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Fitness to PractiSe Panel

19-30 March, 14-28 June 2007 (22 june non sitting day)

7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ

Name of Respondent Doctor:

Dr Marisa VIEGAS

Registered Qualifications:   

MB BS 1980 Lond

Registered Address:   

Jamaica

Registration Number:   

2653479

Type of Case:    

New case of impairment by reason of: misconduct.

Panel Members:   

Dr I Neale, Chairman (Medical)
Dr P Mayer (Medical)
Mr D Taylor (Lay) (19-30 March only)
Mrs K Whitehill (Lay)

Legal Assessor:     

Mr H Narayan

Secretary to the Panel:     

Miss L Meads

Representation:

GMC: Mr S Ramasamy, Counsel, instructed by Field Fisher Waterhouse Solicitors. 

Doctor: Present and represented by Mr G Mansfield QC, instructed by RadcliffesLeBrasseur Solicitors.

allegation

‘1.        Up to around February 2002 the end of 1995 you were Ms A’s General Practitioner; Admitted and found proved

‘2.        At all material times Thereafter you advised Ms A on alternative therapies; Admitted and found proved

‘3.        As Ms A’s General Practitioner At all material times, you knew, or ought to have known that she was under the care of Professor P, Professor of Cardiac Medicine, and had been since 1995; Admitted and found proved

‘4.        a.         On or around 12 December 2001, you received a letter in your capacity as Ms A’s General Practitioner from Professor P, Not found proved

b.         This letter updated you as to Ms A’s heart condition and the medication and treatment prescribed by Professor P to manage it, Not found proved    

‘5.        Around February 2002 Not later than March 1999 Dr F became Ms A’s General Practitioner; Admitted and found proved

‘6.        You remained in touch with Ms A notwithstanding Dr F having taken over as

Ms A’s General Practitioner; Admitted and found proved

‘6A.     a.         On 22 June 2004 you sent an email to G who had been sending and receiving messages on behalf of Ms A, Admitted and found proved

b.         In that email you said: “Stop ALL medications including homeopathic.”, Admitted and found proved

c.         When you sent that email you were aware that conventional medication was being prescribed to Ms A for her heart condition; Admitted and found proved

‘7.   a.         On the 28 June 2004 Ms A was admitted to the Royal Brompton Hospital, Admitted and found proved

b.         On 26 July 2004 Ms A was discharged with a diagnosis of idiopathic dilated cardiomyopathy and pneumonia, Admitted and found proved

c.         Following her discharge from the Royal Brompton Hospital you received a letter written by Professor P dated 26 July 2004, Admitted and found proved

d.         That letter,

i.          informed you of Ms A’s recent admission, Admitted and found proved

ii.         explained the treatment she had received, Admitted and found proved

iii.        explained the medication she had been prescribed, Admitted and found proved and

iv.        explained her current state of health; Admitted and found proved

‘8.        In August 2004,

a.         You were still in touch with Ms A, Admitted and found proved

b.         You received results of her blood tests, Admitted and found proved

c.         Ms A was taking powders recommended by you, Admitted and found          proved

d.         You were advising Ms A on medication by means of telephone and email; Admitted and found proved

‘9.        On 19 August 2004 you received a message sent on behalf of Ms A asking for help, Admitted and found proved

‘10.      a.         On 20 August 2004 you sent an email to H who had been sending and receiving messages on behalf of Ms A, Admitted and found proved

b.         In that email you said: “Can you tell [Ms A] that she is NOT to take the digoxin”; Admitted and found proved

‘11.      On or around the 20 August 2004 you informed Ms A,

a.         That it was her liver not her heart that was the cause of her ill health,     Not found proved

b.         That she no longer needed to take her heart medication; Found          proved

‘12.      On the 23 August 2004, in a further message for Ms A,

a.         You advised “She just cannot take ANY drugs – I have suggested some homeopathic remedies”, Admitted and found proved

b.         You gave dietary advice and added “I feel confident that if she follows the advice she will regain her health”; Admitted and found proved

‘13.      On the 24 August 2004 you responded to an email sent on behalf of Ms A asking for advice by stating,

“She should not take anything but hopefully she is on her way to hospital to be monitored and hopefully not pumped full of drugs”; Admitted and found proved

‘14.      On the 24 August 2004 Ms A was admitted to the Salon de Provence hospital in France; Admitted and found proved

‘15.      It was noted on admission that she had stopped taking her medication for several days before admission; Admitted and found proved

‘16.      a.         On the 1 September 2004 Ms A passed away, Admitted and found proved

b.         The final diagnosis given was “acute heart failure due to treatment discontinuation”; Found proved

‘17.      On 22 June 2004 and between 20 and 24 August 2004 In relation to allegation 6A and allegations 10 – 13 you,

a.         Did not adequately assess Ms A’s condition based upon history, symptoms or an examination,

Found proved in relation to 6A, 10, 11b and 12

Not found proved in relation to 13

b.         Did not take any, or any adequate steps to communicate with Ms A’s General Practitioner and/or treating consultant to ensure that they were advised as to the changes in treatment you were recommending,

Found proved in relation to 6A, 10, 11b and 12

Not found proved in relation to 13

c.         Gave advice by email or telephone which you knew was contrary to advice given and treatment prescribed by Ms A’s treating doctors;

Admitted and found proved in relation to 6A

Found proved in relation to 10, 11b and 12

Not found proved in relation to 13

‘18.      Your actions or inaction as set out at head 17. above conduct at allegation 17 in relation solely to allegations 10 – 13 contributed to Ms A’s death; Found proved

‘19.      Your conduct as set out above was,

a.         Inappropriate, Found proved

b.         Unprofessional, Found proved

c.         Not in the best interests of Ms A, Found proved

d.         Irresponsible; Found proved

By reason of the matters set out above, your fitness to practise is impaired by reason of your misconduct.

Determination on facts

Dr Viegas: The Panel has considered all the evidence adduced in this case. It has taken into account Mr Ramasamy’s submissions on behalf of the General Medical Council (GMC) and those made by Mr Mansfield on your behalf. It has considered all the written evidence, the witness statements read to it, and all the oral evidence of witnesses including your own. The Panel has taken into account the expert evidence of Dr I, a GP Specialist in Cardiology and Dr J Consultant in Hepatology called on behalf of the GMC, and that of Dr K Davies Consultant Physician, Gastroenterologist and Hepatologist called on your behalf.

It has borne in mind all the advice of the Legal Assessor and particularly that it is for the Panel to decide what weight to give to each piece of evidence and that the burden of proof rests on the GMC and that the standard of proof required is that the Panel must be sure.

The Panel has considered each allegation separately. Accordingly, it has made the following findings on the facts:

Allegation 1 (as amended) has been admitted and found proved.

Allegation 2 (as amended) has been admitted and found proved.

Allegation 3 (as amended) has been admitted and found proved.

Allegation 4a (as amended) has not been found proved.

Allegation 4b has not been found proved.

Allegation 5 (as amended) has been admitted and found proved.

Allegation 6 has been admitted and found proved.

Allegation 6A (as amended) has been admitted and found proved in its entirety.

Allegations 7, 8, 9 and 10 have been admitted and found proved in their entirety.

Allegation 11a has not been found proved. Although the Panel is sure that Ms D and Mr C understood that Ms A had formed the impression that her illness was caused by her liver not her heart and that this followed a conversation with you, it could not be sure that you informed Ms A that it was her liver not her heart that was the cause of her ill health.

Allegation 11b has been found proved. The Panel has interpreted this allegation to refer to some of the medication prescribed for Ms A’s heart on her discharge from the Royal Brompton. Therefore the Panel found that you informed Ms A that she no longer needed to take her heart medication because

  • 1.      On 20 August 2004 you sent an email which stated “Can you tell [Ms A] that she is NOT to take the digoxin”.
  • 2.      You told the Panel, in your oral evidence, that on 20 August 2004 you suggested to Ms A that she stop her Candesartan.

Allegation 12 has been admitted and found proved in its entirety. The Panel carefully considered the meaning of your email of 23 August which forms allegation 12a. It found that the words “She just cannot take ANY drugs” were an instruction not a statement. It reached this conclusion as the next line says “she also cannot eat anything except rice, fat free chicken stock and water” which is also clearly an instruction. In the same paragraph of this email, which forms part of your medical record, you said “I feel confident that if she follows the advice she will regain her health” as admitted in allegation 12b. The Panel found that the substance of the advice was the two statements on drugs and diet.

Allegations 13, 14, 15 and 16a have been admitted and found proved.

Allegation 16b has been found proved. It is recorded in the Salon de Provence Hospital records that the final diagnosis given was “acute heart failure due to treatment discontinuation.”

As allegation 11a was not found proved, it no longer forms part of allegation 17.

During June 2004, while you were travelling in the USA, you were contacted by Ms A who reported that she was very ill, had blue lips and had been unable to move out of bed for two days. There are a range of possible diagnoses for a patient with heart failure, such as Ms A, who has these symptoms. In order to adequately assess her, she needed physical examination and investigation, which you could not undertake. Similarly in August, while you were in Jamaica, Ms A updated you as to her symptoms both by email and telephone. These included cough, sleep disturbance, shaking, abdominal bloating, vomiting and confusion. Again to assess such symptoms adequately, Ms A required physical examination and investigation, which you could not undertake.

You gave evidence to the Panel that both in June and during the period 19 - 22 August you gave advice to Ms A that she should go to hospital and/or see a local doctor. However, having considered all of the evidence, including the fact that you make no mention of this in your clinical records, the Panel does not accept your evidence although it does accept that you advised her to go to hospital from 23 August onwards.

Therefore allegation 17a (as amended) has been found proved in relation to allegations 6A, 10, 11b, and 12.

In both June and August 2004, you gave advice that Ms A should stop certain medications. In June, all her medications and in August, Digoxin and Candesartan. As Ms A had serious heart failure, such a decision needed to be communicated promptly to her treating doctors. In June you did not inform Dr F or Professor P nor, in August, did you inform them or Dr L of your advice.

Therefore allegation 17b (as amended) has been found proved in relation to allegations 6A, 10, 11b and 12.

Allegation 17c (as amended) has been admitted and found proved in relation to allegation 6A. This relates to your actions in June.

In August you advised Ms A to stop taking her Digoxin and Candesartan. You knew this was contrary to the advice given and the treatment prescribed by Ms A’s treating doctors. Therefore allegation 17c (as amended) has been found proved in relation to allegations 10, 11b and 12.

Allegations 17a, b and c (as amended) have not been found proved in relation to allegation 13.

Allegation 18 (as amended) has been found proved. The Panel found that your conduct as found proved at allegation 17 in relation solely to allegations 10, 11b and 12 contributed to Ms A’s death. The Panel has considered carefully all the evidence given to it in relation to whether your actions contributed to the death of Ms A. The Panel is in no doubt that this patient, who had severe heart failure, stopped her medication, that this made her heart failure worse, which was a cause of her admission to hospital. She then needed treatment, on an intensive care unit, including diuretics and other drugs which improved her clinical condition. Despite this she subsequently died from an acute arrhythmia.  Such arrhythmias may occur at any time but are more likely to follow episodes of admission and treatment for heart failure. The Panel finds that Ms A was a patient who disliked conventional treatment and who preferred not to take such treatment. She was reducing her medication in early August and her decision to stop all her medication was made between the 19 and 21st August. At this time, you gave advice which reinforced Ms A’s views and informed her decision making process. In this way you contributed to Ms A’s death and therefore allegation 18 is found proved.

You have admitted that you knew Ms A well as a friend and as a doctor. You have agreed that whenever you gave her medical advice it was given to the same standard as you would to any other patient. You had full knowledge of Ms A’s medical condition and knew that she was seriously ill.  The Panel has found that whatever medical diagnosis you reached after communicating with Ms A required confirmation by examination and investigation. This you did not do. Your advice in June was to stop all medication and in August to stop Digoxin and Candesartan. This was contrary to the advice of her own doctors. In such an ill patient any cessation of crucial medication must be communicated promptly to those doctors who have responsibility for her ongoing care such as Drs F, P and L. Your failure to assess Ms A, communicate your alterations to her medication and your actions in stopping drugs advised by her own doctors were inappropriate, unprofessional, irresponsible and not in the best interests of Ms A and therefore allegation 19 is found proved in its entirety.

Having reached findings on the facts, the Panel now invites Mr Ramasamy and Mr Mansfield to adduce further evidence and make any further submissions as to whether, on the basis of the facts found proved, your fitness to practise is impaired. 

Determination on impaired fitness to practise

Dr Viegas: The Panel has considered, on the basis of the facts found proved, whether your fitness to practise is impaired by reason of your misconduct.

Up to around the end of 1995 you were Ms A’s General Practitioner. Thereafter you advised Ms A on alternative therapies. You knew that Ms A had been diagnosed with

idiopathic dilated cardiomyopathy in 1995 and had thereafter been under the care of Professor P, Professor of Cardiac Medicine at the Royal Brompton Hospital.

Not later than March 1999 Dr F became Ms A’s General Practitioner. You remained in touch with Ms A notwithstanding Dr F having taken over as her GP.

Over the next few years you became aware that Ms A had developed her first significant symptoms of heart failure in 2001 while she was in Kuwait and that she had subsequently had treatment for heart failure with conventional medications. You knew Ms A took these intermittently, used alternative remedies and disliked hospitals. You were aware, from correspondence and from a consultation between Ms A and you in April 2004, that her heart failure had gradually worsened.

On 22 June 2004 you sent an email to G who had been sending and receiving messages on behalf of Ms A. In that email you said: “Stop ALL medications including homeopathic.” When you sent that email you were aware that conventional medication was being prescribed to Ms A for her heart condition.

On the 28 June 2004 Ms A was admitted to the Royal Brompton Hospital. On 26 July 2004 Ms A was discharged with a diagnosis of idiopathic dilated cardiomyopathy and pneumonia. Following her discharge from the Royal Brompton Hospital you received a letter written by Professor P dated 26 July 2004. That letter informed you of Ms A’s recent admission, explained the treatment she had received, the medication she had been prescribed on discharge, and her current state of health.

The echocardiograms and MRI scans, referred to in this discharge letter, clearly demonstrated a markedly reduced ejection fraction signifying at least moderate heart failure. Professor P wrote “her drugs will need to be watched carefully”.

In August 2004, you were still in touch with Ms A. She told you about her symptoms and her medication. You also received results of some of her blood tests. Ms A was taking powders recommended by you and you were advising her on medication by means of telephone and email.

On 19 August 2004 you received a message sent on behalf of Ms A asking for help. On 20 August 2004 you sent an email to H who had been sending and receiving messages on behalf of Ms A. In that email you said: “Can you tell [Ms A] that she is NOT to take the digoxin”. On or around the 20 August 2004 you informed Ms A that she no longer needed to take another heart medication namely Candesartan.

Over the next few days, you considered Ms A had developed liver failure, secondary to her heart failure, and might have ascites. You did not take adequate steps to alert any of her treating doctors about the changes you had made to her treatment nor her condition.

On the 23 August 2004, in a further message for Ms A, you advised “She just cannot take ANY drugs – I have suggested some homeopathic remedies”. You gave dietary advice and added “I feel confident that if she follows the advice she will regain her health”.

On the 24 August 2004 you responded to an email sent on behalf of Ms A asking for advice by stating, “She should not take anything but hopefully she is on her way to hospital to be monitored and hopefully not pumped full of drugs”. The same day Ms A was admitted to the Salon de Provence hospital in France.

During her admission she required intensive treatment for heart failure and started to improve. However, on the 1 September 2004 Ms A passed away. The final diagnosis given was “acute heart failure due to treatment discontinuation”.

In June and August 2004 you did not adequately assess Ms A’s condition based upon history, symptoms or an examination. You did not take any, or any adequate steps to communicate with Ms A’s General Practitioner and/or treating consultant to ensure that they were advised as to the changes in treatment you were recommending. You also gave advice by email or telephone which you knew was contrary to advice given and treatment prescribed by Ms A’s treating doctors.

The Panel found that your conduct in August 2004 contributed to Ms A’s death. It also found that your conduct, in both June and August 2004, was inappropriate, unprofessional, not in the best interests of Ms A and irresponsible.

In determining whether your fitness to practise is impaired, the Panel has carefully considered Mr Ramasamy’s submissions on behalf of the General Medical Council (GMC) and those made on your behalf by Mr Mansfield. Mr Ramasamy highlighted to the Panel, various paragraphs from both the GMC’s Indicative Sanctions Guidance (April 2005) and Good Medical Practice (2001). Mr Mansfield submitted that the Panel should take into account the context of the events and how they occurred. He submitted that this was a one off, very unusual combination of events, which came about by you being put under pressure to be involved by Ms A.

The Panel is mindful that it is for it, and for it alone, to decide whether your fitness to practise is impaired, and that this is a matter for its own professional judgement.

It has considered the GMC’s Indicative Sanctions Guidance (April 2005). In particular, at paragraph 11 it states:

“Neither the Act nor the Rules define what is meant by impaired fitness to practise but for the reasons explained below, it is clear that the GMC’s role in relation to fitness to practise is to consider concerns which are so serious as to raise the question whether the doctor concerned should continue to practise either with restrictions on registration or at all.”

The Panel has taken into account the guidance in Good Medical Practice (2001) applicable at the time. Among the duties of a doctor it states:

            “In particular as a doctor you must:

            -           recognise the limits of your professional competence;

            -           make sure that your personal beliefs do not prejudice your patients’ care

            -           work with colleagues in the ways that best serve patients’ interests.”

Further under the title Good Clinical Care it states:

            “2.        Good clinical care must include:

            -           an adequate assessment of the patient’s conditions, based on the     history and symptoms and, if necessary, an appropriate examination;

            -           providing or arranging investigations or treatment where necessary;

            -           taking suitable and prompt action when necessary;

            -           referring the patient to another practitioner, when indicated.”

Also under the heading Sharing Information with Colleagues it states

            “45. If you provide treatment or advice for a patient, but are not the patient’s             general practitioner, you should tell the general practitioner the results of the             investigations, the treatment provided and any other information necessary for          the continuing care of the patient, unless the patient objects.”

Your conduct clearly disregarded all this guidance. The Panel considers that the situation you found yourself in, namely being put under pressure from a friend, is one that doctors frequently find themselves in. It is your duty as a doctor to follow guidance, such as Good Medical Practice, to assist you in conducting yourself appropriately to ensure that you act in the best interests of all patients, including those who are friends.

The Panel is in no doubt that the facts found proved are serious. They relate to one patient and to two periods, June and August 2004, but constitute numerous and quite separate aspects of misconduct. Taken overall they raise serious concerns regarding your fitness to practise.

The Panel is aware of its responsibility to protect the public interest, particularly with reference to maintaining public confidence in the profession and upholding proper standards of conduct and behaviour. It is of the view that your actions fell seriously short of the standards of competence, care and conduct that the public and patients are entitled to expect from doctors and seriously undermines public confidence in the profession. 

The Panel has therefore determined that your fitness to practise is impaired by reason of your misconduct.

The Panel will now invite further submissions from Mr Ramasamy as to the appropriate sanction, if any, to be imposed on your registration. Following this, Mr Mansfield will be given the opportunity to respond on your behalf and adduce evidence in mitigation. Submissions on sanction should include reference to the Indicative Sanctions Guidance, using the criteria as set out in the guidance to draw attention to the issues, which appear relevant to this case.

Determination on sanction

Dr Viegas: The Panel has already found that your fitness to practise is impaired by reason of your misconduct. It found that your conduct, in both June and August 2004, was inappropriate, unprofessional, not in the best interests of Ms A and irresponsible.

Having made and announced its finding that your fitness to practise is impaired, the Panel has now considered what action, if any, it should take with regard to your registration. The Panel has considered all the evidence put forward in mitigation including the oral evidence of Drs N and M. It has read all the testimonials submitted on your behalf. The Panel has taken into account the submissions made by Mr Ramasamy on behalf of the General Medical Council (GMC), who submitted that erasure would be appropriate given the circumstances of your case and also taken into account the submissions made by Mr Mansfield, on your behalf, who submitted that a period of suspension would be appropriate. It has applied the principle of proportionality, weighing the public interest against your own interest.

The Panel has given detailed consideration to the GMC’s Indicative Sanctions Guidance. It is mindful that it has a duty to act in the public interest. The public interest includes the protection of patients, the maintenance of public confidence in the medical profession, and the declaring and upholding of proper standards of conduct and behaviour as set out in the GMC’s document ‘Good Medical Practice’.  The Panel recognises that the purpose of sanctions is not to be punitive, but to protect patients and the public interest, although a sanction may have a punitive effect.

 The Panel considered firstly whether to conclude your case and take no further action. However, in the light of the seriousness of your misconduct, it concluded that to take no action on your registration would be wholly insufficient.

The Panel then considered whether it would be sufficient to impose conditions on your registration. It has borne in mind the Indicative Sanctions Guidance which states that any conditions should be appropriate, proportionate, workable and measurable.  The Panel concluded that the imposition of conditions would not be proportionate nor adequately address the serious nature of your misconduct.

The Panel next considered whether it would be appropriate to order the suspension of your registration. The Indicative Sanctions Guidance states that suspension is likely to be appropriate where the Panel is satisfied that the misconduct found is not fundamentally incompatible with continuing to be a registered doctor, that there is no evidence of repetition of behaviour since the incident and where the doctor does not pose a significant risk of repeating the behaviour. It also advises that a doctor needs to show insight.

The Panel is of the view that your patients believe you are acting in their best interests. This trust in you brings many benefits for patients but there is also risk of harm if your view of treatment and diagnosis differs from others and you are not a patient’s sole physician. Even when your approach to the patient is correct there is a chance that you may cause a patient to be dissatisfied with another doctor who is also treating them and discredit their advice. The Panel considers that, although you lack insight into your conduct in this regard, you have the potential to develop insight into this crucial area of medical care. Doctors must either take full responsibility for all aspects of patient care or communicate their changes to a patient’s medicines and treatment to those who have that responsibility.

The Panel wishes to emphasise the importance of maintaining the professional standards set out in Good Medical Practice (2001), and in particular paragraph 45 under the heading Sharing Information with Colleagues, referred to in the determination on impairment.

The Panel has considered carefully the testimonials from professional colleagues, patients and friends. It has noted that your diagnostic skills are held in high regard, that you have helped patients, particularly with symptoms that are difficult to diagnose, and that you are perceived to be a very caring practitioner.

The Panel’s view is that, in this case, erasure is a sanction which could be appropriate. However, having taken into account the mitigation and the fact that this case involved a single patient, albeit on two different occasions, the Panel has exercised its judgement and determined that a period of suspension is a proportionate response and is sufficient to maintain public confidence in the profession, protect the public and uphold proper standards of professional conduct and behaviour.

The Panel has seen no evidence that you have repeated your behaviour since 2004 and it is satisfied your misconduct is not fundamentally incompatible with continuing to be a registered doctor. However, in view of the serious nature of your misconduct, the Panel is of the view that the suspension of your registration for the maximum period of twelve months is appropriate to send out a signal to you, the profession and the public about the unacceptable behaviour found in this case.

The decision that your registration should be suspended means that, unless you exercise your right of appeal, this decision will take effect 28 days from when written notice is deemed to have been served on you. A note explaining your right of appeal will be supplied to you.

Shortly before the end of the period of suspended registration your case will be reviewed by a Fitness to Practise Panel which you will be expected to attend. You will be informed of the date of this hearing in due course.  At this next hearing, the Panel would be assisted by evidence that you have developed full insight into your actions and understand the gravity of your misconduct so that you are not at risk of repeating this behaviour. In addition, it would be helpful for the Panel to receive evidence that you have kept your clinical knowledge up to date. This could include attending accredited refresher courses in clinical medicine. This Panel expects you to assist the next Panel reviewing your case by furnishing the GMC, in advance of that hearing, with the names and addresses of professional colleagues and other persons of standing to whom the GMC may apply for information as to your conduct during the period of suspension.

Having concluded that your name should be suspended from the Register, the Panel is minded to consider whether it would be appropriate to order the immediate suspension of your registration. The Panel will now hear submissions on this point.

Determination on immediate sanction

Dr Viegas: The Interim Order for the suspension of your registration is revoked forthwith.

Having determined that your registration should be suspended for a period of 12 months, the Panel has now considered in accordance with Section 38 (1) of the Medical Act 1983 as amended, whether this direction should take effect immediately.

The Panel has considered the submissions made by Mr Ramasamy on behalf of the General Medical Council (GMC) that an immediate suspension is appropriate in your case. It noted Mr Mansfield did not oppose this on your behalf.

In coming to its decision the Panel has balanced your own interests against the wider public interest. In view of the seriousness with which the Panel views your actions, as already set out, the Panel has decided it is necessary for the protection of the public and in the public interest that your registration be suspended with immediate effect. 

This means that your registration will be suspended from when notice is deemed to be served on you. The substantive direction for suspension, as already announced, will take effect 28 days from today unless you lodge an appeal in the interim. 

If you do appeal, the immediate suspension will remain in force until the substantive direction takes effect.

That concludes this case.

Confirmed

June 2007                                                                                                                  

Chairman

 

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