For want of support

Sridharan Suresh was a consultant with an ‘exceptional’, ‘unblemished’ professional record and a doting father of two who took his own life while under police investigation. His death raises concerns about the support offered to doctors by employers and professional regulators – and ‘a no-smoke-without-fire culture’ in the NHS. Peter Blackburn reports

Location: UK
Published: Thursday 14 May 2020

‘There was a feeling that the worst was gone,’ Visalakshmi Suresh told an inquest into her husband’s death, recalling the days before he died.

‘Everything was quietening down. He was consistently reassured there were unlikely to be any further actions and that he would be able to return to work as soon as possible… but then all of a sudden something lands on him and he was alone.’

On 2 May 2018, Sridharan Suresh, consultant anaesthetist at North Tees and Hartlepool Hospitals NHS Foundation Trust, received an email from the GMC informing him that he would be subject to an interim orders tribunal.

The drugs used to sedate the patient are ‘well known’ to produce hallucinations
Dr Dwarakanath

Just hours later Dr Suresh sent an email to his wife while she was at work, saying he had done nothing wrong, but could not go on any longer, and took his own life.

It was a ‘bolt from the blue’, a friend of Dr Suresh told the court. And it had a ‘significant impact’ on him, according to HM senior coroner for Teesside Clare Bailey.

A three-day inquest into Dr Suresh’s death, at Middlesbrough coroner’s court, heard that the weeks leading up to Dr Suresh’s death were littered with assumptions, misunderstandings and failures in communication. Questions were also raised about the support available to doctors, and whether the ‘devastating’ effect of GMC referrals can be mitigated or subjected to some sort of risk assessment.

Dr Suresh was under police investigation at the time of his death, following allegations of sexual touching made by a teenage patient undergoing sedation for dental extraction. The father of two, who lived in Ingleby Barwick, Stockton-on-Tees, vehemently denied the allegations and was questioned at Middlesbrough police station as a voluntary attender.

Bolt from the blue

The incident was alleged to have happened during a private operation at the Grace Dental service, which is located on the site of the North Tees trust.

North Tees and Hartlepool NHS Hospitals Trust decided not to refer Dr Suresh to the GMC – the trust’s medical director, Deepak Dwarakanath, told the inquest that the drugs (midazolam and fentanyl) used to sedate the patient are ‘well known’ to produce hallucinations, sometimes of a sexual nature, and that the description of the alleged assailant did not match Dr Suresh ‘at all’.

Dr Dwarakanath told the coroner he hoped the case would be dealt with swiftly and thought little would come of the investigation – he reassured Dr Suresh that there would be no GMC referral and that he had the support of the trust.

However, a breakdown in communication left Dr Suresh in the dark.

While the trust was offering reassurance, Cleveland Police had already decided to make a third-party referral to the GMC. They informed the hospital trust, but neither party informed Dr Suresh, with both assuming the other would do so.

On 2 May – two weeks after the trust had been made aware a GMC referral had been made – the email confirming notice of an interim tribunals order landed in Dr Suresh’s email inbox, with no warning.

The description of the alleged assailant did not match Dr Suresh ‘at all’
Dr Dwarakanath

The inquest heard that trust staff had failed to realise the significance of the referral and had not escalated the information to the medical director. The trust produced a number of documents outlining how gaps in communication should now be removed, to ensure a similar problem does not happen again. The trust also confirmed it would now automatically make occupational health appointments for staff referred to their professional regulator, in an effort to ensure support is in place.

At the inquest Ms Bailey said she was concerned about the trust’s failure to ‘recognise, communicate and escalate information about a third-party GMC referral’ and was concerned about assumptions made by police and the trust that meant Dr Suresh was not told.

But Ms Bailey said she believed ‘very serious lessons’ had been learned and procedures and policies put in place to prevent similar failures in communication in future.

A spokesperson for the trust offered sympathies to the family and described
Dr Suresh as a ‘highly valued colleague’.

He said: ‘Our trust is dedicated to ensuring that the health and wellbeing of all of our employees is an absolute key priority.’

Devastating impact

The three days of the hearing also focused around the ‘devastating’ effect of GMC referrals for doctors, and whether the regulator does enough to assess the risk before sending a communication to doctors, informing them that their careers may be under threat.

Joanna Farrell, the GMC’s assistant director for investigations, was asked whether anything could be done to mitigate the effect on doctors.

She said: ‘I think this is quite a tricky question. We are all aware of the impact of our communication on doctors and we are all aware that any professional being referred to their professional body will cause anxiety.’

Ms Farrell was asked whether alternative options had been considered – informing doctors in person or by phone, telling their responsible officers before and assessing any risk – but did not agree that the steps were appropriate or feasible.

‘We don’t think there is a perfect answer,’ she said.

It is crucial the GMC continues to look to refine its processes
Dr Nagpaul

Representing the family of Dr Suresh, Leslie Thomas QC questioned whether the GMC had conducted any sort of risk assessment or asked whether Dr Suresh was particularly vulnerable before sending the email. Ms Farrell said they had not.

Mr Thomas also queried what happens after a doctor is told the news. ‘You do accept that if you notify someone of very serious allegations by email, the sender has no idea how the information has been received, or the impact on the recipient,’ he said. Ms Farrell agreed.

Concluding the inquest Ms Bailey told the GMC to ensure it asks questions about whether a doctor is vulnerable in advance of sending future communications, and to edit communications to offer doctors phone calls to discuss referrals rather than the news having to come out of the blue in an email.

It is not the first time that the effect of a GMC referral upon doctors has come under scrutiny.

A 2014 review identified 114 doctors who died while under open GMC investigations between 2005 and 2013. Of those, 28 were recorded as suicide or suspected suicide.

The report suggested that doctors under investigation should feel they are treated as innocent until proven guilty and made a number of further recommendations, including emotional resilience training and staff training to increase awareness of mental health issues.

Another report by Professor Louis Appleby, commissioned by the GMC to look into cases where the doctors had died from suicide while subject to investigation over an eight-year period, said the regulator must recognise ‘the vulnerability of any doctor facing a fitness-to-practise investigation, whether or not they are known to have poor mental health’, suggesting ‘investigations can be punitive in effect, even if that is not the intention’.

Safeguards claim

The GMC said it made a number of changes following the review, including changing tone of voice in correspondence to remove legalistic wording and communicate more sensitively, introducing a process to pause investigations to allow unwell doctors to seek urgent treatment, the creation of a specialist team to work with doctors who have health concerns and providing training to staff including an ‘awareness around suicide prevention’.

A spokesperson for the GMC said: ‘This was an extremely tragic case and our thoughts are with Dr Suresh’s family and friends at this difficult time. If we are aware a doctor may be vulnerable we will always put safeguards in place to support them. However, for this to happen we must be made aware of concerns, including if the doctor may be at risk of self-harm. In this case, our investigation was at a very early stage and we had no information to indicate that the doctor was vulnerable or at risk.’

Dr Suresh’s friend and colleague, Vijay Jagannathan, also a consultant anaesthetist, suggested that some of the issues the reviews intended to address remain – describing a ‘no-smoke-without-fire’ culture – at the inquest.

‘Any doctor will say the GMC never writes to you with good news,’ he said. ‘The regime breaks you down – people start making judgements and determinations.

‘It’s an emotional and mental trauma.’

It is a feeling of overwhelming significance that the trust’s medical director Dr Dwarakanath recognised, too. Speaking at the inquest he said: ‘I have yet to meet a doctor who when referred to the GMC does not feel anxious and stressed. It’s a career-defining moment for anyone. As we all know, it could be the end of their career if the worst happens.’

The petition calls for the GMC to be made legally responsible for the wellbeing of doctors who are under its investigation.

It says: ‘They should be held accountable for the loss of life of any doctor they are investigating. The health secretary should bring about change to the statute to achieve this, so that doctors’ lives are protected.’

Little progress

Portrait of BMA chair Chaand Nagpaul NAGPAUL: 'A culture characterised by blame, bullying and intolerable pressure'

A family friend, who works as an NHS consultant in the North East, tells The Doctor that they do not believe the GMC is truly accountable.

He says: ‘If a doctor dies while under investigation, they will conduct their own internal inquiry and they may find some lessons to be learned, but this keeps going on and there does not seem to be any great acknowledgement or change in rules or processes. The family would like to see the GMC become more responsible for loss of life – they should have to provide clear answers about what they did and what they are doing about it.’

Speaking to The Doctor, Ms Suresh says her family is ‘crushed’ by ‘excruciating grief’ – but that she desperately hopes a positive legacy for her husband could be a better system for other doctors.

She says: ‘The systems need to be supportive for doctors – employers need to disclose all information of what is happening around a case, support systems need to be in place and they all need to protect the dignity and integrity of the professional and make
sure all options are explored until allegations are proven.’

An online petition – organised by a Dr Suresh’s family supporter and the medico-legal adviser Rajesh Chaudhary, and calling for greater protection of doctors being accused
of misconduct – has gathered more than 20,000 signatures.

Summing up at the inquest, Ms Bailey described the circumstances that surrounded Dr Suresh’s death as a ‘lacuna in understanding’, and Mr Thomas spoke of ‘fundamental systematic failings’.

BMA council chair Chaand Nagpaul says: ‘A GMC referral is a time of exceptional stress and strain for many doctors – a constant nightmare which can be isolating, stigmatising and worrying.

‘It is of course important the regulator is able to ensure the fitness of staff to practice and to protect patients, but the reality is these processes often offer little or no insight into the emotional state of the doctor involved and can potentially be as harmful as they are helpful.

‘A “no-smoke-without-fire culture”, as it was described during this inquest, worsens a brutal working environment already characterised by blame, bullying and intolerable pressure – an environment which weighs heavily on doctors and ultimately impacts patient care and safety.

‘It is crucial the GMC continues to look to refine its processes, to ensure that the welfare of the vulnerable doctor is an integral part of the decisions taken by its staff, and to ensure the methods of communication used to explain those decisions are compassionate and clear.’

Ultimately, the NHS lost a talented doctor and a family their loving son, husband, father and friend. Wherever lessons can be learned, lessons must be learned.