam is needed, surely owners can just look it up on the internet for themselves?
In defence of the RCVS
At this point in the discussion, RCVS CEO Lizzie Lockett addressed the suggestion that the whole process of investigating and voting on telemedicine was being driven by hidden agendas, something she absolutely and eloquently rejected. She explained that sure, some parties had been more engaged in the whole process than others, but emphatically denied there had been any influence. Council, she said, had asked Standards to investigate and develop a proposal, which it had done diligently. Now it is down to Council to decide whether the proposal stands or falls; the College exists to implement the decision.
RCVS Vice President, Professor Stephen May went further, saying that many present would be aware that he'd been a vocal critic of the way that a number of other regulators in modern society push things out to court for decisions, rather than taking decisions collectively and then sticking by them. "I’m really proud that we are discussing this and I’m really pleased that this is up to us how we move things forward in the interest of animal health and welfare and supporting the public in that."
The need for a more nuanced, less polarised debate
However, he said he was worried about the way the debate was being polarised into a yes or no when he felt the profession should thinking about how it should adapt to the changing circumstances, thinking about cases which are amenable to a distant relationship and in what context that is appropriate, taking into account the risks.
Remote prescription is already happening, illegally
Melissa Donald (MRCVS, small animal practice, Scotland) questioned whether telemedicine and remote prescription is what the public wants. She said that remote prescription is already happening, illegally from abroad, and that the College needs to have a more robust response than "it’s not our problem". She therefore recommended a further period of consultation, particularly with public focus groups, and internet research to see how much remote prescription is already happening.
Vets are professionals
Tim Walker (Lay) said he was struck by the need to assemble better evidence. He felt there needs to be more thought given to the transference of responsibility for cases between a telemedicine provider and a traditional practitioner. Tim also felt that the definition of "under his care" will almost certainly need to be rethought in the not-too-distant future, because the idea of a patient being under the care of just one practitioner is starting to look dated; in the human sphere, patients are looked after by teams of people.
Tim highlighted the approach he said is taken by the GMC, which obliges doctors to be able to demonstrate that they have done sufficient due diligence to prescribe, not that they can simply do so automatically under certain circumstances. That, he said, is what professionalism should be about.
Taking the lead
Mark Castle (Lay) said he thought that the public was looking for a choice, that technology is constantly throwing up new opportunities, and he expected that in the future more and more will be able to be done remotely, so he wanted the RCVS to take the lead in this area.
Lucy Goodwin (MRCVS, BSAVA Head of Education) was positive about the idea of conducting a time-limited, controlled trial: "We say we want evidence, so let’s go and collect it", but had a number of reservations. Not least of these was the fact that the participants in any trial would be on best behaviour, so it may not be able to extrapolate the numbers to the profession at large. Beyond that, she was also concerned that the scope of the trial should be better defined, in particular which categories of drug could be included within it.
Vets don't want a trial of telemedicine
Mandisa Greene said that whilst she is positive about telemedicine as it had been described, and not averse to a trial, she didn’t see the point in a trial when the people who actually do the prescribing don’t want it.
A voice in favour
Chris Tufnell (Past President) began by declaring that he consults to the Affordable Pet Care Company which is shortly to launch a telemedicine service, although he said the service would be unaffected by the decision being taken by Council. He was also at pains to stress that he hadn’t had any other fingers in this particular pie, in particular that he hadn’t been to any of the Standards Committee meetings or presented to them, or been involved in formulating the proposed trial.
Whether you agree or disagree with Chris, it was at least good to hear someone speaking in favour of the motion. Chris opened by arguing that veterinary surgeons are good at making decisions based on imperfect information: "Client histories, as we know, are of variable quality. We make decisions daily on whether we are happy with the information we get from the practice lab or whether we need to send the sample to a reference lab. When I started in practice, practice lab machines were routinely described as random number generators."
"We make decisions on a daily basis on what the limitations of our abilities are. It’s called professional judgement and what we are proposing here is actually a test of our definition of 'in our care'. We’re talking about testing the possibility of making remote prescriptions. The responsibilities around prescribing won’t change, and those responsibilities include the responsible use of antibiotics."
Chris then argued that all the motion was calling for is a trial of something that unlike, for example, deregulating advertising and practice ownership, is not going to give a slice of the consultation fee to non-vets. He also pointed out that people will always be able to highlight cases that would be completely unsuitable for remote prescribing, but that this is not about replacing the consulting room.
Filling the void
What it is about, he said, is removing barriers to care; filling the vacuum between a concerned owner, and the £60 - £100+ they’ll be charged for a consultation. It’s a vacuum that is currently filled by the 'free' (except it's not) phone advice given out by practices, by Facebook and by Dr. Google.
He then pointed to an example from the US, where 83% of people who visited https://www.whiskerdocs.com for pet advice and thought their problem was suitable for home treatment, were in fact wrong and ended up being instructed to visit their veterinary practice. This, he said, could lead to better productivity in practice.
Could telemedicine help retention?
Telemedicine, he said, could also provide a role for people thinking of leaving practice, which is potentially an important factor at a time when retention is proving such an issue.
Evidence-gathering, clinical freedom and professional judgement
Like others, Chris argued that the trial is about putting the RCVS at the forefront of progression in our increasingly digitised society, at a time when remote information from wearables is going to become more and more common. In summary, he said: "This trial is about an evidence-based profession looking for evidence, it’s about clinical freedom and it’s about putting professional judgement in the hands of the professionals."
A two-tier service
Lynne Hill (Past President) said her main concern is about having to redefine "under his care" and how remote prescribing via telemedicine would lead to a two-tier level of care, which she thought would be wrong.
She also highlighted that the College had debated the definition of "under his care" in relation to farm animal practice, where some farmers have multiple vets, some of which offer herd health care and nothing else. Deregulating to account for this has, she said, been responsible for the demise of farm animal practice. Quite simply there are less vets around to see animals.
Show me the money
Lynn also noted the altruistic nature of the debate thus far, and reminded everyone that this is really about business and making money. The companies that are set up to provide telemedicine and possibly take part in the trial will not be in it for the welfare of animals, but to make money.
She also scoffed at the idea that telemedicine and remote prescribing will mean the 10% of people who do not currently have a vet are "now going to get madly involved in telemedicine." The reason they don’t have a vet at the moment, she said, is because they don’t want to pay. Telemedicine doesn’t change that.
Lastly, as others had done, she highlighted the difference between human medicine, where patients can describe their symptoms, and veterinary medicine, where they can’t.
Leadership is about taking the right decision, not jumping on the bandwagon
"Leadership is not always about jumping on the bandwagon and going forward because something is out there. Leadership is actually about looking and deciding and making the right decision."
The disingenuous antimicrobial argument
Dave Leicester (MRCVS) was up next, arguing that it would be wrong to say that a body of professionals can be trusted to make decisions about animal welfare, but not about prescribing. He also felt it was a little disingenuous to do a lot of hand-wringing over antimicrobials when, as a profession: "We’ve managed to make a 3rd generation cephalosporin the most prescribed antibiotic in cats."
Finally, Dave made the point that in his 15-year experience working for OOH emergency service providers, they’d managed to work very successfully without access to patient medical histories.
Setting veterinary standards
Claire McLaughlin (Lay) reiterated that the role of the RCVS is to set veterinary standards, something it can’t very well do without knowing what is going on in practice, and finding out how these things work in practice. “We need to be in a process which takes us to able to set those standards. Whether the trial that is proposed is the right trial or not, we can’t just say no, it’s fine as it is because people will work within their professional competence. As Eleanor [RCVS Registrar] will tell you, they don’t work within their professional competence because they come before disciplinary committee all the time. I think we would be remiss if we didn’t start a process now or continue this process in a way that allows us to set appropriate standards.”
Colonel Neil Smith (MRCVS, Chief Veterinary Office for the Army) began by declaring that he provides telemedicine services for animals in disparate parts of the world as part of his day job, but these animals are very much under care and there is an existing relationship with patients. He is also involved with the provision of limited veterinary services for homeless people via StreetVet, a charity which has had to form relationships with practices that can cover the 125 hours per week when it is not present.
Lowering veterinary standards
Neil explained that his "massive" concern with the proposal lies in particular with the part that says: "Given the limited nature of the service that can be provided by telemedicine alone, however, it is proposed that those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."
This, he said, would lower veterinary standards, if all somebody providing telemedicine has to do is point people in the direction of a practice.
For that reason, Neil said, he could not support the proposal as is, and would instead recommend that it goes back to Standards and is then brought back at the next council meeting with a clearer idea of what the trial is all about.
Accessible care
Caroline Allen then jumped in again, saying that whilst she agreed with the idea that more data is needed, she also thought that telemedicine and remote prescription is being driven by the issue of accessible care, and it is that, in fact, which needs to be investigated and understood and debated first.
The digital age
Past President Professor Stuart Reid highlighted that the veterinary students of today live their lives in the digital environment and their world will be very different from ours. The same goes for pet owners. He reiterated that as the regulator, the RCVS needs to be ahead of the game, and that if this is what the public wants, then it has to find a way of regulating it.
Stuart finished by saying that he felt conflicted about the vote; that he had significant problems with the proposal and is not entirely sure that a trial is the right thing, but: "In the referendum we're about to have, I want to say yes but I want to see what the deal is as well." He added: "I didn't vote out by the way, in case this gets back to my employers, but I do think we have to think very carefully about throwing the baby out with the bathwater here."
Pressure to prescribe
Martin Peaty then recounted how at a Vivet Conference last year, a provider of telemedicine (which he thought was Babylon) explained that doctors on its system were retained on the basis of a post-consultation customer satisfaction survey. That, he thought, would make it difficult for practitioners not to prescribe things when they know it will affect their job.
David Bray (Lay), said he believed the telemedicine and remote prescribing will come and it will become more common to have pets treated by multiple vets, so he was fully supportive of a trial.
When it came to the vote ...
Guessing at which way the people who spoke might have voted, it seemed as though there were probably enough councillors with sufficient reservations about the motion, which would have given the go ahead for the trial, for it to be voted down.
That said, the overall sentiment in the room seemed to be that the discussion about the regulation of telemedicine and remote prescription needs to continue, and not get kicked into the long grass simply because of a disagreement over the proposed trial.
At this point, Jo Dyer and others stepped in to argue that the decision to proceed with the trial should not be made until the issues raised in the debate had been addressed. There was then a lot of going backwards and forwards, discussing whether this would need a new motion, which is not allowed under Council rules, or whether the existing motion could be amended, which is allowed.
In the end, the decision was taken to hold two votes, the first being to refer the issue back to the Standards Committee which was carried by 18 to 12, with one abstention.
The second vote was:
"Council is invited to consider the recommendation of Standards Committee to prepare and develop a proposal for a time-bound and limited trial to assess the benefits and risks of allowing the remote prescription of POM-V with appropriate stakeholder engagement and with consideration of the issues that we've discussed today and the detail on them, including 24/7 care and classes of drugs, especially antimicrobials. So we are asking for the detail on that to be worked up on the basis that it will at some time come back to Council."
The second vote was carried by 21 to 8 with 3 abstentions.
In other words, the trial will not now go ahead unless Standards can develop a new proposal which addresses the concerns raised by Council.
VetSurgeon Conclusion
Looked at solely in terms of its impact on animal welfare, this debate seems to come down to one question, which is whether more animals will benefit from easier, cheaper access to veterinary services available via telemedicine and remote prescription than will suffer as a result of misdiagnoses and missed diagnoses that will surely be the inevitable consequence of veterinary surgeons working only from the more limited, and potentially inaccurate or even false information they will get from a video consultation.
For sure, more wearables are coming, and they will overcome some of the problems caused by the fact that animal patients cannot describe their symptoms. Doubtless someone will also invent a set of weighing scales that makes it possible for owners to do the job reliably accurately. Patient histories will surely become more portable. But these things are not with us just yet.
In any event, it is not just about the immediate impact on the quality of care delivered to patients. The way the trial has been framed thus far takes us in the direction of a two-tier profession. What happens if more veterinary surgeons prefer, or make a better living from working from the comfort of their own home without the added responsibility that comes with providing the physical care. Who’ll do the ‘real' vetting?
If you look at the popularity of human telemedicine, the 30,000 patients who have signed up for telemedicine at the small practice in the Lillie Road in London, it seems obvious that patients want the convenience of consulting online, without having to schlep to the practice and find a parking space. It also seems self evident that if online consultations are offered at a lower price point, it will inevitably lead to more pet owners availing themselves of veterinary advice, though as Lynn Hill said, it’s unlikely to cause a mad rush whilst Dr Google is still free.
Perhaps, though, there is another valid way to solve this conundrum. Rather than rushing headlong into a trial that could irrevocably change the very nature of the profession, how about establishing some pragmatic ground rules from the outset. For example, that unless by unanimous agreement of Council in the future, telemedicine should only be allowed as an extension of the service offered by existing bricks and mortar practices to their existing clients.
When it comes to remote prescribing, surely the safest way to regulate it (if you’re going to allow it at all) is to do so on a drug-by-drug basis. Perhaps trial it with the endo- and ecto-parasticides for existing clients of existing practices. Find out whether the convenience of the online consultation leads to higher standards of parasite control for greater numbers of pets. If it doesn’t, then ditch it. Either way, it doesn't preclude trying another category of drug.
That’s my tuppence worth, for what it’s worth, which probably isn’t quite tuppence!
The RCVS Disciplinary Committee has suspended two veterinary surgeons from the Register after finding them guilty of lying to clients and the College about the circumstances of a castration procedure which led to the death of a dog.
The Committee suspended Mr Mpho Donald Lesolle and Mr Georgi Cheshmedzhiev from the Register for four and two months respectively, following surgery undertaken on Benson, a two-year-old male Labradoodle belonging to Mr and Mrs Grayson.
During the proceedings, the Committee heard that, on 6 August 2013, Mr and Mrs Grayson brought Benson to the Swinfen Veterinary Centre in Stafford, where Mr Lesolle is the practice principal and Mr Cheshmedzhiev was his assistant, for the operation which was undertaken by Mr Cheshmedzhiev. Mr Lesolle did not directly supervise the procedure telling the Committee that he was confident that his colleague could carry out the castration, having permitted him to do so on previous occasions.
The Committee heard that, after the operation, a nursing assistant, Ms Bell, had noticed that there was blood on the bedding and that Benson had a swollen scrotum. Mr Lesolle then performed a scrotal ablation on Benson, who was discharged later that day.
However, on the morning of 8 August 2013, Mrs Grayson discovered that Benson had died during the night. An independent post-mortem concluded that he had probably died of intra-abdominal bleeding which caused circulatory collapse. Mr and Mrs Grayson raised a concern with the RCVS in September 2013.
The charge against Mr Lesolle relates to his actions following the operations and during the investigation. The four parts of the charge were that he failed to be sufficiently open with Mr and Mrs Grayson on the circumstances of Benson’s surgery; that, in September 2013, he wrote to the College indicating that he had in fact performed the castration and failing to state that there had been two operations; that, on 23 January 2014, he informed Pam Mosedale, a Veterinary Investigator employed by the College, that he had carried out both procedures; and that, on the same day, he also encouraged his veterinary nursing assistant Ms Bell to be dishonest with the College’s investigators.
Mr Lesolle, who was present at the hearing, admitted all parts of the charge against him. He told the Committee that he decided to take responsibility for Mr Cheshmedzhiev’s operation out of a desire to protect his colleague whom he regarded as vulnerable and lacking in self-confidence. He also accepted that he had encouraged Ms Bell to lie during her interview. He told the Committee that he had persisted with the deceit until 15 January 2015, when he gave a full account of what had occurred.
The three parts of the charge against Mr Cheshmedzhiev, who was not in attendance or represented at the hearing, were that in a letter to the College sent in September 2013, he indicated that he had not undertaken the castration procedure on Benson; that on 23 January 2014 he had denied carrying out the operation while being interviewed by Pam Mosedale; and that, on 19 June 2014, while being interviewed by a solicitor instructed by the College, he said that Mr Lesolle had carried out both procedures.
The Committee found the charge against Mr Lesolle amounted to serious professional misconduct, falling far short of what is expected of a professional. The Committee highlighted the protracted nature of his deceit and the fact that he encouraged another member of staff to participate in it. However, it did accept that his motivation was to protect Mr Cheshmedzhiev.
In deciding on the sanction for Mr Lesolle, the Committee considered the aggravating and mitigating factors. Ian Green, chairing the Committee and speaking on its behalf, said: “Having taken the calculated decision to deceive the College as to what had occurred, he abused his position of responsibility to obtain support for his deceit by involving a junior employee, without any proper consideration of the effect of that decision upon her. Instead he continued with the deceit until he was presented with incontrovertible evidence that he had not carried out both procedures on the dog. In the Committee’s view he showed a wilful disregard for the College’s investigatory process.”
However, in mitigation, it also accepted that he was protecting a colleague and that there was no financial gain. It also considered his personal circumstances, the fact that he is sole principal of a small mixed practice which provides his sole source of income and that the rented accommodation also provides a home for his wife and two children. Taking all factors into account, the Committee imposed a sanction upon Mr Lesolle of four months’ suspension from the Register.
In regards to Mr Cheshmedzhiev, the Committee did not find the part of his charge relating to the letter sent in September 2013 to be proven but, in respect of the other two parts of his charge, found that his conduct fell far short of what is expected of a professional. It highlighted his willing participation in the deceit over a protracted period and his failure to take responsibility for his own involvement in the operation on Benson.
In deciding the sanction, the Committee said that the fact that Mr Cheshmedzhiev had lied to the College’s investigators on two occasions and did not admit that he had carried out the castration and apologise for his actions until February 2015, after he had returned to his native Bulgaria, was an aggravating factor.
Ian Green added: “The Committee accepts that he allowed himself to be persuaded by Mr Lesolle to provide a dishonest account of what had taken place to the College’s investigator Mrs Mosedale, and solicitor, Mr Hudson. It also accepts that he has been described by Mr Lesolle as a vulnerable person, lacking in self-confidence in his ability to practise as a veterinary surgeon in the United Kingdom.
“Nevertheless, Mr Cheshmedzhiev accepted the obligations contained in the Code of Professional Conduct when he registered as an MRCVS, which included an obligation to cooperate honestly with the College’s investigatory process. It has also noted that he has expressed a present intention not to work in or visit the United Kingdom again.”
Taking into account all factors, the Committee decided the appropriate sanction was to suspend him from the Register for two months.
The charge against Ms Law was that in November 2017, having performed surgery on Kiwi, a German Shepherd/Wolfhound-cross dog, to address gastric dilation volvulus (GDV), she failed to obtain informed consent to the entirety of the surgical process and management, including post-operative aftercare.
The charge also stated that she failed to provide adequate analgesia to Kiwi before, during or after the surgery, failed to provide appropriate and adequate fluid therapy to Kiwi, failed to offer an appropriate and adequate post-operative care plan and/or post-operative transfer for Kiwi to another practice and failed to inform the owners that there would be nobody present at the practice to provide post-operative monitoring and aftercare for Kiwi for approximately seven hours during the night.
Finally the charge stated that Ms Law allowed Kiwi to remain at the practice overnight from 12:30am to 07:45am without adequate monitoring or post-operative aftercare.
Ms Law admitted some of the charges against her, including that she had failed to obtain informed consent, failed to offer an appropriate and/or adequate post-operative care plan, failed to inform the owners that there would be nobody present at the practice and allowed Kiwi to remain at the practice overnight without adequate monitoring and/or post-operative aftercare. However, she denied that she failed to provide adequate analgesia or fluid therapy to Kiwi.
The Committee found all of the charges proved, with the exception of failing to provide adequate analgesia during the perioperative period.
Having considered the facts, the Committee then moved on to consider whether the admitted and proven charges against Ms Law amounted to serious professional misconduct, taking into account any aggravating and mitigating factors. The aggravating features were that, as a result of Ms Law’s failures in relation to analgesia and fluid therapy, there was either actual injury to Kiwi, or a risk of such injury.
In mitigation, the Committee considered that she promptly and accurately diagnosed GDV, and proceeded to perform the necessary emergency surgery. The Committee considered that the charges related to a single isolated incident and that Ms Law has had an unblemished career to date. They also noted that Ms Law had made open and frank admissions as to the majority of the charges.
The Committee found that the conduct of Ms Law set out in the majority of the charges did not amount to serious professional misconduct. However, in the judgement of the Committee, Ms Law’s conduct in allowing Kiwi to remain at the practice overnight without adequate monitoring or post-operative aftercare did amount to serious professional misconduct.
Jane Downes, who chaired the Committee and spoke on its behalf, said: "The Committee considers that the respondent (Ms Law) has insight into the serious mistake that she made in failing to ensure that Kiwi was checked or monitored overnight. The Committee has found that this was a single isolated incident, which involved a serious lapse of clinical judgement, which will probably stay in the mind of the respondent for the rest of her career.
"The respondent has been in practice for some nine years now, and apart from this incident, there is no suggestion that the respondent has fallen short of the standards expected of her on any other occasion. The Committee does not consider that there is a risk that the respondent is likely to leave an animal overnight after major surgery again, without ensuring that it is checked during that time, and, as such, the Committee considers that there is no future risk to the welfare of animals so far as the respondent is concerned."
The Committee considered that the finding of disgraceful conduct in a professional respect in this case is too serious for no further action to be taken, having regard to the need to maintain public confidence in the profession and declare and uphold proper standards of conduct.
The Committee therefore concluded that the appropriate sanction in this case was to issue a reprimand to Ms Law, in relation to the finding of serious professional misconduct.
Jane Downes added: "The Committee considers that this sanction, coupled with the findings of fact and disgraceful conduct made against the respondent, is sufficient to maintain public confidence in the profession and uphold proper standards of conduct. The Committee does not consider it necessary to issue a warning to the respondent about her future conduct, on the basis that the Committee has concluded that there is no risk of repetition."
There were three charges against Ms Creese, all pertaining to the period between July 2016 and November 2017.
The first charge was that she failed to ensure that there were adequate systems and processes in place for out-of-hours’ care for in-patients.
The second charge was that she publicised that the practice had "24 hour care provided by our vets at our practice" and/or "Care 24/7 for your pets" on its website, which suggested that staff were present at the practice 24 hours a day when they were not and as such publicity was dishonest and/or misleading.
The third charge against Ms Creese was that she failed to ensure that Kiwi's owners were informed about arrangements at the practice for out-of-hours’ care for in-patients.
At the outset of the hearing, Ms Creese denied all the charges against her.
After hearing evidence from relevant witnesses, the Committee considered that the practice did have in place systems and processes for out-of-hours care for in-patients and that there was no evidence of repeated or ignored failures of these systems and processes. The Committee therefore found the charges against Ms Creese not proved and all three were dismissed.
The updated guidance follows a public campaign known as ‘Tuk’s Law’, which was started after a healthy dog by that name was euthanased despite its microchip being dually registered with a rehoming centre as a 'rescue backup'.
In response, the RCVS and the BVA agreed that more should be done to prevent occasions where a dog might be needlessly put to sleep, but voiced concerns that a legislative approach could undermine a vet’s clinical judgement, unfairly involve veterinary surgeons in ownership disputes or potential criminality, and leave vets unfairly exposed to financial sanctions.
In consultation with Defra, the RCVS and BVA therefore jointly agreed to strengthen the Code of Professional Conduct as follows:
Chapter 8 (para 8.9)
There may be circumstances where a request is made by a client for the destruction of a dog, where in the clinical/professional judgement of the veterinary surgeon destruction of the dog is not necessary, for instance where there are no health or welfare reasons for the dog to be euthanised.
In these circumstances, before carrying out the request for euthanasia the veterinary surgeon should scan the dog for a microchip and check the relevant database if a microchip is found.
Chapter (paras 29.25 -29.27)
Clients may have a contract with the shelter from which they acquired the dog such that it can be returned to that shelter, and that it may be appropriate to discuss this with them prior to euthanasia. Alternatively, there may be another individual willing to take responsibility for the dog (who may be named on the microchip database), and this may also be discussed with the client.
The updated guidance supports existing best practice in terms of discussing alternatives to euthanasia with clients, and give vets flexibility where, in their professional judgment, scanning is not appropriate; this might be if scanning would itself cause a welfare problem, or where a vulnerable client might be involved.
The RCVS Standards Committee says it recognised the difficulties experienced by veterinary surgeons in dealing with the current microchip database system, but felt that introducing these provisions into the guidance was a more proportionate response than the alternative of legislation with substantial fines.
BVA Senior Vice President Dr Daniella Dos Santos MRCVS said: “One of the most important jobs as a vet is having those difficult conversations with clients about euthanasia where we talk through all the options that are in the animal’s best interests. But where the vet doesn’t consider that euthanasia is necessary, the new guidance clearly sets out the steps we need to take. We support this constructive approach that addresses the campaigners’ concerns without undermining veterinary judgement.”
Vet Futures, the joint initiative by the RCVS and the BVA to help the profession prepare for and shape its own future, has published a guest blog in which an academic argues that the profession needs to introduce safeguards to prevent inappropriate profit-seeking behaviour.
David Main is Professor of Animal Welfare at the School of Veterinary Sciences at the University of Bristol, with research interests in welfare assessment, animal welfare education and intervention strategies to improve welfare.
In his blog (www.vetfutures.org.uk/discuss), Professor Main says he believes the vast majority of individual veterinary surgeons and practices are not motivated by money and do have animals’ best interests at heart, but that the differences between the business structure of veterinary and medical practitioners in the UK means the profession is always at risk of standing accused of excessive profiteering.
He said: “Since we still live in the age of the media scare story, it would seem prudent for the profession to embed some anti-profit seeking safeguards in our regulatory controls before, rather than after, a problem is highlighted.” One suggestion he makes is for the prohibition of turnover-based incentive schemes in favour of incentives based on health outcomes.
He believes that such safeguards, which he says could be incorporated into the RCVS Practice Standards Scheme, would be a “healthy demonstration” that the profession has animal welfare rather than profit as its main priority.
Professor Main also argues that the profession urgently needs to deliver on society’s expectation of vets as animal welfare experts: “Veterinarians could perhaps... do more at an individual level to act as animal welfare advocates. It is easy to inform clients on the technical rationale for a specific husbandry change but then walk away knowing full well the client will not action the advice. In the medical profession, advanced communication techniques are becoming more widely accepted to promote positive change within their patients. Perhaps we should be more explicit in teaching our veterinary students influencing skills.”
In response to David’s blog, this month’s Vet Futures poll asks visitors ‘Do vets always act as animal welfare advocates?’
The previous month’s poll, which was based on an article co-written by Erwin Hohn and Adi Nell from MediVet, asked to what extent vets would be willing to work collaboratively with others if it would benefit all. Of the 50 people who answered the poll, 60% said they would be completely willing to work with others, 32% a lot and 8% to some degree – no one said they would be unwilling to work with others.
The RCVS Disciplinary Committee has suspended a veterinary surgeon formerly practising in Southampton for failing to make animal welfare his primary concern.
At a hearing this week, adjourned from September 2010, the Disciplinary Committee heard charges against Michael Albring, formerly of VetCall practice, Bitterne, Southampton. Mr Albring was said to have failed to make a home visit to attend Bear, a Newfoundland dog belonging to Mrs Thacker, when he knew, or ought to have known, that there were clinical or welfare grounds making a home visit necessary.
The hearing was held in Mr Albring's absence; the Committee considered that, having postponed the case last year at his request, Mr Albring had had ample time to prepare his case and submit any mitigations, and sufficient opportunity to attend. Additional adjournment would further delay the matter's resolution and not be in the wider interests of justice, or public confidence in either the RCVS disciplinary system or the veterinary profession.
On the evening of 19 December 2009, Mr Albring had been the veterinary surgeon on duty at VetCall, a practice that provides the out of-hours emergency cover for several local veterinary practices, including the one where Bear was registered. When Mrs Thacker's daughter, Ms Davidson, telephoned VetCall to request a home visit as the dog had collapsed, she was told that it was against practice policy for the practice to be left unmanned so this would not be possible. This was despite a written policy which accepted and made provision for the rare occasions when a home visit would be necessary. Phoning again later, the information about practice policy was repeated and Ms Davidson directed to a local animal ambulance service, which attended.
The ambulance driver found that the dog could not be transported in the ambulance and telephoned VetCall to say a home visit was needed. This was refused by Mr Albring even, the Committee noted, when the ambulance driver offered to collect Mr Albring, drive him to Ms Davidson's home 10-15 minutes away, assist with the euthanasia, and return him to the clinic. In the interim, Ms Davidson had also sought help from a separate practice and, subsequent to Mr Albring's refusal to visit, their on-duty veterinary surgeon attended and euthanased Bear.
The Committee found that Mr Albring's refusal to visit, once it was clear Bear could not be transported, and he knew that a home visit was necessary on welfare grounds, resulted in Bear spending longer than necessary in pain and distress. This was not a case where the pressure of work or the welfare needs of other animals prevented Mr Albring from attending, and it was also relevant that Mr Albring was specifically employed to work out of hours in an emergency clinic. Serious, too, was his failure to reply promptly to communications from the RCVS, or show insight into the seriousness of his conduct.
In mitigation, the Committee accepted that this was an isolated case, and there were no previous findings against Mr Albring. He was in sole charge of an emergency clinic covering 15-20 practices across Southampton and Portsmouth, which would make, in some circumstances, home visits difficult.
Professor Sheila Crispin, chairing the Disciplinary Committee, said: "The Committee is concerned that the actual policy pursued by the clinic regarding domiciliary visits was different to the written one.
"In effect, a no-visits policy existed at the VetCall clinic and this must have added to the pressure under which the Respondent [Mr Albring] was working.
"The Committee is mindful that the object of sanctions is not to be punitive, but to protect animal welfare, to maintain public confidence in the profession and to maintain appropriate standards," she continued, noting that as animal welfare had knowingly been neglected and Mr Albring had demonstrated no insight, a warning or reprimand would not be enough. "A period of suspension would be sufficient to maintain public confidence in the profession and uphold standards," she said.
The Committee directed that Mr Albring's name be suspended from the RCVS Register of Veterinary Surgeons for ten months.
Dr Thomason initially denied both heads of charge, but on the third day of the hearing he changed his plea and admitted the charge in its entirety.
The first part of the charge related to the fact that the seller of the horse was a both a client of Dr Thomason’s practice and a personal friend of his, and he therefore had a potential and/or actual conflict of interest.
Dr Thomason did not disclose this professional and personal relationship to the prospective purchaser before the pre-purchase exam.
The prospective purchaser only discovered Dr Thomason’s relationship with the seller when reading the vetting certificate at home, and stated that, in the past, she had had a similar experience in which the horse was then found to be lame. She later found out the extent of the personal relationship, when invited to join the seller on a social media site.
The Committee found that, in this set of circumstances, Dr Thomason should not have undertaken the pre-purchase exam at all, and, at the very least, disclosed his personal and professional relationship with the vendor.
The Committee also found that although Dr Thomason did have a system in place to inform any prospective purchasers if the vendor was a client of his practice, this failed to work on this occasion and neither the practice nor Dr Thomason told the prospective buyer that the seller was a client before booking the pre-purchase exam. Dr Thomason had no similar system in place to disclose any close friendships with sellers.
Dr Thomason did not consider there was a conflict of interest as he felt confident he could carry out the pre-purchase exam impartially. In addition, it was his belief that the seller had been alerted to the conflict through a system in place at his practice, implemented to safeguard against this type of error. He stated that he in no way attempted to hide his relationship with the seller to the prospective purchaser.
It was not alleged that Dr Thomason had acted dishonestly.
Ultimately, the Committee found Dr Thomason not guilty of disgraceful conduct in a professional respect.
Ian Green, chairing the Committee and speaking on its behalf, said: "Whilst the Committee concluded that the respondent’s view of his obligations to disclose both the professional and personal relationships he had with the vendor was mistaken, it did not find any improper motivation on his part. It has already noted that he sought to disclose to the prospective purchaser through his system the fact that the vendor was a professional client of his.
"The Committee has weighed all these matters very carefully. It is for the client to determine whether or not to proceed with a PPE when in possession of all relevant facts in relation to any potential conflict of interest, and not for the veterinary surgeon to decide. The autonomy of the client must be respected. The Committee was firmly of the opinion that a failure to comply with the Code is very serious. However, taking into account the particulars of this case, the Committee does not consider that the actions of the respondent amount to disgraceful conduct in a professional respect."
The RCVS Disciplinary Committee heard two charges against Dr Nemes, the first being that he had posted comments on social media about another veterinary surgeon, his employer, Dr Toth, which were offensive and/or derogatory and/or inappropriate.
The second charge was that Dr Nemes had posted his comments without having sufficient regard to maintaining their confidentiality and/or privacy.
Dr Nemes admitted the charges, though he did inform the Committee that his admission with respect to the second charge was caveated by the proposition that the comments were posted in private messages on Facebook with a limited membership, namely employees of Healers Veterinary Centre (Dr Toth’s practice).
The Committee noted the Respondent’s admissions as to the charges raised against him and pronounced the facts found proved.
In relation to the first charge, the Committee found that the comments on social media were, without a doubt, highly unprofessional. They included offensive language, were gratuitously personal against Dr Toth, and were made within an online chat which included junior lay staff, all employed by Dr Toth.
This behaviour was seen to directly contravene a numbers of parts of the RCVS Code of Professional Conduct, in particular Paragraph 5.3 that states: "Veterinary Surgeons and Veterinary Nurses should not speak or write disparagingly about another Veterinary Surgeon or Veterinary Nurse."
In relation to the second charge, the Committee found that Dr Nemes had paid no regard to maintaining the confidentiality and/or privacy of his malicious and damaging entries to the chat.
At the outset of his evidence, Dr Nemes admitted that the proven charges amounted to serious professional misconduct. The Committee noted however that the question of whether he was guilty of serious professional misconduct or not was in fact a matter for it to decide, notwithstanding his admission.
The Committee considered the fact that the period of time that Dr Nemes was involved in making postings was effectively about two weeks, that his involvement followed his wife’s dismissal from employment (representing a breach of Dr Nemes’ resignation conditions), and that he was very stressed at the time.
It also considered Dr Nemes’ point that he had never anticipated that Dr Toth would see the Facebook Messenger conversation, and that the relevant RCVS supporting guidance to the Code concerning good practice when using social media and online networking forums was only published in late November 2014 when Dr Nemes’ involvement in the conversation was virtually at an end.
In summing up, Ian Green, Chair of the Committee, said: "The Committee carefully considered the circumstances surrounding the Facebook Messenger entries which the Respondent posted from 13 November 2014. It noted that at the time he had handed in his resignation, morale at the practice was very low. The Facebook Messenger chat site had been started amongst the receptionist/animal carers. A perusal of the entries before the Respondent joined on 13 November 2014 demonstrates that morale was low among that group.
"…Notwithstanding the nature of the remarks posted on the Facebook Messenger, which the Committee deplores, it has reached the conclusion that, whilst the Respondent’s behaviour amounts to misconduct and falls short of the standards expected of a member of the veterinary profession, it does not amount to serious misconduct and does not fall far short.
"In the circumstances it has reached the unusual conclusion that, notwithstanding the Respondent’s admission, the appropriate finding is that he is not guilty of disgraceful conduct in a professional respect."
Peter Keniry has convictions dating back to 1986 in his native South Africa for fraud and impersonating a veterinary surgeon. The College says that in the UK, he has been known to steal the identities of legitimately registered members in order to support fraudulent applications for employment or practise fraudulently.
The College says that in the past, Mr Keniry has been able to gain employment in large and small animal practice and greyhound racing. He is known to have ties in Norfolk, Swindon, Somerset and possibly Cornwall.
Michael Hepper, Chief Investigator at the RCVS, has worked with several police forces in order to bring Mr Keniry to justice. He said: "Peter Keniry’s modus operandi is to steal the identity of properly registered members to obtain work as a veterinary surgeon. As he impersonates members of the College whose names are legitimately on the Register, this can make it extremely difficult, even for practices that do check prospective employees’ credentials, to identify him.
"He is well known to the College and to the police having been convicted in 1998, 2001, 2005 and 2011 and has served custodial sentences for practising as a veterinary surgeon and fraud.
"Peter Keniry is a repeat offender and we suspect that he will continue to re-offend. We hope that by publishing his photograph it will help practices recognise him and contact the RCVS Professional Conduct Department should he apply for employment as a veterinary surgeon."
The RCVS Professional Conduct Department can be contacted on profcon@rcvs.org.uk or 020 7202 0789.
The main change to the guidance was from:
A veterinary surgeon who has an animal under their care should have a 24/7 facility to physically examine the animal or visit the premises in the case of production animals, farmed aquatic animals and game.
to
A veterinary surgeon who has an animal under their care must be able, on a 24/7 basis, to physically examine the animal or visit the premises in the case of production animals, equines, farmed aquatic animals and game.
Where a veterinary surgeon is not able to provide this service, they must make arrangements for another veterinary service provider to do so on their behalf, details of which must be provided to the client in writing in advance of providing veterinary services.
The new guidance elaborates on the details which must be given to clients:
Veterinary surgeons should provide clients with full details of this arrangement, including relevant telephone numbers, location details, when the service is available and the nature of service provided.
The amended guidelines maintain that the prescription of antimicrobials and controlled drugs requires a physical examination in all but exceptional circumstances, but clarify that for antimicrobials, this applies to all except production animals, farmed aquatic animals and game.
The guidance for limited service providers, such as vaccination and neutering clinics, has been amended with the requirement that if they engage the services of another provider to provide 24-hour emergency cover, this arrangement must be confirmed in writing with the client before veterinary services are offered.
Council voted unanimously for a review of the guidance to be conducted 12 months from the implementation date, with the caveat that the Standards Committee would continue to monitor any impacts on an ongoing basis.
The full details of the amendments can be found in the papers for the March 2023 RCVS Council meeting at: www.rcvs.org.uk/who-we-are/rcvs-council/council-meetings/
Linda Belton MRCVS, Chair of the RCVS Standards Committee, said: “I would like to thank all the organisations and individuals within the professions who helped provide the crucial content and context for the case study scenarios, as well as feedback to make sure they were realistic and applicable in practice.
"Thank you also to all those who have fed into the further improvements that have been made to the guidance and I would like to reassure those with concerns that the guidance is robust, we have considered how it will be enforced and we will continue to review the guidance.”
Eleanor Ferguson, RCVS Registrar, added: “Ahead of it coming into force, we will also be publishing resources about the guidance, including the case studies that we are currently finalising, and some FAQs.
"We hope these will help to further explain the context behind the guidance changes, and help to counter any misunderstanding about the impact of the guidance and what it will actually mean for practising professionals on a day-to-day basis.”
For further information about the guidance and the consultation process that led to its development visit: www.rcvs.org.uk/undercare
The Queen's Medal is the highest honour the College can bestow upon a veterinary surgeon.
Dr Johnson is the Chairman of World Horse Welfare, travelling internationally and lecturing on behalf of the charity with a particular involvement in fundraising, profile-enhancing and education. He is also the Chairman of the World Horse Welfare International Committee, and a regional representative for the Veterinary Benevolent Fund as well as being Deputy Lord Lieutenant for Lancashire.
After graduating from the University of Liverpool in 1969 he established an equine and farm animal practice in 1974 on the Fylde Coast. He then quickly became involved in many other lines of work, lecturing at the Myerscough College for thirty years, acting on the Agricultural Training Board, and serving as RCVS President from 1993-1994. He was also an RCVS Council Member for 28 years (1986-1998; 2000-2016) and served on many RCVS Committees.
Barry said: "This is an enormous honour for a practitioner from Lancashire. I have always enjoyed being a veterinary surgeon and am grateful to my colleagues and clients for making my career so fulfilling rewarding and fun."
He was nominated by fellow veterinary surgeon, Dr Peter Jinman, a current member of RCVS Council. In his nomination Dr Jinman said: "There are few members who have contributed so much of their personal time for the benefit of the veterinary profession both locally and nationally… That this has been done often without the knowledge of the public or the rest of the profession and at no little personal expense, demands recognition… Barry represents the very best of what a veterinary practitioner can achieve both in terms of his profession and in wider society."
The College has also announced that Kathy Kissick has won this year's Golden Jubilee Award, the highest honour that can be bestowed on a veterinary nurse.
Kathy is a trustee of the Alderney Animal Welfare Society and has previously acted as the Head of School for Veterinary Nursing and Farriery Science at Mysercough College in Lancashire. She qualified as a veterinary nurse in 1983 and, since then, has acted as an external examiner and adviser for a number of veterinary nursing course providers over the years and is currently on the editorial board for The Veterinary Nurse.
She has also been very active within the RCVS, initially as a nursing examiner and then as both a Member and then Chair of the RCVS Veterinary Nurses Council.
Kathy said: "I am delighted, honoured and humbled to accept the Golden Jubilee award and hope that I can continue to inspire veterinary nurses, throughout their careers, to always do the very best for their patients, clients and colleagues but not to forget to follow their dreams."
The winners will receive their accolade at this year’s RCVS Day, which takes place on Friday 7 July at the Royal Institute of British Architects.
Prior to the start of the hearing, the RCVS received correspondence from Mr Kombert confirming that he did not intend to attend the hearing, either in person or via a video-link, nor did he intend to send legal representation in his stead.
The Committee, chaired by Dr Martin Whiting, decided to proceed with the hearing in the absence of Mr Kombert and any legal representation, on the basis that it was in the public interest and the interests of justice to proceed and that Mr Kombert had been given the opportunity to attend or be represented.
The Committee heard that staff at the practice where Mr Kombert was working as a locum had undertaken a check of the medicines kept in the practice’s controlled drugs cabinet and discovered that 5.5ml of ketamine and 1.5ml of methadone was missing. After the code to the controlled drugs cabinet was changed, Mr Kombert was observed taking an additional 3ml of methadone, which he then administered to himself while on duty at the practice.
After Mr Kombert was confronted with the evidence, he was given the details of the Vetlife charity for support and asked not to return to the practice.
The police were contacted and, on 4 January 2019, Mr Kombert was arrested and interviewed. He received a police caution for theft, with conditions that he should attend and complete a drug-use awareness course, and engage in a restorative justice process, which involved attending the practice to discuss his offences. At this meeting, Mr Kombert admitted stealing the drugs and administering them to himself while on duty, which meant he was not in a fit state to see patients. He apologised for his actions and the matter was then also reported to the RCVS.
In relation to the fact that Mr Kombert had accepted the police caution, made the admissions at the restorative justice meeting and had emailed the RCVS apologising for his actions, the facts of the case were found proven.
The Committee then went on to consider if Mr Kombert’s actions amounted to disgraceful conduct in a professional respect (henceforth called ‘serious professional misconduct’), something which Mr Kombert had admitted to in correspondence with the RCVS.
The Committee found that Mr Kombert’s actions did amount to serious professional misconduct. Dr Martin Whiting, chairing the Committee and speaking on its behalf, said: "The respondent’s conduct was dishonest; it constituted both a breach of trust and an abuse of his position with regards to access to veterinary medicines; it risked animal welfare and jeopardised the reputation of colleagues. It fell far short of the conduct expected of a member of the profession and amounts to disgraceful conduct in a professional respect."
The Committee then considered what the appropriate sanction against Mr Kombert should be, taking into account both aggravating and mitigating factors.
In terms of aggravating factors, the Committee took into account the risk of harm to animals, his dishonesty, the premeditated nature of the misconduct, the breach of trust and the fact it was repeated.
It also took into account three previous matters recorded against Mr Kombert in the United States of America.
These were: a letter of admonition from the Colorado State Board of Veterinary Medicine for practising when his licence had expired; a stipulation order from the same body in which he agreed to relinquish his licence in that state following an allegation that he took controlled substances from a veterinary practice and self-administered them; and a criminal conviction in New York State for obtaining an opioid controlled drug by deception, for which he was sentenced to three years’ probation. The Committee was made aware of the New York State criminal conviction after Dianne Norris, a Probation Officer based in that state, had contacted the RCVS after hearing about the inquiry and informed the College that Mr Kombert was in breach of his probation conditions.
Dr Whiting said: “The Committee has considered the witness statement of Ms Dianne Norris, a probation officer employed by Putnam County Probation in New York, who was responsible for supervising the respondent as part of his probation. Ms Norris explained that the respondent breached his probation on numerous occasions, which took place from November 2017 to 2018…. As a result of the breaches, Ms Norris required the respondent to increase his attendance at support groups to an inpatient treatment program for 28 days from 13 July 2018. He failed to attend.
"Ms Norris explained that warrants were issued for the respondent’s arrest…. The Committee noted that the conduct of the respondent in relation to obtaining controlled drugs from his employers for his own use while in the United States of America was similar to his conduct … [described in] the charges."
In mitigation the Committee considered that Mr Kombert had consistently admitted the charges against him as well as accepting and agreeing with the evidence against him.
However, the Committee decided that in light of the seriousness of his misconduct, including dishonesty and risk of serious harm to animals, removal from the Register was the most appropriate and proportionate sanction.
Summing up, Dr Whiting said: "The respondent has failed to uphold the requisite standards to be expected of him on multiple occasions. The Committee considers that the only sanction that is sufficient to protect the welfare of animals, maintain public confidence in the profession and declare and uphold proper standards of conduct is one of erasure."
Mr Kombert has 28 days from being informed of the outcome of the hearing in which to make an appeal to the Privy Council.
The full facts and findings from the case can be found at www.rcvs.org.uk/disciplinary
The announcement came in the form of a written statement by the then Home Secretary Sajid Javid to the House of Commons on 23rd July, which said: "The Government is happy to accept all of the MAC’s recommendations on the composition of the SOL and the necessary amendments will be made in the Autumn Immigration Rules changes."
Being on the shortage occupation list means that employers do not need to advertise jobs for veterinary surgeons in the UK for 28 days before advertising abroad (the Resident Labour Market Test). In addition, there are lower visa fees and it provides exemption from the minimum income threshold.
RCVS President Niall Connell said: "Both the Royal College of Veterinary Surgeons and the British Veterinary Association worked together to ensure this outcome, which will see a lowering of the immigration barriers, for example, in terms of visa requirements, for overseas veterinary surgeons who wish to live and work in the UK.
"We also considered this a vital piece of preparation for the UK leaving the EU, as around half of those registering as veterinary surgeons with the RCVS in a given year are non-UK EU nationals and we would not want to see this vital supply of veterinary talent immediately dry up should ‘freedom of movement’ end when the UK leaves the EU.
"We thank Mr Javid for accepting the Committee’s proposals and congratulate his successor Priti Patel on her appointment and look forward to the decision being implemented. The new Prime Minister pledged on the steps of Downing Street to do more to promote the welfare of animals, and having veterinary surgeons on the Shortage Occupation List will help in our mission to uphold animal health and welfare and ensure that vital veterinary work can continue to get done, whatever happens with the relationship between the UK and the EU."
Amongst the proposals agreed by Council was to move towards an independent appointment system for Council membership to replace the current election system.
In addition, Council voted:
Council was tied on whether to separate the position of RCVS President and the Chair of RCVS Council, meaning that this will come back for decision at a later date following the consultation.
RCVS President susan paterson, said: “The unique way that RCVS Council is currently constituted with annual elections to Council is an old model of self-regulation which is no longer found in other professions including doctors, nurses, pharmacists, solicitors and social workers, among others.
“As a responsible regulator we have a duty to operate in a way that recognises modern principles of regulation, and best meets our objectives to enhance society through improved animal health and welfare by setting, upholding and advancing the educational, ethical and clinical standards for the veterinary professions.
"The College’s recommendations would see us retain self-regulation in the sense of independence from government, and maintain registrants within our governance framework, while better assuring the public that we are acting on their behalf.
“It is our firm belief that, among other things, moving to an all-appointed Council member system, whereby those who serve on Council are selected via an independent process based on their knowledge and experience to ensure input from all parts of the veterinary sector, will better serve our aims, as will having a better balance of professional and lay members.
"Of course, veterinary expertise, knowledge and experience will also remain a vital part of any future arrangements throughout our committee structure, so the veterinary voice will be as important as ever in our policy and decision-making processes.
rcvs.org.uk/who-we-are/rcvs-council/council-meetings/18-january-2024/
Further details about the consultation process will be published in due course.
Discuss here: https://www.vetsurgeon.org/f/non-clinical-questions/30878/what-do-you-think-about-the-rcvs-proposals-to-stop-council-elections-and-move-to-appointed-members-with-equal-or-almost-equal-number-of-lay-members/243481
Mr Wood was removed from the Register in 2018 after being convicted of posessing indecent images of children and made subject to a Sexual Harm Prevention Order for five years.
Mr Wood first applied to rejoin the Register in 2020 but his application was rejected.
At the outset of his second application last month, Mr Wood’s counsel argued that he is professionally competent to be restored, that he had strong mitigation for his offending, that he had consistently and repeatedly expressed and demonstrated profound remorse, that he posed a low risk of re-offending, that he had proactively engaged with the Probation Service and voluntary counselling to gain further insight into his offending, and that he had completed his community sentence and was no longer subject to any of the court orders arising from his conviction.
The Committee then weighed up whether Mr Wood had accepted its original findings in 2018, the seriousness of the offences, whether he demonstrated insight, protection of the public and the public interest, the future welfare of animals should he be restored to the Register, the length of time off the Register, Mr Wood's conduct since he was removed and evidence that he had kept up-to-date with veterinary knowledge, skills and practice.
Dr Kathryn Peaty MRCVS, chairing the Committee and speaking on its behalf, said: “The Committee is satisfied that Mr Wood has done everything required of him in order to be able to satisfy the Committee that he is fit to be restored to the Register.
“At the last application in June 2020, he was unsuccessful largely because of the outstanding ancillary Court Orders that did not conclude until early 2023. Those Orders have now concluded
“He has shown significant insight into his offending behaviour. He has been proactive in his rehabilitation and taken significant steps to ensure there would be no repetition.
“He has a small, but strong, network of people around him who appear to genuinely care about him and support him. He has worked hard at maintaining his skills and knowledge, in so far as he has been able to in light of not being able to practise as a veterinary surgeon.
“He is thoughtful and realistic about his prospects going forward. His responses to questions about addiction were appropriate and persuasive. He has expressed genuine remorse and there is, in the Committee’s view, a public interest in allowing him to be restored to the Register.”
www.rcvs.org.uk/disciplinary
The RCVS Disciplinary Committee has severely reprimanded and warned as to his future conduct a veterinary surgeon who failed to make sufficient enquiries about the location or condition of a cat; unreasonably refused to provide it with first aid and pain relief; and failed to provide it with adequate 24-hour emergency care.
Following a three-day hearing, the Committee found Marcus Kutschera, of South London Emergency Veterinary Centre, Streatham, guilty of serious professional misconduct in relation to events on 16 May 2011. Mr Kutschera was Clinical Director of the practice, which provided out-of-hours emergency services to several London veterinary practices. At about 1.45am, the practice received two telephone calls from a representative of a registered charity about a cat, which the caller considered should be seen by a veterinary surgeon as soon as possible. The charity was itself a client of one of the practices whose out-of-hours emergency services were provided by the South London Emergency Veterinary Centre. The cat was later euthanased by the RSPCA.
After listening to a recording of a telephone call between a representative of the charity and Mr Kutschera, during which Mr Kutschera failed to ask about either the condition or location of the cat, the Committee was in no doubt that the caller believed Mr Kutschera would not see the cat unless he was able to pay when it was presented. The Committee said that, once the telephone call had been received, the primary responsibility of the veterinary surgeon was the welfare of the animal, and Mr Kutschera had no good reason not to see the cat or to follow the procedures set out in the Guide to Professional Conduct 2010. If he had made proper inquiries, he would have been able to make a provisional diagnosis that the cat was likely to be euthanased. Mr Kutschera was guilty of unreasonably refusing to provide first aid and/or pain relief to the animal, and of failing to provide adequate 24-hour emergency care.
The Committee concluded that Mr Kutschera's conduct fell far short of that to be expected of a veterinary surgeon. Although he did recommend that the cat should be taken to the RSPCA, his primary concern was the ability of the client to make a payment on presentation of the cat, and not the animal's welfare. He had a responsibility for ensuring that proper emergency cover was provided.
In mitigation, the Committee noted that the event was a single, short telephone call between Mr Kutschera and the client in the early hours of the morning, and there was no evidence to suggest similar behaviour on his part on other occasions. Mr Kutschera accepted that he made no inquiries into the cat's condition or location, and the Committee accepted that he had shown some insight into what went badly wrong. He said that he had subsequently changed his practice when speaking to clients on the telephone. The Committee also took account of the impact on Mr Kutschera of the case hanging over him since the complaint was made in August 2011 and, as the cost of the Disciplinary Committee inquiry was not covered by his professional indemnity insurance, he had taken on a substantial financial commitment to pay for legal representation.
Professor Peter Lees, chairing and speaking on behalf of the Committee said: "The primary purpose of the sanction is not to punish but to protect the welfare of animals, maintain public confidence in the profession and uphold proper standards of conduct. Whilst there are undoubted financial issues that can arise in the operation of an out-of-hours service, the primary responsibility of the veterinary surgeon is for the welfare of the animal."
The Committee recommended that Mr Kutschera undertake, within 12 months, continuing professional development training, with a particular emphasis on animal welfare, ethics and client care, in the context of providing out-of-hours services. It imposed on Mr Kutschera the sanction of a severe reprimand and a warning as to his future conduct.
The first charge was that in April 2016, having examined a horse named Alfie on behalf of his owner, Mr Villar gave an opinion to the potential buyers but failed to make it clear that he had not undertaken a pre-purchase examination; failed to declare to the buyer that he had a conflict of interest with regard to the owner; and, failed to explain the pre-purchase examination process to the buyers.
The second charge was that, in July 2016, during a telephone conversation with the buyer, Mr Villar was dishonest and failed to provide clear and accurate information because he told the buyers that he had only been asked to trot Alfie to check he was sound when he had, in fact, carried out a more substantial examination.
The third charge was that Mr Villar had offered to either the owner or the buyer, or both, that he would prepare a veterinary insurance certificate in relation to Alfie when he knew he did not have sufficient records (eg the microchip or passport number) to do so.
The fourth charge was that Mr Villar failed to respond adequately to communications from the buyers about Alfie.
The Committee found that Mr Villar had not in fact carried out a pre purchase examination (“PPE”) and referred to guidance from the British Equine Veterinary Association which identified that pre-purchase examinations are carried out on behalf of buyers. It noted that in this case, Mr Villar had undertaken an examination on behalf of the owner. Accordingly, it did not find that Mr Villar had failed to explain the PPE process to the potential buyers.
However, the Committee did find that Mr Villar had failed to declare that he had a conflict of interest in regards to Alfie’s owner. The Committee said that Mr Villar should have told the buyer that he had been acting on behalf of the owner and was not a neutral party in the potential sale.
The Committee found all aspects of the second charge not proven, on the basis that it was not satisfied so as to be sure that Mr Villar had told the potential buyers that he had only been asked to trot Alfie and check that he was sound.
The Committee found all aspects of the third charge proven on the basis that, in an email sent to the College in March 2016, Mr Villar admitted that he did not have the sufficient records to prepare a veterinary insurance certificate.
The Committee found the fourth charge not proven on the basis that the buyers were not his clients. The Committee therefore concluded that he had no obligation to respond to them, and indeed could not do so in certain respects in order to preserve the confidentiality of his client.
The Committee then determined that the charges found proven, when taken individually or in combination, did not amount to serious professional misconduct.
Ian Green, chairing the Committee and speaking on its behalf, said: "The following mitigating factors were present in this case: the circumstances of the incident, the fact that there was no premeditation, the fact that he was requested by his client to advance an opinion to [the buyers] concerning Alfie and that his ill judgement was on the spur of the moment and the fact that he had no financial gain. These are all important factors. Likewise, the fact that he did not know that the [buyers] regarded him as their pre-purchase examination vet is an important matter.
"The respondent’s conduct was clearly against the principles of behaviour articulated by Mr Morley [who acted as an expert witness for the College] in his expert report and in his evidence. Nevertheless, the Committee does not find that in the particular circumstances of this case, namely being asked to speak to a potential purchaser without warning and without being made aware of the contractual arrangements which had been made between the respondent and [the owner], the respondent should not properly be the subject of a finding of disgraceful conduct in a professional respect."