In the recent case of Metastasio v GMC, a doctor lost his appeal against erasure for an inappropriate relationship with a vulnerable patient.  The case serves as an important reminder to all doctors to ensure they maintain appropriate professional boundaries with patients at all times.

Metastasio v GMC

In this case, a doctor failed to overturn a decision by a Medical Practitioner’s Tribunal (MPT) to erase his name from the medical register.

A summary of the case’s background is that, in November 2017, a young woman (‘Patient A’), who was diagnoses of Emotionally Unstable Personality Disorder (‘EUPD’) and Bipolar Affective Disorder, was referred by a Crisis Resolution Team to St Pancras Hospital in relation to risk of suicide, alcohol addiction and use of cocaine.

Shortly thereafter, Patient A was transferred and admitted to Highgate Mental Health Centre, where she was an in-patient between 23 and 30 November 2017. Whilst Patient A was an in-patient, the doctor was her treating Consultant Psychiatrist, where he had four direct interactions with her.

The allegations against the doctor arose from his contact with Patient A.  Patient A, using a pseudonym (which I shall refer to as ‘M’), was working as a sex worker and appearing in pornographic films.

In 2018, Dr Metastasio began following ‘M’ on social media, he contacted her several times, paid her for sexual services on 14 February 2019, and then sought a further meeting with her in August 2020. Patient A complained to the Trust when the doctor contacted her again in August 2020.

In short, the MPT found that the doctor had engaged in this conduct knowing that ‘M’ was his former patient. The MPT concluded that his fitness to practise was impaired by reason of misconduct, and that the only appropriate and sufficient sanction was one of erasure.

Maintaining Professional Boundaries

The Good medical practice states, doctors:

“…must not use their professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.”

• See also: Good Medical Practice – when was the last time you actually read it?

The GMC’s “Maintaining a professional boundary between you and your patient” guidance goes on to say:

“Trust is the foundation of the doctor-patient partnership. Patients should be able to trust that their doctor will behave professionally towards them during consultations and not see them as a potential sexual partner.”

Vulnerability, as was relevant to the Metastasio case, is seen as particularly problematic for doctors with the same GMC guidance noting that:

“Some patients may be more vulnerable than others, and the more vulnerable someone is, the more likely it is that having a relationship with them would be an abuse of power and your position as a doctor.”

Will an improper relationship with a patient always result in an erasure?

Each case will be determined on its individual merits.  Medical Practitioner’s Tribunals (MPT) will consider each sanction in turn, starting with the least restrictive.  In deciding the proportionate sanction, the MPT will consider the GMC’s Sanctions Guidance.  In relation to professional boundaries, the guidance states (6 February 2018), in summary:

• Patients must be able to trust doctors with their lives and health, so doctors must make sure that their conduct justifies their patients’ trust in them and the public’s trust in the profession (see paragraph 65 of Good medical practice). Although the tribunal should make sure the sanction it imposes is appropriate and proportionate, the reputation of the profession as a whole is more important than the interests of any individual doctor.
• Erasure may be appropriate even where the doctor does not present a risk to patient safety, but where this action is necessary to maintain public confidence in the profession. For example, if a doctor has shown a blatant disregard for the safeguards designed to protect members of the public and maintain high standards within the profession that is incompatible with continued registration as a doctor.
• Any of the following factors being present may indicate erasure is appropriate (this list is not exhaustive)…A particularly serious departure from the principles set out in Good medical practice where the behaviour is fundamentally incompatible with being a doctor.
• Under the heading “Cases that indicate more serious action is likely to be required”, the Sanctions guidance states (omitting footnotes), “Abuse of professional position – 143 Doctors must not use their professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.

Social media

When considering professional boundaries, doctors must also be mindful of their use of social media.  Social media can blur the boundaries between a doctor’s personal and professional lives and may change the nature of the relationship between a doctor and a patient.

The GMC makes clear that doctors must be prepared to explain and justify their decisions and actions including those that relate to their use of social media.  Fundamentally the issues that may arise through the use of social media does not change; privacy and confidentiality, maintaining professional boundaries, respect for colleagues, anonymity and conflict of interest.

The GMC’s guidance goes on to say that “serious or persistent failure to follow our guidance that poses a risk to patient safety or public trust in doctors will put your registration at risk.”

Insight & Remediation

When a MPT considers the proportionate sanction to impose, the guidance states that mitigating factors include evidence of insight and remediation.  Improper relationships are seen as particularly serious misconduct and whilst insight and remediation are unlikely, by themselves, to lead to allegations found unproven, both will assist a doctor in increasing the likeness of lesser restrictive sanctions.

Insight Works Training

Developed by leading legal representatives for medical professionals facing health and social care tribunals, Insight Works Training have designed unique and practical courses with focus on impairment, reflections and remediation. 

Courses are delivered by both leading healthcare experts with years of experience in mentoring and coaching who also sit on regulatory tribunal panels and, leading legal experts in the field of defence at health and social care regulatory tribunals. 

Insight Works Training will help give you a clear and easy to follow understanding of the regulatory process, explanation of the central role of impairment, how to approach insight and remediation, how to evidence this at your hearing and a directed approach to presenting your learning with evidence in writing and verbally.

Kings View Barristers

With over 30 years combined experience, Kings View Chambers have established itself as one of the best when it comes to fitness to practise defence.  We fully understand that fitness to practise defence is not merely about processes and procedures.  We also understand that we are working with people who are anxious and worried about what investigations might mean for them, their professions and the reputations.

We are proud to be rated ‘excellent’ by our clients.  Our commitment to client care is genuine in both seeking the very best outcomes for our clients, but also ensuring we do what we can to support them through the process.

Contact us today for a no obligation and free telephone consultation about your case in the knowledge that you are speaking to one of the best in the business.