Botox remote

BACKGROUND

Dr J is a specialty registrar in dermatology who in addition to her NHS job runs a private practice in aesthetic medicine.

She contacts MDDUS having been notified of a complaint to the General Medical Council raised by an aesthetic nurse whom she had met at a conference meeting. The nurse expressed concern that Dr J is providing a remote prescribing service for cosmetic treatments.

The nurse claims that Dr J informed her that she routinely prescribes Botox after telephone consultations with patients, and without a face-to-face consultation.

A letter from the GMC informs Dr J that her case has been referred to an interim orders tribunal hearing (IOT) to consider restricting her registration while the allegations are being investigated.

The GMC letter quotes NHS advice stating: “Botulinum toxin can only be prescribed in a face-to-face meeting by a qualified medical practitioner, such as a doctor, dentist, pharmacist prescriber or nurse prescriber.”

It also refers to GMC Guidance for doctors who offer cosmetic interventions which in paragraph 11 states: “You must carry out a physical examination of patients before prescribing injectable cosmetic medicines. You must not therefore prescribe these medicines by telephone, video link, online or at the request of others for patients you have not examined.”

The GMC letter concludes that to prescribe botulinum injections for patients without seeing them face-to-face raises serious concern.

ANALYSIS/OUTCOME

An MDDUS lawyer reviews the full notes and instructs a barrister to provide legal representation for Dr J at the IOT, which is conducted remotely due to Covid-19 restrictions at the time. The tribunal imposes an interim order stating Dr J must in future always carry out a face-to-face consultation and physical examination of all patients before prescribing injectable cosmetic medicines and must keep a log of all such prescriptions.

MDDUS lawyers then focus on responding to the initial (Rule 4) letter from the GMC. The letter of response includes Dr J’s personal reflections on the matter, stating that she had mistakenly believed that the guidance on remote prescribing of injectable cosmetic medicines had at the time been relaxed due to the Covid-19 pandemic.

The response letter includes details of two patients provided with prescriptions after video consultations. Dr J restates that this was due to a misinterpretation of the situation and not in disregard of guidance, but she accepts that advice from the GMC should have been sought before undertaking the video consultations. Dr J further states she has never prescribed on the basis of a telephone assessment alone.

In the letter Dr J also offers an apology to the patients and complainant, and the GMC for departing from guidance, which she acknowledges places patients at risk of harm and can affect the public’s confidence in the reputation of the profession.

The letter further details remediation undertaken, including reading and reflection, to ensure that she is completely up to date with GMC prescribing guidance and Joint Council for Cosmetic Practitioners (JCCP) guidance for prescribing (PDF). The response states that her misinterpretation of the guidance is easily remediable, and on the basis of CPD, reflection and her own logbook this has already been addressed and her lapse is highly unlikely to be repeated.

Six months later Dr J receives a letter from the GMC stating the case examiners have concluded the case with no further action. An appendix to the letter provides the reasoning behind the decision.

The document summarises the evidence considered, including witness statements from the two patients contacted and the report of an independent expert. Having examined the notes in detail the expert finds there is no direct evidence that Dr J had said she routinely prescribes Botox without face-to-face interaction – though it is understandable how the aesthetic nurse may have formed that impression.

Witness statements from the two patients confirmed that both had previously been seen by Dr J in face-to-face consultations for routine Botox treatment. The expert concluded failing to conduct a subsequent face-to-face assessment did fall below the standard expected of a reasonably competent doctor but not seriously below as there had been no discernible change in the health of both patients.

Considering all the evidence, the GMC case examiners decided there is no realistic prospect of establishing that Dr J’s fitness to practise is currently impaired to a degree justifying action on her registration.

The interim order of conditions was also removed at the conclusion of the case.