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chrisjr75 ...at... yahoo ...dot... com
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24/12/06 - Below are the letters referenced on the Home page's entry for this date -
The following is her letter to the expert-witness surgeon (I withhold his name and mine) -
Dear [name withheld]
I refer to my letter of 28 October 2005 and your response of 28 November 2005, received on 1 December 2005. The purpose of this letter is to ask you to assist the GMC with further and more specific material in support of your report about Mr X. Until receipt of such material the GMC is unable to progress this matter.
A little background will help explain the current situation. In summary, you first contacted the GMC by letter of 21 September 2004. It contained a summary of your concerns about Mr Nasser’s treatment of Mr X. On 11 October 2004 Mr X wrote, citing your concerns, to urge the GMC to re-open its dismissal (on 9 October 2002) of his complaint against Mr Nasser. By letter of 27 October 2004 the GMC declined to re-open. On 21 January 2005 Mr X wrote promising a report from you within about three weeks. After several further statements by the GMC maintaining the refusal to re-open, Mr X forwarded to the GMC a copy of your report on 29 July 2005. The front page of the report was dated 7 March 2005 but the last page was signed and dated 28 June 2005. I do not know the reason for this delay or the discrepancy between the dates. On 28 October 2005 I wrote asking you to provide “any evidence” in support of your criticisms of Mr Nasser’s treatment of Mr X. Your letter of 28 November 2005 provides no evidence. Instead, it gives really the same brief summary of your conclusions as was set out in your letter of 21 September 2004. So it does not add to, or substantiate, your report.
Against that background, it may help if I explain what I had in mind when writing to you on 28 October 2005. There are two areas on which I need your help: first, evidence to substantiate your views and, second, further details in relation to your curriculum vitae.
Evidence
Typically, expert reports cite and attach copies of all supporting documentary evidence: for example, copies of articles and/or research papers and/or official statements of applicable professional standards. This is good practice. It is also what the GMC normally receives, and would expect in this instance. Your report criticises Mr Nasser’s treatment of Mr X: see, especially, paragraphs 3.3, 3.4, 4.1 – 4.6, 5.2-5.3 and 6.1 – 6.3. But, quite apart from being rather brief, your report neither refers to nor attaches any of the documents normally annexed: see the above examples of documents that the GMC would expect to see. Accordingly, I should be grateful if you would provide copies of the following:
Any relevant research papers/articles on rhinoplasty procedures from 2000 to date.
Any relevant research papers/articles on patients with Body Dismorphic Disorder (“BDD”) and cosmetic surgery from 2000 to date.
Any guidelines/protocols published by the British Association of Plastic Surgeons, the British Association of Aesthetic and Plastic Surgeons, the British Association of Cosmetic Surgeons, the Royal College of Surgeons or any other relevant UK body on rhinoplasty procedures from 2000 to date.
Any guidelines/protocols from any of those bodies on treating patients with BDD.
It would also be helpful if you could explain, with cross-references, which documents/passages support which of your criticisms. If you prefer to produce another version of your report, with these explanations and cross-references integrated into the text or included in footnotes, please feel free to do so. Could you also please explain whether, in your view, there have been any relevant changes in standards/practice between October 2000 (when Mr Nasser treated Mr X) and now. If so, please describe those changes and provide any supporting material.
I hope that this is not too onerous a task. In my conversations with Mr X's solicitors, Messrs Hodge, Jones and Allen, I was led to believe that you have various pieces of such supporting evidence readily to hand (accumulated by you in your role as Mr X’s expert in his clinical negligence claim).
Finally as regards evidence, could you please also send me copies of the documents listed in paragraph 1.2 of your report so that I can see what was before you when you wrote your report. The GMC is happy to pay your reasonable copying charges.
Once it has all this material the GMC will be in a position to assess the weight of your report.
Curriculum vitae
A copy of your curriculum vitae is helpfully attached to your report. But it raises four issues:
It appears that your “present appointment” as an examiner in surgery came to an end this year. Is that correct?
Your publications (books, chapters, papers and presentations), expert witness experience and teaching all seem to have been undertaken before 2000. Is that correct?
I also note that since May 1999 you have been an “independent practitioner in plastic and reconstructive surgery”. Do you still practise in that field? If not, when did you stop? If so, in what post and where? Could you please give a brief description of your practice since May 1999 and your current practice.
Whether or not you are still practising, please describe the steps you take to keep up to date with developments in your field.
Again, without this information it is difficult to assess the force of your report.
To avoid further delay, I should be very grateful if you could please respond to me at the address above promptly: i.e. within 21 days of the date of this letter.
Thank you very much for your assistance in this matter.
Yours sincerely,
Janet Gray
Solicitor
Direct Dial: 0161 923 6467
Fax: 0161 923 6490
E-mail: jgray@gmc-uk.org
Copy to: Mr X
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Her letter to me -
Dear Mr X,
I refer to my letter of 28 October 2005 and our recent telephone conversations. The purpose of this letter is to explain the stage reached by the GMC, vis-à-vis Mr [name withheld] in particular, in deciding whether to maintain its previous decisions not to re-open your complaint against Mr Nasser.
The background, in very brief summary, is that on 9 October 2000 Mr Nasser performed a rhinoplasty on you. On 8 April 2002 you complained to the GMC about that treatment and made an allied complaint against Dr Veale (who referred you nto Mr Nasser). On 9 October 2002 both complaints were dismissed by the GMC’s screeners. By letter of 21 September 2004 the GMC was contacted by Mr [name withheld], your expert in your clinical negligence claim against Mr Nasser which the GMC understands was compromised in 2004. That letter contained a summary of Mr [name withheld]'s concerns about Mr Nasser’s treatment of you. On 11 October 2004 you wrote citing Mr [name withheld]'s concerns and (by implication but not explicitly) urging the GMC to re-open its dismissal of your complaint against Mr Nasser but not Dr Veale. By letter of 27 October 2004 the GMC declined to re-open. On 21 January 2005 you wrote promising a report from Mr [name withheld] within about three weeks. After several further statements by the GMC (on 19 November 2005, 2 March 2005 and 8 April 2005) maintaining the refusal to re-open, you forwarded to the GMC a copy of Mr [name withheld]’s report on 29 July 2005. The front page of the report was dated 7 March 2005 but the last page was signed and dated 28 June 2005. I do not know the reason for this delay or the discrepancy between the dates. On 23 August 2005 and 16 September 2005 the GMC again maintained its refusal to re-open your complaint against Mr Nasser. On 27 October 2005 I wrote to your solicitors, Messrs Hodge Jones and Allen stating that, without prejudice to the GMC’s position that any judicial review challenge was out of time, the GMC would consider (by reference to Mr [name withheld]’s report) whether it should continue to maintain its refusal to re-open your complaint against Mr Nasser. Accordingly, on 28 October 2005 I wrote to Mr [name withheld] asking him to provide “any evidence” in support of his criticisms of Mr Nasser’s treatment. Unfortunately, he took one month to reply and, when he did, his letter of 28 November 2005 provided no such evidence. Instead, it gave really the same brief summary of his conclusions as was set out in his letter of 21 September 2004. So it did not add to, or substantiate, his report.
Against that background, I have today written to Mr [name withheld] asking him to provide further information to support his report. I enclose a copy for your information. I think it is self-explanatory. I appreciate your view that his report alone should be sufficient. But, for the reasons explained in my enclosed letter, the GMC does not agree. It is simply not in a position to make a properly informed assessment on the information currently available. Mr [name withheld]’s report does not contain the material routinely expected of such a document. Good practice requires that experts support their statements and opinions with documentary evidence in the form of reports or research studies/articles. We would also expect to be referred to and provided with copies of the applicable guidelines/protocols formulated by the relevant specialist bodies: for example, in this case, the Royal College of Surgeons and/or the British Association of Plastic Surgeons. Your solicitors led me to believe that Mr [name withheld] already had this type of information readily available (accumulated in his role as your expert in your clinical negligence claim). Incidentally, I note that your clinical negligence claim was compromised out of court in 2004. So I presume that Mr [name withheld]’s evidence was not tested in that forum.
I shall revert to you once Mr [name withheld]’s substantive response is received and considered (I have asked him to provide it within 21 days). Until then, the GMC is simply not in a position properly assess Mr [name withheld]’s report and to take this matter forward. I know that you will find this frustrating. But the GMC is in Mr [name withheld]’s hands. I note also that there has been considerable delay on your part. The complaint was made 18 months after the events in question. Mr [name withheld]’s letter was received almost two years after the dismissal of the complaint. It then took a further 10 months for his report to reach the GMC.
...Please be reassured that I shall keep you informed of progress without the need for you to press me.
Yours sincerely,
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30/12/05 - Below is the email referenced on the Home page's entry for this date -
Dear Ms Ali,
You will no doubt by now have received a copy of a letter from Janet Gray of the GMC to me dated 22 December 2005, enclosing a further letter from her to Mr [name withheld] of the same date. The purpose of this email is to ask whether, in the light of those letters, you now consider it appropriate to become involved in the case again and would be able to obtain public funding to do so.
The stance taken by the GMC in Ms Gray’s letter is, in essence, that it is “not in a position” to take its investigation of Mr Nasser any further unless Mr [name withheld] provides all sorts of additional information to support the views expressed in his report. To provide the material which Ms Gray claims she needs would inevitably involve Mr [name withheld] in a considerable amount of additional work (indeed Ms Gray at one point suggests that Mr [name withheld] should provide a new, revised report). My brother has not yet had an opportunity to speak to Mr [name withheld] about this, but we anticipate that he will be reluctant to carry out all this additional work free of charge, and we are not in a position to fund him to do it. Perhaps more importantly, however, I do not see on what basis the GMC can say that it is entitled to receive this information before it will investigate the complaint against Mr Nasser – or, at any rate, that it is entitled to receive the information at Mr [name withheld]’s or my family’s expense. I cannot believe that there is any obligation at all on a member of the public who raises a concern about a doctor’s fitness to practise to provide an expert’s report to back up the complaint. On the contrary, I would have thought that once a complaint has been raised which, on the face of it, appears to be a serious complaint meriting further investigation, then the GMC must act (including commissioning any reports which it considers necessary). Surely we have already done far more than is usual by providing a report from an acknowledged, independent expert in the relevant field. It seems to me that Ms Gray’s recent letters are simply setting up further obstructions to the investigation which the GMC should now be undertaking – and her attitude to Mr [name withheld] appears, in places, to be little short of harassment (see, for example, the rather petty comments on his CV).
As I see it, therefore, we are back at square one: the GMC has effectively rejected Mr [name withheld]’s report in its current form, and, unless it can be persuaded to see why it is not appropriate for it to be asking for all this additional information from us/Mr [name withheld], we will need to issue judicial review proceedings in order to get the GMC to act. My brother and I were going to write to Ms Gray, making these points, but it seemed sensible to contact you first since, if you are able to become involved again, no doubt you would prefer to write to her yourself, without the waters being muddied by us.
I would be grateful if you would let me know your views as soon as possible since, if you are not able to become involved again, it is important that I should respond to Ms Gray’s letters quickly. I would also be grateful if you would let me know whether you have any comments on the reference she makes to a conversation she says she had with you in justifying her requests for further information.
With kind regards
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P.S. For your information, I summarise below the main points I would make in a reply to Ms Gray if you consider that I, rather than you, should write to her:-
(1) The GMC is not entitled to ask for this information. There is no obligation on a complainant to provide a report at all. The independent report from an acknowledged expert in the field goes far further than anything needed by the GMC to appreciate that a serious complaint has been raised that requires further investigation. It is then for the GMC to carry out whatever investigations it considers necessary, including commissioning any relevant reports. The suggestion that the GMC is “in the hands” of Mr [name withheld] is wrong, and is simply an abdication of responsibility. It cannot possibly be the case that before the GMC acts, it is entitled to require the complainant to provide an extremely detailed expert’s report citing all relevant medical literature and professional guidelines – all at the complainant’s or the expert’s expense.
(2) It appears that Gray believes it to be significant that, because the clinical negligence claim was settled in 2004, [name withheld]’s evidence in that action was not tested in cross-examination. It is, of course, true that the action was settled before trial – it is also wholly irrelevant. Surely it is not being said that the opinion of an FRCS, with acknowledged expertise in the relevant field and particular knowledge of this case (whose knowledge was gained in his role as expert witness), is only of interest to the GMC if it has been approved by a Court.
(3) Detailed responses to the various allegations concerning delay & matters relating to the chronology set out in Gray’s letter:-
a. Initial 18 months. Unsurprisingly, it took time for me to establish what Nasser had done. Involved numerous consultations with rhinoplasty surgeons in the US and UK – discovering in the process that the procedure adopted by Nasser had no clinical purpose.
b. [name withheld]'s letter. The clinical negligence case commenced in the spring of 2002 and was not compromised until shortly before [name withheld] sent his letter in September 2004. It would obviously have been inappropriate for [name withheld], whilst an expert witness in a clinical negligence case, to have written to the GMC.
c. It is suggested that in my letter of 11 October 2004 I, “by implication but not explicitly”, urged the GMC to re-open its investigation. It is not clear what point is being made, but since the statement is obviously disingenuous it ought to be corrected. As Gray is aware, my letter referred in its final paragraph to an enclosed letter from my brother and asked the GMC to copy all correspondence to him, explaining that he had my authority to deal with the GMC in relation to this matter. The enclosed letter from my brother clearly and expressly stated that we wished the GMC to investigate Nasser’s fitness to practise – and to advise if there were any other avenues of redress open to me. The GMC ignored my brother’s letter and has never responded to it or copied any correspondence to him.
d. [name withheld]’s report. This certainly took longer than I expected or would have wanted. It appears that Mr [name withheld] had an exceptionally busy schedule at that time and was out of the country for substantial periods. This delay was a matter of some concern to me. I therefore wrote to the GMC on 4th April explaining that there had been a delay. I received a letter in response from Andy Laing of the Fitness to Practise Directorate on 8th April 2005 making it clear that the GMC would nevertheless consider the report once it had been prepared and taking no point at all about delay. In those circumstances it is not now open to the GMC to complain about delay in the preparation of the report. Nevertheless, it is plainly silly to suggest that it took 10 months for the report to be prepared. It was commissioned in late January (at about the time that the GMC was informed by letter dated 21 January that it would be commissioned) and delivered in July. The entirely trivial discrepancy in dates between the front sheet and the signature page is (obviously) explained by the fact that the date on the front sheet is (at says) the date of the first draft of the report which was left on in error.
e. Delay post-July 2005. The most significant delay in this period is the GMC’s own delay between July and 28 October 2005 in raising any suggestion at all that it would be necessary for [name withheld] to provide further information to supplement his already entirely adequate report.
(4) It is a matter of considerable concern that the GMC should be devoting so much of its energy to establishing obstacles to its investigation of Mr Nasser’s fitness to practise, rather than getting on with the investigation. Only acted at all when threatened with judicial review proceedings. But even then only to raise entirely illegitimate reasons for delaying investigation further. Any fair-minded observer would appreciate that attitude to [name withheld] appears to be to harass him rather than engage constructively with the detailed information he has previously provided.
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18/8/06 - Copied below are Mr John Devine's report and my response to it (referenced on the Home page's entry for this date) -
Mr Devine's report: http://www.flickr.com/photos/bddstory/
My response to Mr Devine's report :
Dear Ms Gray,
I set out below my comments on Mr Devine’s report dated 25 July 2006.
Before commenting in detail on the report, I should make a couple of general observations.
First, I reserve my position as to whether it is appropriate for the GMC to have commissioned the report at this stage at all. You have chosen (without any prior warning or explaining your reasons for the decision) to instruct Mr Devine to comment on many of the matters which will be the subject of the substantive investigation, once the GMC finally decides to conduct one, without the benefit of evidence which would become available through that investigation and, in particular, without him meeting or examining me. By contrast, Mr [name withheld] saw me in person, as did the independent expert instructed on behalf of Mr Nasser’s insurers for the purposes of my successful medical negligence claim against him. You already have a clear and unequivocal account of Mr [name withheld]’s independent, expert views on Mr Nasser’s treatment of me. The independent expert instructed on behalf of Mr Nasser’s insurers was also outraged by his treatment of me (and his refusal to support Mr Nasser is evident from the fact that Mr Nasser’s insurers considered it necessary to settle the claim for a substantial sum, rather than expose Mr Nasser to a trial).
Second, I question why Mr Devine was thought to be the right expert. Despite giving a detailed description of his career to-date (including courses attended, qualifications and experience etc.), there is no reference in Mr Devine’s CV to any training, let alone any practical experience, in giving evidence as an expert witness. In this respect, too, Mr Devine’s report contrasts unfavourably with Mr [name withheld]’s: [name withheld] has considerable experience of meeting the particular demands of presenting independent expert evidence to tribunals. As described below, this apparent difference in experience is particularly glaring at the point when Mr Devine addresses the central issue in my complaint about Mr Nasser, namely whether the incisions he made along, and extending from, the supra alar crease on both sides of the nose had any proper or recognised medical or cosmetic purpose.
I comment below on individual sections of Mr Devine’s report, using the same subject divisions as he uses.
The decision to operate (sections 4-5)
Mr Devine’s clear conclusion is that, in the circumstances in which I presented to Mr Nasser, he should not have operated at all (let alone operated using incisions in and around the supra alar creases), and the decision to do so was “clearly wrong” (paragraphs 5.1, 5.4 and 5.5).
That being so, the matters referred to by Mr Devine in paragraphs 4.4, 5.2 and 5.3 of the report are irrelevant, but in any event: (1) it is unclear whether Mr Devine considers that Mr Nasser falls within the category of “highly expert rhinoplasty surgeons” or not (but it is plain that he does not: see [name withheld]’s report); (2) if Mr Devine considers that I had a ‘facial deformity’ prior to the operation (again, this is not clear from his report – he simply says that the nasal tip “appears to be slightly bulbous pre-operatively”) it was at most ‘slight’; (3) it is absolutely plain that Mr Nasser did not allow himself to be guided by his specialist psychiatric colleague at all – on the contrary, he embarked on a procedure which ran entirely contrary to views of Dr Veale.
Mr Devine considers that three questions should have been asked by a surgeon considering whether to operate. Unhelpfully, he does not attempt to address what the answers to those questions should have been to a surgeon in Mr Nasser’s position. It is clear, however, that the answers should have been: (1) There was absolutely no chance of the patient being satisfied if the procedure was carried out: see Dr Veale’s clearly expressed view in the referral letter that “no amount of cosmetic surgery is going to change his internal image”. (2) There was a very considerable risk that the procedure could make the patient worse off: the surgical plan involved inflicting highly visible, obviously surgical, scarring on a prominent part of the face of a BDD sufferer. (3) Had Mr Nasser paid any heed to him, Dr Veale plainly considered that the patient’s psychiatric condition could improve following therapy: see the treatment plan he recommended on 14 September 2000 which included cognitive behaviour therapy.
Given that everything pointed away from operating, and in the unequivocal view of both Mr Devine and Mr [name withheld], Mr Nasser should not have operated, the question (which cries out for thorough investigation by the GMC) is why Mr Nasser nevertheless went ahead and operated – and, in particular, operated using a procedure (intentionally scarring both sides of the nose) which neither independent expert has found any precedent for and which Mr [name withheld] considers was without medical, cosmetic or functional purpose whatever – see below.
Quality of pre-operative care and consultation (sections 6-7)
In light of his conclusion that Mr Nasser should not have operated at all, Mr Devine’s view that “overall” he can find no fault in the quality of pre-operative care and consultation (see paragraph 7.1) is singularly bizarre. That care and consultation included taking no account whatever of Dr Veale’s views, and taking the decision to operate when he plainly should not have done so.
Mr Devine places particular emphasis on Mr Nasser’s use of a face mask as a consultative tool (paragraph 6.3). However, use of this tool could only be considered to represent an acceptable standard of care and consultation if the information gleaned from its use is taken account of. In my case, Mr Nasser learned that I had unrealistic expectations of surgery which were impossible to achieve. Yet he went ahead and operated anyway, using a method which was bound to exacerbate my problems.
In paragraph 6.2, Mr Devine describes Mr Nasser’s note-taking as “meticulous”. This description is directly contradicted in paragraph 12.1 of the report where he states that he is unable to establish from the clinical record what Mr Nasser’s reasons were for carrying out “additional external incisions”: that is, the external incisions in and around the supra alar crease which are at the heart of the present complaint.
More generally, Mr Devine’s observations in this section of his report typify the dangers of asking him to comment without having the full evidence available to him. There are a number of matters which Mr Devine has not taken into account and which are relevant to the question of Mr Nasser’s pre-operative care and consultation and to the investigation of Mr Nasser generally:- Mr Nasser’s notes contain no indication that he gave any consideration to the effects of scarring (particularly on a BDD sufferer); or of the relevance of the fact that I smoked; or of scar-monitoring after the operation; or of possible ways to treat the scars post-operatively. Nowhere in Mr Nasser’s notes is there any consideration of the reasons for, or potential effects of, making incisions in and leaving scarring on the sides of my nose. This precisely reflects the lack of care and consultation which went into the decision to make these incisions: Mr Nasser did not tell me of his intention to make the incisions until the meeting before surgery, and even then he did not explain the purpose of the incisions or even where they would be placed – he simply told me that they would enable him to achieve the effect I wished him to achieve (which I now know was simply untrue).
In paragraphs 3.4 and 3.5 of his report, Mr [name withheld] addresses the statement in Mr Nasser’s letter to Dr Veale of 4 October 2000 that “volume reduction can only be achieved by placing external incisions along the shadow lines, which demarcate the anatomical sub units of the nose”. As Mr [name withheld] points out, this was untrue and misleading. Mr Devine does not take this letter, and its inaccuracy, into account at all – although it is obviously relevant to a consideration of the level of pre-operative care and consultation which I received from Mr Nasser.
The operation (sections 8-9)
I of course accept, as Mr Devine states (see paragraph 9.1), that it is an accepted technique to place external incisions at the junctions of the alar base with the cheek and excise excess skin at that point. The important point is that, with this technique, the resulting scars are hidden at the junction of the cheeks and nose.
The incisions which require investigation are those which Mr Nasser made in, and extending from, the supra alar crease (although Mr Devine describes them as incisions in the supra alar crease, they in fact extended far further than that – something he would be aware of if he had had the opportunity to examine me). Mr [name withheld] addresses these incisions in paragraphs 4.1 to 4.6 (amongst others) of his report. He condemns their use by Mr Nasser unequivocally, making the points: (1) that the incisions were wholly inappropriate, had no medical, cosmetic or functional purpose whatever, and would only result in unacceptable, distinctive and unnecessary scarring; (2) that no reasonable body of plastic, reconstructive/cosmetic surgeons would support their use, which is contrary to any normal, acceptable practice; (3) that the inevitably resulting scars would be unacceptable to any patient, but particularly one with BDD. He concludes that an investigation by the GMC is warranted: see paragraphs 4.3 and 4.6.
By contrast, Mr Devine’s attempt to address these incisions is wholly inadequate. He records that use of such skin incisions “is not a technique I am aware of” and that their use “does seem rather strange”. Although this at least reveals that he is unable to endorse Mr Nasser’s use of the incisions, it is also an unacceptable evasion of his responsibility as an independent expert to grasp the central issue of whether the incisions had any proper or recognised medical or cosmetic purpose. The same problem arises in paragraph 12.1 where, rather than addressing Mr Nasser’s use of these incisions, he merely notes that the reasons for their use “are not clear from the documents enclosed”. This is an issue about the legitimacy of Mr Nasser’s use of the incisions (both in my case and in any other cases in which he has used them) and it needs to be confronted head-on, as Mr [name withheld] has done.
Mr Devine compounds this fault by going on to speculate: “I can only assume that Mr Nasser … has learned this technique … and has used [it] successfully before”. As any experienced independent expert would know, it is wholly inappropriate for Mr Devine to make such an assumption, thereby supplying, by way of conjecture, his own assumed ‘facts’ in order to make sense of Mr Nasser’s conduct. This is obviously unacceptable: it is precisely the absence of any explanation for the use of the incisions, combined with the facts that neither Mr [name withheld] nor Mr Devine have been able to find any support for them in the relevant literature, or are aware of any other precedent for their use, or are able to indicate what clinical or cosmetic purpose they could possible serve, which makes an investigation by the GMC necessary.
Mr Devine then goes on to consider Mr Nasser’s decision to excise para-glabellar skin. As Mr Devine notes (paragraph 9.2), Mr Nasser’s use of this procedure was also “very strange”, and is not included in the consent form which he and I signed. However, Mr Devine takes it on himself, again, to elaborate on the information known to him in order to provide an explanation for Mr Nasser’s conduct. In paragraph 9.2(c) he concludes that “having reviewed the photographs, I feel that some discussion with the patient [about the excision of para-glabellar skin] has taken place”. Again (and for the same reasons as above), it is entirely improper of Mr Devine to make this assumption. This is another matter for the GMC’s substantive investigation, rather than conjecture on Mr Devine’s part. Precisely the same fault arises again in paragraph 12.1 when Mr Devine returns to the photographs. The truth is that the photographs Mr Devine refers to do not indicate any consultation with me at all: the line markings on my nose and between my eyes were put on by Mr Nasser and photographed just minutes before the operation. No explanation was made – I simply assumed that Mr Nasser was working something out in preparation for the operation.
Post operative care (sections 10-11)
As Mr [name withheld] points out (see paragraph 5.1 of his report) there is little in Mr Nasser’s notes about the clinical aspects of his post-operative care. Although Mr Devine does not comment on it, the post-operative diagram which Mr Nasser produced of the scars is different from the pattern of the actual scars he inflicted (the pattern is inverted), which again suggests that there was no legitimate clinical method underlying them. The post-operative care should have included careful monitoring, advice and treatment of the scars which certainly was not provided. The few steroid injections I received were insufficient to cope with such trauma to the skin. I have been informed by a dermatologist that dermabrasion would be largely ineffective and would be very traumatic in healing terms. As a consequence of the inadequacies of Mr Nasser’s post-operative care, I have had to consult other specialists at a considerable cost. The scars inflicted by Mr Nasser have taken a lot of money and several years to achieve even some improvement, while carrying significant social stigma which I will be dealing with for life.
As to Mr Nasser’s suggestion that the para-glabellar excisions he performed (without my consent) could be reversed by a skin graft, both Mr [name withheld] (paragraphs 5.2 to 5.3) and Mr Devine (paragraph 10.2) are agreed that this would not have worked. It was therefore plainly wrong, and not merely “not … recommended” as Mr Devine puts it. As Mr [name withheld] points out, the fact that Mr Nasser could make such a suggestion, which is so divergent from any acceptable practice, again calls into question Mr Nasser’s experience and practices.
Mr Devine refers to my post-operative correspondence with Mr Nasser as “very abusive”. This ignores what I was having to deal with as a consequence of the scars inflicted on me by Mr Nasser. In fact in the main I was respectful for some considerable time, until consultations with a number of leading rhinoplasty surgeons in the US made it clear that I should not have suffered the scars he had left me with. Whilst I am not proud of at times allowing my extreme shock at what he had done to me to boil over in correspondence with him, it is to my mind unsurprising that this should have happened in circumstances where Mr Nasser had inflicted a monumental abuse on me. [However, I reject the description of my correspondence as abusive and consider it a perverse reversal of what ought to be the description for Nasser's behaviour. My correspondence to Nasser simply expressed my disgust at what I suspected him of doing, that is all.]
Was Mr Nasser’s treatment in accordance with accepted standards and practice? (section 12)
This section of Mr Devine’s report is largely a restatement of earlier passages of the report which I have dealt with above and will not repeat here.
The GMC has now received reports from two independent experts. Mr [name withheld]’s report is clear and unequivocal in its criticisms of Mr Nasser and presents a clear case for the GMC to investigate Mr Nasser’s conduct. As identified above, Mr Devine’s report is seriously deficient in a number of important respects. Nevertheless, even with these deficiencies it too contains some damning criticism of Mr Nasser. Amongst other things, Mr Devine concludes (1) that Mr Nasser was clearly wrong to have operated on me at all; (2) that the external incisions on and about the supra alar creases of the nose are “rather strange”, have no precedent in his experience, are not justifiable by reference to Mr Nasser’s notes, and are contrary to the imperative to “to minimise the amount of external incisions to an absolute minimum” in the case of a patient with BDD; and (3) that the para-glabellar excisions were “very strange indeed” and were not covered by the consent form.
Whether taken independently or in combination, these two independent reports make it clear that the matters which they address cry out for a thorough and careful investigation by the GMC, and I would urge Professor Catto to put that investigation in motion without any further delay.
Yours sincerely
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