Siddiqi v Medical Council of Ireland [2019] IEHC 686 (31 May 2019)

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JUDGMENT of Ms. Justice Creedon delivered on Friday the 31st of May, 2019:

1. This matter came before the High Court by way of an application by the appellant for

cancellation of the decision of the respondent (“the Medical Council”) dated the 23rd

March, 2016, to attach certain conditions to the appellant’s ongoing registration following

a finding of poor professional performance in respect of certain matters by the Fitness to

2. The case was heard over thirteen days between the 9th November, 2017, and the 22nd

3. The appellant, Dawar Siddiqi, worked as a locum consultant radiologist at Bantry General

Hospital from May to September, 2013. On the 5th December, 2014, J.A. McNamara, CEO

of Cork University Hospital, expressed concern over the appellant’s fitness to practice

primarily in relation to his reporting on CT scans. Consequently, the respondent made a

complaint to its Preliminary Proceedings Committee (“the PPC”) which, following

investigation, referred the complaint to its Fitness to Practise Committee (“the FPC”) on

4. Following a five-day hearing which took place from the 25th November to the 1st

December, 2015, the FPC concluded in its report on the 9th December, 2015, that

Allegation 1 against the appellant was proven in relation to eleven of the twenty-two

cases identified by Dr. Peter Ellis in his reports of the 1st July, 2015, and 8th October,

2015 (two of the cases were withdrawn on Day 3 of the hearing), and that the allegation

as proven amounted to poor professional performance. Whilst the FPC noted that the

circumstances that Dr. Siddiqi, the appellant, found himself in when he commenced work

in Bantry General Hospital were far from satisfactory, they highlighted that he had been

recruited on the basis of his competency and experience in CT on the basis of both his

curriculum vitae and his interview when, on his (Dr. Siddiqi’s) evidence, this was not the

5. Consequently, pursuant to s. 71(a) of the Medical Practitioner’s Act 2007 (“the Act”), the

Irish Medical Council, the respondent in this case, made a sanction decision at a sanction

meeting on the 23rd March, 2016. They advised the appellant that they would be

attaching certain conditions to his ongoing registration. The Medical Council attached

seven conditions to the appellant’s name remaining on the Register of Medical

Practitioners following the finding of poor professional performance in respect of certain

matters by the Fitness to Practise Committee of the Medical Council.

6. The following day (the 24th March, 2016), these conditions were communicated by letter

to the appellant, Dr. Siddiqi, under the provisions of the Medical Practitioner’s Act 2007.

Dr. Siddiqi was advised in relation to his professional performance. To “advise” is one of

the sanctions under s. 71(a) of the Medical Practitioner’s Act 2007. However, that is not

the subject of this appeal. It is the conditions that the Medical Council imposed in relation

to the continuation of Dr. Siddiqi’s name on the register maintained by the Council

pursuant to s. 7(c) of the Medical Practitioner’s Act, 2007, that are the subject of this

appeal. They were outlined in the letter to the appellant Dr. Siddiqi as follows: -

“(1) You must work with a nominated person who is acceptable to the Medical Council to

formulate a professional development plan specifically designed to address the

deficiencies in the following areas of your practice; (a) CT reporting.

(2) You must work with a nominated person who is acceptable to the Medical Council to

formulate a professional development plan to the Medical Council within three

(a) You must meet with your nominated person who is acceptable to the Medical

Council on a regular basis to discuss your progress towards achieving the

aims set out in your professional development plan. The frequency of your

meetings is to be agreed by your nominated person who is acceptable to the

Medical Council, supplying reports to the Medical Council about your progress

(b) You must agree to your nominated person who is acceptable to the Medical

Council supplying reports to the Medical Council about your progress when

the conditions attached to the retention of your name in the register and

agree to any such visit or inspection and/or report deemed appropriate by

(3) You must be responsible for and discharge any and all costs involved in the

implementation and compliance with the above mentioned attached to the retention

(4) That these conditions attached to the retention of your name on the register remain

7. While the Medical Council also advised the appellant, Dr. Siddiqi, in relation to his

practise, it is accepted by the appellant that as far as this sanction is concerned, it cannot

be part of the reliefs he seeks in these proceedings by reason of the provisions of the

Medical Practitioner’s Act, 2007, ss. 71(a), 74 and 75. This appeal, therefore, is confined

8. This case was heard over thirteen days between the 9th November, 2017, and the 22nd

9. Ms Orla Hannick Lennon, radiographer at Bantry Hospital, outlined to the Court that a

radiologist is a medical doctor who is specialised in radiology for the purposes of

interpreting images and diagnosing from those images. She said that 80% of her time is

spent CT imaging and 20% time is spent plain film x- raying. She told the Court that she

had been working in Bantry General Hospital since 2006. She said that in the Radiology

Department there are two X - ray rooms and that one of these rooms doubles as a

fluoroscopy room. She said that there was one ultrasound room and one CT scanner. In

terms of staff, she told the Court that the allocation was 8.6 whole time equivalent staff

however the actual number would always fluctuate up and down from this allocated figure

. The staff was composed of one Radiology Services Manager who had overall

responsibility for managing the unit, one Clinical Specialist Radiographer in CT scanning

who takes overall responsibility for the CT. She said that at the time of this hearing this

post was shared between herself and Aida Collins. There was also one Clinical Specialist

Radiographer Post in ultrasound, one Senior Radiographer post and 3 basic grade posts.

10. She was referred to two documents while giving evidence. The first was a note of a

meeting she had with Ms Jackie Daly. She said that she had phoned Ms Daly with

concerns that she had about the CT service and how things were going within the X- ray

department. She said that Dr. Siddiqi had asked her to sit with him and review CT scans

on a number of occasions. She said in particular he would ask her to comment on CT

pulmonary angiogram examinations and CT carotid angiograms. She said that she felt

that despite what he said at the time, he had never done this as a means of furthering

her own education as he would never pass comment on or critique any of her

observations on what he was asking her to look at. He also never discussed with her any

11. She said that subsequently, after reviewing some of his reports she had noticed that

comments she had made to Dr Siddiqi were appearing “verbatim” on his reports and this

had caused her concern as she was a radiographer not a radiologist. She said that as a

radiographer she was not trained in either interpretation or diagnosis. She felt that Dr

Siddiqi was doing this because he was unsure of himself. She reported this back to her

RSM (Roisin O’Carroll) and told her she was not going to sit in on these sessions anymore

and subsequently began to find excuses to avoid the sessions with Dr Siddiqi.

12. This witness was referred to a second memo which detailed the concerns that she had

raised with Ms O’ Carroll, her RSM. This detailed her sitting in on sessions with Dr Siddiqi

but also outlined that he had complained to her about his workload and how he wanted

her to reduce his CT workload. She said that she had explained to him that she could not

reduce the workload as the only numbers she had control over were outpatients. She

informed him that the only way she could help was to try to reduce the numbers of

13. She said further that she had to assist Dr Siddiqi in using the internet. She gave her

opinion that using an internet search engine was new to him. She said the internet is

something that in recent years, radiologists would commonly use when reviewing images.

She said that most radiologists would now use radiology internet sites to assist them with

findings and diagnosis. She said that when reviewing images for diagnosis Dr Siddiqi

would use the hard copy versions as opposed to using digital monitors.

14. Under cross examination Ms Hannick Lennon outlined the difference between the PACS

system (picture archive communication system) and the system that was in place in

Bantry. She said that amongst her concerns was the fact that scans were being left

unreported, sometimes by up to two weeks. She said that when the PACS system went

live staff received training from Adam Davis, the PACS clinical specialist from CUH. She

rejected the assertion put to her that when she was invited to sit with Dr Siddiqi her

assistance was being sought with the technology and not with the diagnosis and she

highlighted that during those meetings, it was only ever hard copies of scans that were

reviewed therefore technical assistance was not needed. She said that she would also

have discussed her concerns with her colleague Aida Collins. She was not in a position to

15. Aida Collins gave evidence that she was also a radiologist at Bantry Hospital since 2006

with responsibility for the management of the CT department. She said that she too had

raised concerns and was often asked by Dr Siddiqi to sit in on reporting sessions with

him. She said that he would ask her for her opinion on the images and that she was

concerned that what she expressed would form part of his final report. She said that

when she communicated this concern to Dr Siddiqi he assured her the exercise was

educational and something she would benefit from. She said she never got the impression

her assistance was being asked for in order to use the technology and that Dr. Siddiqi’s

16. Dr Julie McCarthy gave evidence that she is a full time Cytopathologist in CUH and part-

time National Clinical Lead with the Clinical Director Programme in Ireland. She also holds

a PhD in cellular Immunology from Trinity College Dublin, she is a medical practitioner

and a fellow of the Faculty of Pathology in Ireland. She outlined further that she is a

Fellow of RCPI Ireland, holds a diploma in Cytopathology and a diploma in Quality and

Leadership in Healthcare. She was the Clinical Director in diagnostics for CUH from Feb

2012 to December 2014. She confirmed to the Court that she had no direct dealings with

Dr. Siddiqi. She said that the issue of radiology reporting came to her attention as part of

her job profile. She said that she was contacted by Jackie Daly who was general manager

of Bantry Hospital asking for guidance regarding concerns which Ms Daly had in respect of

17. In August 2013 there was an executive board meeting and subsequent to this she was

asked to arrange an audit of the appellant’s work. In this regard there were a number of

e-mails between her and Ms Daly which were opened to the court. These emails were to

try to establish whether or not the complaints and the concerns that were raised were

valid. She explained that as a consultant cytopathologist she was not directly involved in

the Radiology Department but as a part of her brief as Clinical Director she approached

the Chair of the Division of Radiology in order to ascertain whether their department

18. She said that during this time Ms Daly was becoming more cognisant that there were

potential inaccuracies in reporting of radiology imaging. She confirmed that Dr Siddiqi was

the only radiologist working on site in Bantry at the time. She said that ultimately the

Faculty of Radiology commissioned an audit and that was externally conducted by two

independent reviewers. The chair of the Faculty of Radiology reported back the findings of

that audit to herself, Ms Jackie Daly and the Local Area Management Team. She named

the two independent reviewers as being Professor Peter Kelly and Dr. Ugobi. She

informed the Court that she did not have anything directly to do with selection process in

relation to either the plain films, the ultrasounds or the scans that were used for the

19. Under cross examination, she confirmed that the Clinical Director is typically a consultant

of senior years who takes a role within the HSE and whose job description is to ensure as

much clinical excellence as is possible within the resourcing constraints in the HSE. She

said that her brief included all forms of pathology radiology, endoscopy and outpatient

cancer services at the time. She confirmed that her position was a local designation as

distinct from a national designation and that she is now in a national role. She explained

to the court how Bantry, Mallow and CUH hospitals form part of the South / Southwest

Hospital Group. She confirmed that the audit eventually took place from August 2013 to

20. Ms Deirdre Doolan a clerical officer in the X-Ray department at Bantry General Hospital

gave evidence about how the various films were selected for the audit. She confirmed to

the court that she had no medical training. She said she selected random films with no

set criteria. She was asked to compile a number of CT’s plain films. She said there was a

total of 640 that had to be audited - this was broken down into 62 CT, 44 ultrasounds and

over 500 plain film. She explained how the reports were compiled, that they were

dictated onto a tape and that she would have transcribed the reports onto the radiology

information system. At that point the report would have been printed and brought to Dr

Siddiqi to check and if he was satisfied he would sign off and verify the report.

21. Ms Roisin O’Carroll, a radiology services manager in Bantry General Hospital gave

evidence. She outlined to the Court that she was the operational manager and line

manager to the radiographers. Furthermore, she would have been in charge of the day to

day running of the Radiology department. She explained to the Court that this was a

small hospital and therefore the radiology department was also small scale. She said that

the department was equipped with 2 plain X-ray rooms, it had one CT scanner and one

ultrasound machine. She said that approximately 25,000 patients per annum would

present at the department across the three modalities (i.e. general radiography,

ultrasound and CT). With regard to management structure and personnel she told the

Court that she worked directly under the Hospital Manager as the Radiography Services

Manager. She said that under that there are two Clinical specialist posts, one of which is

in CT (this job was shared by two people) and the other in ultrasound (this job was also

shared by two people). There was also a senior radiographer, a radiation safety officer,

3. 6 basic rate radiographers and one consultant radiologist. She informed the court that

Ms Jackie Daly was her immediate superior and that she herself was manager to Ms Orla

22. She said that as the department was small she would have worked closely with Dr Siddiqi

on a daily basis as he was the sole radiologist. She said that she would have first met Dr

Siddiqi on the 9th of May 2013. He discussed the backlog in films with her on their first

encounter. She said that he raised with her that there were films from before his start

date that had not yet been reported on. She agreed with him that this cohort of films

would not be his responsibility and that they would be outsourced for reporting.

23. She said that most days that she was working with Dr Siddiqi he would seek her out and

raise concerns. She told the Court that some of his concerns were not within the role of a

radiologist. She said that for example, he raised HR issues such as wanting to manage the

annual leave of the radiographers and the layout and design of the department. He also

raised issues about his workload and the manner in which work was brought to him. She

said that during this time and at his request, the office was renovated so that working

24. She said that his main concern was that he felt his workload was quite heavy. She said

that she reported this to Jackie Daly and they explored ways to manage his plain film

workload. She said she knew that he was struggling because of the delays in reports

coming through. She said that he was not meeting his targets regarding turnover times of

reports. She also stated that during Dr Siddiqi’s five and a half months, they arranged to

outsource approximately 34% of plain film reporting to be reported on by another hospital

25. She said that Dr Siddiqi requested that no CTs or Ultrasounds were to be conducted after

3pm so as to enable him to have time to complete his reports. Likewise, she said that

also on foot of a request from Dr Siddiqi, a waiting list for outpatients was also introduced

in order to reduce activity levels within the radiology department.

26. Whilst Ms O’Carroll did note that the department was a busy one for a sole radiologist she

highlighted to the court that the same workload had been managed on a three-day week

basis by the previous radiologist .Furthermore, once Dr Siddiqi indicated that he was

struggling with the workload they worked with him to reduce it. She felt that following

the outsourcing of certain scans and the introduction of a waiting list for outpatients

attending the department his workload was reasonable for one radiologist.

27. She said that issues and concerns were brought to her attention regarding Dr. Siddiqi’s

performance. She said that clinical specialists had begun to indicate doubts about his

confidence in CT reporting and that he was asking for their assistance. She named these

people as being Orla Hannick and Aida Collins. A document she wrote regarding concerns

around Dr Siddiqi was opened to the court. This document noted that Ms Hannick had

reported to Ms O’Carroll that Dr Siddiqi had often requested Ms Hannick to sit with him

and asked her opinion while he was reporting. The rest of the document produced to her

in court was a summary of concerns raised about Dr. Siddiqi at this time. The document

outlined that when Aida Collins queried requests by Dr Siddiqi to sit with him she was told

by him that it was a training exercise yet she believed she was learning nothing from

28. She said that when she received this information she brought it to the attention of her

superior Jackie Daly. Under cross examination she confirmed that Dr Siddiqi was

contracted to a four-day week and that during that time as it was Summer, she herself

would have taken 15 days off in annual leave. She confirmed that she was not present for

any interactions between the clinical CT specialists and Dr. Siddiqi. She said that there

was one specific case in relation to a brain tumour that she could remember where one of

the clinical specialists Ms Aida Collins noted that she had disagreed with the radiologist.

He had diagnosed an abscess and she had concerns that it was more serious than that.

29. She confirmed that until 4th September 2013, there was a manual dictation system in

place for completing reports. These were then given to Ms Doolan to get typed up. They

would subsequently be furnished to Dr Siddiqi for his approval and sign off. If he signed

the report it would be circulated with the signature. If he wasn’t happy he could insert

changes which would go back to the clerical officer who would insert the changes and

verify the report for circulation. There could be an addendum report but this would be an

additional report. She outlined to the Court that the difficulties that Bantry Hospital had in

getting the PAC system to go fully live meant that reports were still being dictated up

until September of that year and therefore a voice recognition system was not in yet in

place. She said that at the time, it was the electronic RIS system they were working with

but continued with the old method of reporting from hard copy film.

30. Jackie Daly gave evidence that she was the Hospital Manager in Bantry from December

2010 to 10th Feb 2017. She said that she was responsible for the operational

management of the hospital and she described to the Court the interviewing process that

Dr. Siddiqi underwent prior to being offered his position in Bantry General Hospital. She

said that she was not directly part of that process but a transcript of the interview by

telephone was provided to the Court. She said that it was put to him that there was a lot

of CT involved in the post as it was a standalone post in a small rural hospital. She said

that he responded by saying that he had done a lot of CT in the past.

31. She said the Dr Siddiqi would have had support in relation to the PACS system. She said

that after concerns had been raised to her by Ms Hannick and Ms O’Carroll she would

have corresponded with other consultants and clinicians requesting feedback or

32. Both radiographers indicated to her that some reports would vary between what was

reported to them orally and what would be stated in the final report. She would have

encouraged them to voice their concerns to Dr Siddiqi. She told the Court she raised the

issues with her general manager as issues of this nature had never previously arisen in

Bantry Hospital. She also said that prior to this there was never an audit conducted on

the workload of the radiologist in Bantry. She provided statistics in respect of Dr Siddiqi’s

workload which were provided to Dr Ellis when he was asked to give his opinion on Dr

33. She outlined to the Court that the PAC system had to be introduced on a phased basis as

34. Expert evidence was given on behalf of the Medical Council of Ireland by Dr Peter Ellis,

consultant radiologist, Royal Victoria Hospital, Belfast. Expert evidence on behalf of the

appellant, Dr Dawar Siddiqi, was given by Dr Tanveer Butt, consultant radiologist and

Head of Radiology Services, United Lincolnshire Hospitals, NHS Trust. Both experts gave

evidence on foot of their written reports and both witnesses were extensively cross-

examined on their evidence. The Court does not intend to traverse all of this evidence

which is on the transcript. However, the Court will briefly refer to the 8 cases considered

by Dr Peter Ellis, the expert on behalf of the Medical Council of Ireland to be serious.

(1) Case 6, where Dr. Siddiqi, the appellant, identified a primary 3cm lung tumour

stating “there is a 3cm mass within the bronchus intermedius.” Dr. Ellis opined that

this scan was normal and that there was no mass in the bronchus intermedius as

reported by Dr Siddiqi and further opined that to report the presence of a tumour

where there is none is very serious. Dr Butt agreed in evidence that no 3cm lung

tumour was present but indicated that Dr Siddiqi believed that the report dated the

29th August, 2013, was not his final correct report and may have related to a

different patient. However, Dr Butt acknowledged that he had no knowledge of the

existence or otherwise of another final report by Dr Siddiqi and that in the absence

of another report he agreed that the discrepancy in respect of Dr Siddiqi’s reporting

of case 6 was a serious one. No evidence was advanced by the appellant with

(2) Case 8 involved a CT scan undertaken in order to identify whether a patient’s

prostate cancer had spread to secondary areas. Dr Ellis gave evidence of “a very

large and very unsubtle par aortic lymphadenopathy” which was a significant

spread of cancer that was not mentioned in Dr Siddiqi’s report. Dr Ellis indicated

that this omission was on the upper end of serious. Dr Butt referred to the

appellant’s assertions that he had written some further handwritten notes and

orally advised the referring doctor of enlarged nymph nodes and further that an

addendum report may have been lost. Dr Ellis gave his opinion of the inadequacy of

any finding being given verbally to the referring doctor and confirmed that the

omission was on the upper end of serious. Dr Butt accepted under cross-

examination that the discrepancy in Dr Siddiqi’s report was on its face a serious

(3) Case 31 was a case where Dr Siddiqi was requested to carry out a CT scan of the

lumber spine area of a patient with a possible disc problem in their back. Dr

Siddiqi’s report stated that disc material is centrally protruding out and bilaterally

protruding on L3 and L4. Dr Ellis’ report in evidence stated that the CT scan actually

shows extreme lateral disc pressing on the right L3/4 nerve root and that this

finding was missed by Dr Siddiqi. Dr Ellis’ opined that given the patient’s symptoms

and the purpose for which a CT scan was request, it was clear that it was for Dr

Siddiqi to report where there was any disc protrusion and that this was almost

certainly the source of the patient’s symptoms. Dr Butt stated that he would “really

struggle with identifying the disc bulging observed by Dr Ellis”, however he

conceded that he could not disagree with the view expressed by Dr Ellis that this

protrusion was the cause of the patient’s symptoms. He did not agree with Dr Ellis’

(4) Case 34 involved a patient referred for a CT scan of the brain. Dr Siddiqi diagnosed

a haemorrhage or, secondly, an abscess. However, Dr Ellis found that Dr Siddiqi’s

diagnosis was incorrect and that the CT scan showed “an enhancing nodule within

the oedema in keeping very much with the tumour”. Dr Ellis’ report stated that

“this is clearly not” a brain haemorrhage. In his evidence he stated that this was a

clear tumour. Dr Ellis’ finding was that this was a classical tumour which required

urgent referral to a neurosurgeon. Dr Ellis described this as “very basic radiology”

and indicated that “of all of the cases in this case, this was the worst”. In his

report, Dr Butt describes the description in Dr Siddiqi’s report as “absolutely right”

but in evidence conceded that he agreed with the analysis of the report provided by

Dr Ellis, in particular, he agreed that the scan would require an immediate referral

to a neurosurgeon and that such a referral would not have taken place based on

the report provided by Dr Siddiqi. Insofar as Dr. Butt’s report stated that there was

no discrepancy in Dr Siddiqi’s reporting of this case, in evidence, he confined that

statement to the description of the scan rather than the diagnosis. Dr Butt further

conceded that Dr Siddiqi’s failure to mention the presence of a tumour amounted to

(5) Case 39, this was a case in which Dr Siddiqi was asked to perform a CT scan of the

chest, abdomen and pelvis for a patient with cancer of the oesophagus. Dr Ellis’

report confirmed that it appeared that Dr Siddiqi had failed to measure the density

value of what appeared to be cysts when performing the CT scan. While the steps

to measure density were not taken by Dr Siddiqi, he nonetheless stated in his

report that there were liver metastases. Dr Ellis stated that this was not apparent

from the CT image itself and that Dr Siddiqi would need to have evidence of a high

density value to support such a conclusion. Dr Ellis stated in evidence that Dr

Siddiqi’s reporting of these scans presented a serious issue and that the report if

taken at face value, that the patient had an oesophageal cancer and liver

metastasis, would have taken the patient down a completely different treatment

plan which could have included surgery. Dr Butt in his report stated that he did not

think that” mentioning about these hypo dense liver lesions to be compatible with

liver metastasis in a known primary is overcall or wrong”. In evidence Dr Butt

changed his position and conceded that Dr Siddiqi should not have called the

lesions as cysts or metastasis and that he should have referred the case for further

imaging. Dr Butt expressed the view that on the basis that Dr Siddiqi’s overcall

could have been confirmed or corrected at a later stage in the treatment process,

he was of the view that the mistake was an overcall but not a discrepancy.

(6) Case 41, In this case Dr Siddiqi reported an unremarkable CT scan of the patient’s

thorax, abdomen and pelvis. Dr Ellis’ report found that the CT scan displayed clear

indications of symptoms that indicated cancer was present. Dr Ellis stated that Dr

Siddiqi failed to mention bowel wall thickening which Dr Ellis very strongly

suspected represented recurrent lymphoma. Dr Ellis stated that at the very least,

the bowel wall thickening should be mentioned in his report which Dr Siddiqi had

not done. Dr Butt said that it was hard to comment on the wall thickening because

the images were in hardcopy and he did not have the previous CTs. He said that he

would be very hesitant to mention the nonspecific findings of thickening of the

small bowel as reoccurrence of lymphoma in the absence of other masses. Dr Ellis

conceded that access to previous imaging would be useful but nevertheless

maintained that Dr Siddiqi failed to mention this “subtle finding” in order to allow

for further investigation to take place. In evidence, Dr Ellis stated that although his

view and Dr Butt’s report were “not far apart”, in relation to the scan, the

discrepancy in Dr Siddiqi’s reporting was a serious one. In evidence, Dr Butt said

that in light of the fact that Dr Siddiqi had been aware when looking at the scans of

the patient’s history of lymphoma, the discrepancy in his reporting was a serious

(7) Case 50, This patient was referred to Dr Siddiqi for a CT scan of the abdomen and

pelvis. Dr Ellis stated in his report that though Dr Siddiqi correctly identified a mass

in the oesophagus, he failed to mention the spread of the tumour in the “left gastric

coeliac and portal nodes”. Dr Ellis also identified liver lesions which “could be

metastases” and which would require an MRI scan to clarify the situation. In his

report, Dr Butt agreed that Dr Siddiqi failed to mention the upper abdominal lymph

nodes “which were important given the findings” of a tumour in the oesophagus. He

stated that Dr Siddiqi mentioned insignificant nodes in his report and said that

“inaccuracy in the measurement” of the size of the nodes may be because there

was no PACS system. He said he was “not convinced” about the liver lesions as

they were “too small to be characterised” and “appear simple cysts”. However, he

accepted that they needed “further assessment” and “should have been assessed

with MRI liver or ultrasound liver”. Dr Ellis stated both in his report and in evidence

that a further assessment would be unlikely to take place in circumstances where

Dr Siddiqi had not flagged the abnormalities in the liver in the first instance. Dr Ellis

gave evidence that the patient’s lymph nodes “were not remotely subtle” and

“massively enlarged” and that the discrepancy was a serious one. In response to Dr

Butt’s view expressed in his report about the impact of the absence of PACS, Dr

Ellis expressed the view that whether a doctor was looking at it on the PACS or on

hard copy or on a viewing box or rollator, that the lymph node was not in any way

normal on CT size criteria. Dr Butt’s position changed during his evidence before

the court, in particular he accepted that the lymph nodes were enlarged to an

abnormal degree, that such a finding would be obvious whether a radiologist was

using a PACS system or a hard copy, that it was a “remarkably unsubtle” finding

(8) Case 59 was a case where a patient was referred to Dr Siddiqi for a CT of thorax.

Dr. Siddiqi’s report of this CT scan stated that there was a “bronchiectasis and

emphysema present”. In Dr Ellis’ report, he stated that there was no evidence of

bronchiectasis or emphysema at all. Dr Ellis stated that there was instead evidence

of sarcoidosis, a lung disease, which was apparent from the presence of indicators

such as calcified hilar nodes, interlobular septal thickening and perilymphtic

nodules. In his report, Dr Butt accepted that Dr Siddiqi had not mentioned the

basal atelectasis/fusion but stated that it is a “small discrepancy” and “clinically

insignificant”. He said that because he had mentioned the hiatus hernia and that

“could be the cause for the dilated oesophagus”. He did not agree that there is an

“overcalling” of emphysema and bronchiectasis and thinks both of these conditions

are present. Dr Ellis having considered Dr Butt’s analysis concluded that his findings

were “so radically different to Dr. Butt’s comments” that he questioned whether Dr

Butt was looking at the correct scan. He conceded that this is a difficult area of

radiology and that not every radiologist is going to be aware of all those different

pathways but that a radiologist should at least be able to know that that is not

emphysema and is interstitial lung disease. Dr Butt in his evidence before the court

resiled from the position outlined in his report in relation to the presence of

emphysema, however, he stood by the remainder of the contents of the report and

stated he disagreed with Dr Ellis’ conclusion that this was a serious discrepancy. Dr

Butt did, however, concede that this error when taken as part of a pattern of other

35. In summary, as stated earlier, of the 19 cases at issue in these proceedings, Dr Ellis

concluded that Dr Siddiqi’s report in 8 of these cases, as outlined above, namely Cases 6,

8, 31, 34, 39, 41, 50 and 59 were each serious errors in their own right. Dr Ellis stated

that Dr Siddiqi’s reports in relation to the remaining eleven scans were each mild or

moderate errors in their own right which when taken collectively and part of a pattern

amounted to a serious error. In evidence, Dr Butt agreed that five of the cases, namely 6,

8, 34, 41 and 50 were each serious errors in their own right. He stated that a further

eleven cases; 5, 9, 21, 22, 23, 26, 30, 36, 45, 59 and 62 were non serious discrepancies.

Dr Butt said that in relation to six of these cases, cases 22, 26, 30, 36, 45 and 59, he

conceded in evidence that these errors, although moderate in his view, amounted to a

36. Dr Siddiqi, the appellant, gave evidence. He outlined to the Court that he is a registered

medical practitioner who is trained in radiology. He said that he qualified in Pakistan, as a

doctor in 1979 and he went through the various positions he held since qualification in

various hospitals in the Middle East culminating in Sheikh Zaid Hospital as a specialist

radiologist. He said that he gained a lot of experience in Sheikh Zaid Hospital and also

gained experience when he came for short-term training to Hammersmith Hospital and

then in the London Chest Hospital. He said that he never undertook MRI training.

37. He told the Court he had practised radiology for approximately 36 years and had never

been made aware of any serious concerns in respect of his CT Reporting. He said that he

then undertook fellowship training for radiology before doing a diploma with the Royal

College of Radiologists. He said that once he finished that he came to Limerick as

Registrar in Radiology in Limerick University Hospital. He said that as Sheikh Zaid Hospital

was a federal postgraduate hospital while he was working there he would have provided

training to junior doctors. He informed the Court that he had relevant examinations for

specialising in radiology and that one of these was from Pakistan and the other was from

the Royal College of Surgeons in the UK. He went on to tell the Court that he had worked

in hospitals unsupervised as head of radiology and also had experience of cross-sectional

radiology. He said that while he was working in a post as a locum consultant in Drogheda

it was suggested to him he might want to apply for the post in Bantry. He said that he

sent his CV to the agency interviewing for the job and they asked him to obtain

references from Saudi Arabia. He confirmed that he only stayed 28 days in Drogheda as a

38. When asked about his experience with the PACs system he told the Court that he had

been using it since 2006 and that as far as he was aware this system was standard

practice in most modern hospitals. He told the court it was used in Saudi Arabia and the

better hospitals in Pakistan. He described it as being a better system as it did not require

the radiologist to go through the administrative staff unless they wanted to query

something. He explained to the Court how PACS works by explaining that when you

report your X-Ray it starts writing straight away as the system has voice recognition. He

said that while he is reporting he knows exactly what the PACS system is writing as it is

being done as he speaks. He said the PACS system allows for corrections and reviews. He

said that the information appears on a big screen as well as previous X-rays and

information about examinations the patient has already undergone.

39. With regard to his interview for his position at Bantry he confirmed that his interview took

place on the 18th April 2013. He said that this was via phone while he was still working in

Drogheda. He said that he spoke to Marion Kearney in Administration. The record of the

interview shows that a Doctor Kelly and a Doctor Oliver de Bhul were also part of the

interview conversation. He said that at the conclusion of his interview he was unaware

that PACS was not in place in Bantry at that time. He said that this only became apparent

to him when he arrived on site and saw hard copy films in use. He said that he started

working in Bantry on the 7th May 2013 and said that by his third day at work there he

raised the issue of the backlog. He said that he told management that the backlog was

increasing and he said that they were still expecting him to deal with that as well as his

current workload. He said that he became annoyed with management very early on in his

40. He said that by the end of June 2013, staff were told that PACS was being introduced. He

said that what ultimately happened was that the RIS system was introduced in July 2013

and PACS in September 2013. He said that having PACS would have made his work easier

and he wold have been able to manage his time better had it been in place. His said that

his workload was also impacted and increased by the ultra-sonographer having to

unexpectedly take leave in July of that year. He said that in July 2013 Jackie Daly asked

him how he felt about peer review and he said he would be open to this but he never got

any further feedback either from her or the clinicians about it after they had this

conversation. He said that when she mentioned this to him he asked her was there an

issue with his work, that she said no and that it was just something that the hospital was

41. He said further that a Dictaphone was not provided to him meaning that he would often

have to handwrite a note and then sent it to be typed. He also told the Court that viewing

facilities provided to him for hardcopy film were not adequate and that any additional

requests he made specific to this were denied. He conceded to the Court that he sought

the help of the radiographers because they were quicker at using the computer to bring

up images but that he was not relying on them for help with interpretation or diagnosis.

He said that the help he was receiving from the radiographers in order to use the monitor

allowed him to save time. He said he was not given any protected time to complete his

reports and that resultantly, he often found himself working outside of his contracted

hours. He said that he spoke with Deirdre Doolan about the process of reporting and

signing off on reports and he raised the issue that unless a report was signed by him he

42. He went on to address specific cases. In respect of Case 8 he confirmed that it was his

handwriting on the back of the clinical request card. He said this case related to a para

aortic lymphadenopathy. He said that notes on the back of cards were taken as an aid

memoir and the fact that the ultimate diagnosis/ report differed from what was on the

back of his cards could be explained by the fact he was just taking these notes as an aid

memoir for himself. Under cross examination he accepted this error as being a serious

43. With regard to Case 31 which related to a CT Lumbar Spine, he said that the referring

doctor wanted to rule out any collapse of the vertebra. He said this CT was conducted

because the patient was not able to lie flat for an MRI. Dr Siddiqi stated that nobody goes

to surgery on a CT lumbar spine alone. Under cross examination he said it is only a

radiologist’s duty to recommend further investigations if they themselves cannot make a

diagnosis. He said if the diagnosis had been established then it was his practice to leave

44. He was questioned about his qualifications and conceded that the diploma he has, has

been replaced by FRCR and that this could be misleading to any person reading his CV

including a medical doctor. Discrepancies between his registration form and his CV were

opened. It was put to him that on his CV from Global Medics it could be understood that

he was a Consultant Radiologist as opposed to an Assistant Consultant Radiologist in King

Fahad Medical Hospital. He maintained in his evidence that his DMRD allows him to be a

consultant anywhere. Dr Siddiqi further accepted Dr Ellis’ evidence in respect of PACS

which was read out to him and further accepted that he had worked for a large part of his

career using hard copy images and was well used to reading hard copy images. He

further accepted that he was aware that he was being taken on for a single handed

position in Bantry Hospital but he also accepted that he had not communicated this to his

own expert Dr Butt. He accepted when it was put to him that his own expert Dr Butt on

being shown the statistics opened in Court that it was his professional opinion that Dr

Siddiqi’s workload was heavy but not extremely heavy as previously opined by him in his

45. When it was put to him that there was no educational reason for Orla Hannick being with

him for scans he maintained that she was only there for logistical help in bringing up the

scans. He disputed Dr Ellis’ view that he was not sufficiently trained to pick up on the

findings or to assess clinical importance or to decide on the next steps in relation to CT

scans. He disputed that he over called and under called particular scans. He confirmed

that the monitor that was available to him in his rooms was more than a light box and

that it could zoom in and out of scans but still stated that having Aida Collins or Orla

Hannick help him use the larger computerised screen was a more efficient way at looking

46. Counsel for the appellant stated that the Medical Council placed no express restrictions

on the practise of medicine by Dr Siddiqi as part of the conditions it imposed. They further

stated that it was clear from the notice of inquiry dated 28th October, 2015, that the

Council’s Preliminary Proceedings Committee (“PPC”) formed the opinion that there was a

prima facie case warranting further action be taken in relation to a complaint made by

J.A. McNamara, CEO of Cork University Hospital, following which the complaint was

referred to the Council’s Fitness to Practice Committee “on the grounds of professional

47. In the Notice of Inquiry the only allegations ultimately pursued were of poor professional

performance, it being alleged that while practising as a locum consultant radiologist at

Bantry General Hospital from May, 2013, to September, 2013, in respect of 62 CT scans

reported on by Dr. Siddiqi and subsequently selected for review:-

(1) You made serious errors in one or more of the 22 cases identified by Dr. Ellis in his

(2) Your rate of error arising from one of the above was unacceptably high.”

48. The Appellant refers to the fact that the Medical Council commissioned a report from Dr

Ellis, consultant radiologist, Royal Victoria Hospital, Belfast. His report reviews 62 CT

scans and Dr Siddiqi’s reports thereon. The appellant submitted that whereas Dr Ellis

indicated that he had sight of the clinical request cards for each examination, it appeared

that these were not in fact furnished to him until just prior to the hearing before the

Fitness to Practise Committee. The Appellant further refers to the fact that in his report,

Dr Ellis identified significant challenges in relation to the unsatisfactory nature of Dr

Siddiqi’s working conditions. He also outlined the limitations on the review he was tasked

49. The appellant submitted that of the 62 scans Dr Ellis was asked to review, he agreed with

Dr Siddiqi’s report on the scans in relation to 40 cases. They further state that Dr Ellis

identified mild to moderate discrepancies between his opinion and Dr Siddiqi’s reports in

respect of a further 14 cases. He did not, however, consider these to be serious

discrepancies and they were unlikely to have had any patient consequences. The

appellant says that in the remaining 8 scans, he reported that he identified “very serious

discrepancies which could potentially have significant clinical consequences for the

patients involved”. The appellant submitted that it was these latter 22 scans (14 + 8)

which were the subject of the notice of inquiry despite Dr. Ellis not identifying serious

50. The appellant said that 62 scans were ostensibly selected as a random 10% sample of Dr.

Siddiqi’s CT scan reports for the purposes of an earlier audit carried out on behalf of the

HSE by the Faculty of Radiologists of the Royal College of Surgeons in Ireland. However,

the appellant says that analysis of the dates of the sample scans by reference to the

reports actually completed over the relevant period does not disclose that it was truly

51. Dr Ellis furnished a second report to the Medical Council on the 8th October, 2015. The

appellant said that Dr. Ellis revised his views in this report and criticised the appellant’s

clinical ability to interpret scans in 15 cases describing it as inadequate. In his conclusion,

Dr. Ellis noted that the appellant, Dr Siddiqi “had demonstrated a pattern of failure to

appreciate significant findings, misinterpretation of findings and lack of knowledge of what

further investigations may be required for significant findings” and taken as a whole “this

constitutes poor professional performance”. Dr Ellis also identified significant contributory

52. Counsel for the appellant said that following the hearing before the FPC on the 9th

December, 2015, it decided that having regard to the evidence adduced, allegation 1 of

the notice of inquiry was proven as to fact in 11 of the 22 cases referred to it and that

this amounted to poor professional performance. Allegation 2 in the notice of inquiry was

withdrawn by the Medical Council. The decision on sanction has already been referred to

53. The appellant said that it is clear that the High Court may consider any evidence adduced

or argument made to the FPC pursuant to s. 75(2) of the Medical Practitioner’s Act, 2007.

54. The appellant argued that as the hearing in front of this Court is a de novo hearing, it is

not a mere appeal of the combined decisions of the FPC and the Medical Council. In this

regard, the appellants opened In re M, a Doctor [1984] IR 479, in support of this point.

55. Moreover, the appellant contends that had Dr Siddiqi decided not to appeal and the

Medical Council had applied to the High Court to confirm its decision to impose conditions

on his continued registration pursuant to s. 76 of the Medical Practitioner’s Act, 2007, the

powers of the court would have been relatively circumscribed and confined to the issues

raised by the Medical Council’s decision. The appellant opened Medical Council v. Lohan-

Mannion [2017] IEHC 401, 23rd June 2017 (Kelly P.) in support of this assertion. They

also argued that in the circumstances, requiring the appellant, Dr Siddiqi, to answer

allegations that were found not proven by the FPC and not considered by the Medical

Council when the question of sanction arose, imposes an additional and unfair burden in

56. The appellant claimed that the onus of proof lies with the Medical Council to establish (1)

the correctness of the finding that Dr Siddiqi has been guilty of poor professional

performance and (2) the correctness of the Council’s decision in relation to sanction and

they opened again In re M, a Doctor [1984] IR 479, in support of this assertion.

57. The appellant further argued that the applicable standard of proof in this case is that of

proof beyond a reasonable doubt. They opened O’Laoire v. Medical Council (unreported)

Supreme Court, 25th July, 1997 (Hamilton C.J., O’Flaherty, Denham, Barrington and

Murphy J.J.) and Georgopolous v. Beaumont Hospital Board [1998] 3 IR 132, in support

58. Furthermore, they argue that the only allegations facing the appellant, Dr Siddiqi, were

poor professional performance as defined in s. 2 of the Medical Practitioner’s Act 2007.

They argue that it is accepted that the sanctions available to Medical Council under the

2007 Act in the case of finding “poor professional performance” are identical to those

applying in the case of a finding of “poor professional conduct”. Similarly, they accept that

the High Court has cognate powers on any appeal by a registered medical practitioner

against a sanction imposed for alleged poor professional performance.

59. The appellant opened the principles set out by the Supreme Court in Corbally v. Medical

Council [2015] 2 IR 304, and stated that they are relevant to the matter at hand and set

(a) A threshold of “seriousness” must apply to findings of poor professional

(b) Only conduct that represents a serious falling short of the expected standards of

the profession can justify a finding of poor professional performance;

(d) The threshold of “seriousness” has to be met before a prima facie case for holding a

(e) A finding of poor professional performance does not depend on an assessment of a

representative cross-section of practitioner’s work, nor is such “fair sample” test a

preliminary requirement to the making of a complaint against a practitioner;

(f) A finding of poor professional performance or misconduct does not depend on

conduct that impairs practitioner’s fitness to practice or which calls into question his

(g) The same threshold of “seriousness” applies whether the allegation involves a

(h) Conduct that can truly be described as trivial, minor or that can be classified as de

60. Counsel for the appellant stated that the question arose as to whether or not Dr. Siddiqi,

was guilty of poor professional performance in his reporting of CT images as alleged.

Counsel for the appellant argued that Dr Siddiqi’s reporting of 62 CT scans within the

limitations and structural difficulties identified by Dr Ellis had been reviewed by up to four

consultant radiologists; two radiologists (Prof. Peter McCarthy, consultant radiologist,

Galway University Hospital, and Dr Sale Ogboni, consultant radiologist, Lagan Valley

Hospital, Lisburn) (and perhaps a third arbitrator) on behalf of the Faculty of Radiologists

of the Royal College of Surgeons in Ireland at the request of the HSE, and Dr Peter Ellis

on behalf of the Medical Council. Dr Tanveer Butt, consultant radiologist and Head of

Radiology Services, United Lincolnshire Hospitals, NHS Trust, has also reviewed the 22

61. Counsel for the appellant opened a section of Dr Ellis’ report for the Medical Council to

further highlight the constraints under which Dr Siddiqi was working under. It stated: -

“Radiology involves decision making under conditions of uncertainty and, therefore,

will not always produce infallible or perfect interpretations or reports. The issue of

error in radiology has been known for many years and multiple studies have shown

a discrepancy rate between observers of somewhere between 2 – 20%. Recent

reviews have found “real time” error rate amongst radiologists in their day to day

practise of approximately 3 – 5%. Errors are inevitable and the concept of

necessary fallibility must be accepted. Also a threshold of competency is required of

all professionals involved in the delivery of imaging services.”

62. They further highlighted that in his report, Dr Ellis cautioned against “hindsight bias”.

Moreover, they highlighted to the court that Dr Butt’s reports noted that there is a range

of reasonable reporting practises and that Dr Siddiqi did not fall out with them.

63. The lack of a radiology quality assurance process within Bantry General Hospital in

accordance with the Faculty of Radiologists guidelines for the implementation of a national

quality assurance programme in radiology was also raised by counsel for the appellant as

being a significant factor in this case. They argued that any issues would have been

identified and appropriate action taken if there had been routine retrospective peer-

review for evaluating diagnostic accuracy of radiology reports. They stated that the lack of

appropriate clinical governance arrangements to effectively implement recommended

guidelines, effectively left Dr Siddiqi isolated within Bantry Hospital. Given these

circumstances, they argued that a finding of poor professional performance cannot be

considered to meet the relevant evidentiary threshold and is inconsistent with the object

64. Furthermore, it was argued by the appellant that whilst Dr Ellis reported that he believed

that there was poor performance in the present case, his report also recognised the fact

Dr Ellis also referred to high expectations and the non-availability of the PACS system and

stated that while in his view, Dr Siddiqi’s reading of the CT scans had demonstrated poor

performance, they could be partly explained by the environment in which this doctor was

placed. The appellant asserted that the above conditions constitute mitigating factors and

that the court should be cognisant of these when determining what weight to attach to

the evidence of experts when considering (a) whether or not Dr Siddiqi’s work amounted

to poor professional performance and (b) the appropriate sanction.

65. The appellant argued that the court has three options opened to it: -

(a) To conclude that Dr Siddiqi is not guilty of poor professional performance in which

(b) Accept the evidence of Dr Butt that any discrepancies in Dr Siddiqi’s practise can be

dealt with by him practising in centres with appropriate feedback mechanisms.

The appellant further submitted that there is no evidence from any expert that would

66. Counsel for the respondent submitted that the FPC’s finding of poor professional

performance was based upon “the totality of the evidence, oral and documentary

including exhibits and submissions”. They stated that whilst the FPC did take into account

various mitigating factors, that it nonetheless found that the appellant had been recruited

as a consultant with competency in CT and that he himself admitted in his own evidence

that this was not the case. Despite the mitigating factors, the committee had stated that

it was “satisfied that this lack of competence by D. Siddiqi is a core element of his

employment and was a significant contributing factor to the errors made by D. Siddiqi”.

67. The respondent opened the cases highlighted by Dr Ellis in his reports, where he

identified 22 cases where the appellant’s conduct constituted poor professional

performance due to a low standard of competence in CT reporting. Two of these

allegations (namely cases 42 and 54) were withdrawn on Day 3 of the hearing before the

FOC and one further case was withdrawn during the course of these proceedings leaving

68. In summary, the respondent stated that of those 19 cases, Dr Ellis concluded in his

evidence that Dr Siddiqi’s report in 8 of these cases (namely cases 6, 8, 31, 34, 41, 50

and 59) were each serious errors in their own right. Further that Dr Ellis stated that Dr

Siddiqi’s reports in relation to the remaining 11 scans were each mild or moderate errors

in their own right which when taken collectively and as part of a pattern amounted to a

69. The respondent stated that in evidence, Dr Butt agreed that 5 of the cases (namely 6, 8,

34, 41 and 50) were each serious errors in their own right. Further that Dr Butt in

evidence agreed that a further 11 cases (5, 9, 21, 22, 23, 26, 30, 36, 45, 59 and 62)

were non-serious discrepancies. Of these 11 cases, in relation to 6 cases numbers 22, 26,

30, 36, 45 and 59, Dr Butt conceded in his evidence that these errors, although moderate

in his view, amounted to a serious error when viewed collectively as a pattern.

70. The respondent noted that there was considerable agreement as regards the

discrepancies in the scans as between Dr Ellis on behalf of the CEO and Dr. Butt on behalf

of Dr Siddiqi. They stated that where there is disagreement, the respondents submitted

that the court should prefer the evidence of Dr Ellis on the following grounds: -

(i) He is the most trained, qualified and experience of the two experts.

(ii) That it was clear from his evidence that prior to providing his report and before

giving evidence, Dr Butt did not know the definition of “poor professional

performance” on which he was purporting to opine and neither was he familiar with

the Medical Practitioner’s Act, 2007. “Poor professional performance”, in relation to

a medical practitioner, means a failure by the practitioner to meet the standards of

competence (whether in knowledge and skill or the application of knowledge and

skill or both) that can reasonably be expected of medical practitioners practising

(iii) And that in the course of his evidence under cross-examination before this Court,

Dr Butt resiled from his professional opinions contained in his written reports.

71. The cases highlighted by Dr.Ellis were then categorised by the respondent as follows: -

(iii) Mild or moderate discrepancies which when taken as a pattern amount to serious

72. The respondent stated that Dr Ellis in his report states that radiology “will not always

produce infallible or perfect interpretations or reports” and that errors are “inevitable”.

However, the respondents stated that Dr Ellis also stated that there is nonetheless “a

threshold of competency” required of all professionals involved in the delivery of imaging

services. The respondent said that Dr Butt agreed in evidence that there are certain

mistakes or discrepancies which are so serious that they do not fall within the ordinary

radiology discrepancy rate of between 3–5%. The respondent went on to say that

reluctantly Dr Siddiqi agreed in cross-examination that the discrepancy rates (which he

stated were between 3–5%) were not relevant where the error was serious.

73. The respondent pointed out that Dr. Ellis used hardcopies of the CT images and Dr.

Siddiqi’s reports in relation to those CT images as the sole sources in considering each

case. They state that he was not aware of the clinical history or patient outcome and

reached his own conclusions on each scan before looking at Dr Siddiqi’s report. The

respondent does confirm that Dr Ellis acknowledged that if he had been looking at the

scans in a hospital environment, he would not have had the benefit of working

74. Prior to the conclusions reached in the Faculty of Radiologists report, the respondents said

that Dr Ellis prepared his report for the FPC from a review of the 62 CT scans conducted

by Dr Siddiqi during the period that he worked in Bantry. They stated that the previous

review had been conducted internally by the Faculty of Radiologists which assessed 10%

of the appellant’s scans. The respondent said that contrary to the appellant’s assertion, it

was Dr Ellis’ evidence that he was aware of the existence of the audit by the faculty but

75. The respondent said that the appellant’s legal submissions submit that the views of the

appellant’s expert Dr Butt, Dr Ellis and the authors of the faculty review “cannot be

considered ad idem in any major respect”. The respondent says that this suggests that a

divergence of opinion exists as to whether the errors demonstrated in the 20 scans

originally highlighted were of an acceptable nature which the respondent says is clearly

not the case. They stated that first, it was hardly surprising that the appellant’s expert’s

interpretation of the appellant’s work contrasts with that of the respondent which is a

matter for adjudication by this Court and that secondly, Dr Butt’s assessment is limited to

20 cases as opposed to the 62 cases reviewed by Dr Ellis and the Faculty. The respondent

further stated that insofar as the appellant appears to suggest that the differences in

finding points towards a divergence in the clinical assessment, they respectively submit

76. They stated that the Faculty report did not seek to assess whether Dr Siddiqi had

demonstrated poor professional performance but instead addressed the issue of adverse

impact. The respondent said that accordingly the conclusions of the Faculty are not

comparable to the conclusions of Dr Ellis or Dr Butt but that nevertheless Dr Ellis’ report

aligns with the findings of the Faculty in relation to the discrepancies in each of the five

77. The respondent further said that Dr Ellis reviewed the 62 scans which formed part of the

audit by the Faculty. They state that Deirdre Doolan gave evidence that the 62 scans

were selected as a random 10% sample of the appellant’s CT scan reports. The

respondent said that the appellant’s submissions allege that an “analysis of the dates of

the sample scans by reference to the reports actually completed over the relevant period

does not disclose that it was truly random”. The respondent said that nothing further is

offered in support of this contention and the respondent respectively submits that there is

78. The respondent further went on to address the appellant’s working conditions and the

appellant’s contention that had there been routine retrospective peer review that “any

issues would have been identified early and addressed at discrepancy meetings”. The

respondent said that the appellant appears to suggest that in the absence of such

meetings a finding of poor professional performance cannot be made. The respondent

said that the review of the appellant’s work conducted by the Faculty and by Dr Ellis both

concluded that in relation to CT scanning, the appellant’s knowledge was deficient. The

respondent contended that the role of multidisciplinary meetings and peer review cannot

supplant basic competency and the respondent claimed that it is clear from the report of

Dr Ellis and from his evidence that the appellant requires supervision to meet basic

79. The respondent asserted that whilst the appellant’s working conditions may very well

have contributed to the discrepancies, his deficiency remains in circumstances where the

appellant applied for and purported to undertake a locum consultant position in a post

that was unsupervised. The respondent further claimed that the appellant sought to rely

on the failure of Bantry General Hospital to implement PACS (Picture Archiving and

Communication System) during the course of the appellant’s employment there

particularly in circumstances where he had used PACS in his previous posts. The

respondent stated that whereas there were difficulties in introducing PACS in Bantry

General Hospital, the respondent’s position is that the seriousness of the discrepancy in

the appellant’s reporting cannot be excused by the fact that the appellant was reporting

using hardcopy scans and the respondent says that this position was endorsed by the

“I suppose before 2011 in the Republic of Ireland everybody was reading from

hardcopies. So it is not really a basis for I don’t think anybody has shown that since

PACS came in that radiology reports have improved in quality dramatically. Yes,

previous films are more available and yes, films that used to go missing on the

ward are now available to you at all times. But other than that, you still apply your

professional opinion to an image and I don’t see why you should be much better

80. The respondent went on to say that the court should note that the appellant was aware

when he commenced employment at Bantry General Hospital that the position was that of

a single handed radiologist. The respondent claimed the clear implication of the expert

evidence tendered in these proceedings is that the appellant lacked the requisite

competence and experience to perform in that role. In that regard the respondent

asserted that it should be noted that the appellant accepted that the CV he submitted for

the position misrepresented the nature and seniority of the positions he had previously

81. Addressing the appellant’s workload, the respondent noted that the appellant has

suggested that the workload he was faced with in Bantry General Hospital was so large

that it contributed to any errors made in his CT supporting. In that regard, the

respondent made two points. Firstly, they stated that Dr Ellis was clear in his evidence

that the appellant’s workload was not particularly onerous and he supported that view

with the statistics provided in respect of Dr Siddiqi’s workload. And secondly, the

workload was one which the appellant’s predecessor was capable of managing on a three-

day week basis in accordance with the evidence of Ms. Roisin O’Carroll. The respondent

says that although it must be noted that the Corbally decision expressly states that

workload is a factor in determining the seriousness of an error in cases such as this, the

respondent submits that the appellant has advanced no credible evidence to ground any

suggestion that the size of his workload was so great as to either excuse or mitigate the

82. Addressing alleged bias on the part of the respondent’s witnesses, the respondent said,

that in evidence, Dr Siddiqi alleged that Dr Ellis was not acting as an independent expert

witness and was hired by the respondent to prove that Dr Siddiqi was not a competent

radiologist. The respondent said that Dr Siddiqi also alleged that staff from Bantry

General Hospital who gave evidence on behalf of the respondents were acting as part of a

conspiracy against him. The respondents say that no evidence was offered in support of

these propositions nor were they put to any other witness during the course of the

83. Section 71 of the Medical Practitioner’s Act 2007, sets out the procedure to be followed by

the Medical Council of Ireland in determining disciplinary complaints. Section 71 provides,

“……. the Council shall, as soon as is practicable after receiving and considering the

report of the Fitness to Practise Committee in relation to a complaint concerning a

registered medical practitioner decide that one or more than one of the following

restrictions on the practice of medicine that may be engaged in by the

Further s. 2 of the Medical Practitioner’s Act 2007 sets out the definition of “poor

““poor professional performance”, in relation to a medical practitioner, means a

failure by the practitioner to meet the standards of competence (whether in

knowledge and skill or the application of knowledge and skill or both) that can

reasonably be expected of medical practitioners practising medicine of the kind

In light of the Supreme Court’s decision in Corbally, this definition must be read as if

(2) The Court may, on the hearing of an appeal under subsection (1) by a medical

practitioner, consider any evidence adduced or argument made, whether or not

(3) The Court may, on the hearing of an appeal under subsection (1) by a medical

(ii) cancel that decision and replace it with such other decision as the

(b) give the Council such directions as the Court considers appropriate and direct

Further, the Medical Council of Ireland is empowered to publish advice to practitioners

under s. 12 of the Medical Practitioner’s Act 2007. The Guide to Professional Conduct and

Ethics for Registered Medical Practitioners (7th Ed.), published in 2009, was the

applicable guide during the period between May and September, 2013. At para. 2.2, it

“A failure by the practitioner to meet the standards of competence (whether in

knowledge and skill or the application of knowledge and skill or both) that can

reasonably be expected of medical practitioners practising medicine of the kind

84. The leading authority on the meaning of poor professional performance is the case of

Corbally v. Medical Council [2015] 2 IR 304. In that decision, the Supreme Court

concluded that there is a “seriousness” threshold that must be passed before a finding of

“poor professional performance” can be made. It concluded that the definition of poor

professional performance must be read as if qualified by the word “serious” in the same

manner as the phrase “professional misconduct” is. The Court went on to state that “it is

neither desirable nor necessary to try by some other form of words or expression to

further elaborate on what the word “serious” means. It can, however, be said that not

every error, lapse or mishap will qualify: conduct which can truly be described as trivial,

minor or which can be classified as de minimis will fall outside its meaning. Whilst

outcome adverse consequence or causative effect are not essential where present such

will be factors for consideration…..” The Court went on to indicate that while one incident

can justify a finding of poor professional performance, it was acknowledged that it would

be more difficult to meet the threshold of seriousness if there is but one incident alleged.

85. The summary of the main findings in the case of Corbally were set out in the appellant’s

submissions and are set out earlier in this judgment. O’Donnell J. in his concurring

judgment emphasised that he did not believe that seriousness “should mean very serious”

nor did he believe that “only conduct sufficiently serious to put registration in issue is

covered by the Act”. O’Donnell J. concluded that conduct “sufficiently serious to merit

public censure, admonishment or advice, may constitute poor professional performance.”

Importantly, he further stated at para. 58 that “only a serious error or a series of errors

(which may therefore be serious) can justify a finding of poor professional performance.”

86. The onus of proof lies with the Medical Council to establish (1) the correctness of the

finding that Dr. Siddiqi has been guilty of poor professional performance, and (2) the

87. The applicable standard of proof in this case is that of proof beyond a reasonable doubt.

This was contended for by the appellant who opened O’Laoire v. Medical Council

(unreported) Supreme Court, 25th July, 1997 (Hamilton C.J., O’Flaherty, Denham,

Barrington and Murphy J.J.) and Georgopolous v. Beaumont Hospital Board [1998] 3 IR

132, in support of this assertion and was not refuted by the respondent.

88. In Hermann v. Medical Council [2010] IEHC 414, Charleton J. stated that Court must

decide what sanction is appropriate in light of the findings of fact which led to the

“The Medical Council retains the burden of proving that the sanction was correct.

The court is obliged to assess what is appropriate in light of the findings of fact

which led to the imposition of the sanction by the Medical Council in the first

instance. That decision, and the reasoning underpinning it, should not be ignored.”

Charleton J. went on to state the following test where the Court is considering an appeal

“In considering the question of the sanction, the court's focus should be both on the

conduct underpinning the sanction and the reasoning of the Medical Council in

arriving at its decision. Because of the relatively greater experience of the Medical

Council in imposing sanctions, its knowledge as to relevant precedents and the

expert nature of the task undertaken, the High Court, on an appeal as to sanction,

should treat the decisions of the Medical Council with respect. If the level of

sanction is one which is justified by the material before the Medical Council, then

the Court would need to find a specific reason for altering it on the evidence

89. Charleton J. went on to consider the range of sanctions available and the conditions in

“Where the nature of the misconduct is such that a doctor has been shown to lack

sufficient competence, or where otherwise the Medical Council is concerned about

the continuance of practices by the doctor that led to the finding, it may attach

conditions to the registration of a doctor. This includes circumscribing the nature of

the practice that may be engaged in; for instance, that the doctor should no longer

perform particular kinds of operation, or should only do so in conjunction with

90. Similar sanctions were considered in the case of Medical Council v. Lohan-Mannion

[2017] IEHC 401. In that case, an anaesthetist admitted to professional misconduct in respect of

absenting herself twice from theatre and failing to record the administration of certain

drugs during surgery. She also admitted failings in monitoring a patient’s blood pressure

during surgery amounting to poor professional performance. The FPC recommendations

for re-education and training in the management of anaesthesia in a theatre setting were

confirmed by the Medical Council. Kelly P. stressed the leniency of the training and re-

education sanctions within the range of available sanctions and stated as follows: -

“There is no doubt but that the sanction imposed here is at the lower end of the

scale of sanctions that might have been applied. There is no element of suspension

of the respondent from medical practice even during the time that she is satisfying

the various conditions applied against her. Nonetheless, it is said that the Medical

Council has adequately addressed its obligations and that its decision cannot be

regarded as so unreasonable as to warrant the court refusing the application.”

91. The Court has considered the evidence of all of the witnesses, in particular the two expert

witnesses and the appellant himself who also gave evidence. The Court has also

considered the case law opened by both the appellant and the respondent. Both experts

gave extensive direct evidence and were also extensively cross-examined on their

evidence. The Court does not intend to traverse the evidence of all of the witnesses or

indeed the evidence of the two experts all of which is on the transcript but has outlined in

this judgment details of the 8 cases considered to be serious by the respondent’s expert.

92. The Court notes that the relevant legislation is the Medical Practitioners Act 2007 which

sets out the procedure and defines poor professional performance. The Court notes that

the leading authority on the meaning of poor professional performance is the case of

Corbally v Medical Council [2015]2 IR 304 which found that a “seriousness” threshold

must be passed before a finding of “poor professional performance” can be made.

93. The Court accepts that the onus of proof lies with the Medical Council to establish (1) the

correctness of the finding that Dr. Siddiqi has been guilty of poor professional

performance and (2) the correctness of the Council’s decision in relation to sanction. The

Court accepts that the applicable standard of proof in this case is that of proof beyond a

94. There is a considerable amount of agreement between the two experts as set out above.

The Court has been urged by the respondent, that where there is disagreement, to prefer

the expert evidence of Dr. Peter Ellis for the reasons outlined by the respondent set out

earlier in this judgment. In his evidence Dr. Butt confirmed that both at the time of

finalising his report and when giving his direct evidence before this court he was not

familiar with, nor had he been briefed on, the Medical Practitioner’s Act, 2007, and in

particular, the statutory definitions contained therein. He further confirmed that he was

not familiar with the Corbally case and the impact of that decision on the statutory

definition of poor professional performance on which he was giving his professional

opinion to the Court. In respect of a number of cases; under cross-examination Dr. Butt

resiled from the position he took in his report and made a number of concessions. The

concessions made by Dr. Butt in respect of a number of the 8 cases considered serious by

95. In determining the facts of this case and in considering the expert evidence given by the

experts before the Court, the Court notes that both experts are in agreement as to the

seriousness of the five cases on which they agree. The Court further notes that the

experts are in further agreement that six further cases, although mild or moderate errors

in their own right, when taken collectively and as part of a pattern amounted to a serious

error. As stated above, Dr. Ellis goes further in his evidence than Dr. Butt and indicates

that eight of the cases could be considered serious for the purposes of the definition of

poor professional performance as set down in the Medical Practitioner’s Act, 2007, and

that a further 11 cases, each of which were mild or moderate errors in their own right,

when taken collectively and as part of a pattern amounted to a serious error.

96. In considering the expert evidence, the Court notes the factors submitted to it, set out

above, as to why it should prefer the evidence of Dr. Ellis and having considered those

factors and the evidence of Dr. Ellis and Dr. Butt, the Court preferred the expert evidence

of Dr. Peter Ellis and where there is disagreement attaches more weight to his expert

97. In addressing the appellant’s arguments in respect of mitigating factors the Court notes

that whilst the FPC did take into account various mitigating factors, it nonetheless found

that the appellant had been recruited as a consultant with competency in CT and that he

himself admitted in his own evidence that this was not the case. Despite the mitigating

factors, the committee had stated that it was “satisfied that this lack of competence by

Dr. Siddiqi is a core element of his employment and was a significant contributing factor

98. The Court notes further that the respondent’s expert Dr Ellis, did acknowledge a number

of mitigating factors in forming his opinion of poor professional performance. Dr. Ellis in

his report states that radiology “will not always produce infallible or perfect

interpretations or reports” and that errors are “inevitable” but that there is nonetheless “a

threshold of competency” required of all professionals involved in the delivery of imaging

services. Dr. Butt agreed in evidence that there are certain mistakes or discrepancies

which are so serious that they do not fall within the ordinary radiology discrepancy rate of

between 3–5%. and Dr. Siddiqi agreed in cross-examination that the discrepancy rates

(which he stated were between 3–5%) were not relevant where the error was serious.

99. With regard to the appellant’s working conditions and the appellant’s contention that had

there been routine retrospective peer review that “…any issues would have been identified

early and addressed at discrepancy meetings” the court does not agree that in the

absence of such meetings a finding of poor professional performance cannot be made.

The Court accepts the evidence arising from the review of the appellant’s work conducted

by the Faculty and by Dr. Ellis which concluded that in relation to CT scanning, the

appellant’s knowledge was deficient and further accepts the evidence of Dr. Ellis that the

appellant requires supervision to meet basic competency in CT scanning. The Court is

supported in this by the fact that the appellant applied for and purported to undertake a

100. The appellant was aware that the position which he applied for at Bantry General Hospital

was that of a single handed radiologist and he accepted in his evidence that the CV he

submitted for that position misrepresented the nature and seniority of the positions that

he had previously held. With regard to his workload the evidence from Dr Roisin O’Carroll

was that this workload was managed by his predecessor on a three-day week basis and

Dr Ellis opined on the statistics provided that the workload was not particularly onerous.

101. The appellant has sought to rely on the failure of Bantry General Hospital to implement

PACS (Picture Archiving and Communication System) during the course of the appellant’s

employment there for errors in his work particularly in circumstances where he had used

PACS in his previous posts. The Court on the evidence does not accept that the

seriousness of the discrepancy in the appellant’s reporting can be excused by the fact that

the appellant was reporting using hardcopy scans. The Court considers that the evidence

suggests that the appellant was more comfortable with hard copy slides and Dr Ellis is

clear in his evidence that there is no basis to suggest that radiology reports have

improved dramatically in quality since the introduction of PACS and that he sees no

reason why applying professional knowledge to a PACs rather than a plain film should

102. There is no evidence before the Court to suggest any bias on behalf of any of the

witnesses called on behalf of the respondent to include the expert witness.

103. With regard to the audit the evidence before the Court was that Dr Ellis reviewed the 62

scans which formed part of the audit by the Faculty and Deirdre Doolan gave evidence

that the 62 scans were selected as a random 10% selection of the appellants CT scan

reports. The Court finds no evidence as contended for by the appellant that the sample of

scans was not a random sample. Furthermore the court notes that it was held in the case

of Corbally that “A finding of poor professional performance does not depend on an

assessment of a representative cross-section of practitioner’s work, nor is such a “fair

sample” test a preliminary requirement to the making of a complaint against a

104. The Court accepts the expert evidence of Dr. Ellis that of the 19 cases in issue in these

proceedings, that Dr. Siddiqi’s report in 8 of these cases, as outlined above, namely Cases

6, 8, 31, 34, 39, 41, 50 and 59 were each serious errors in their own right. The Court

further accepts the expert evidence of Dr. Ellis that Dr. Siddiqi’s reports in relation to the

remaining eleven scans were each mild or moderate errors in their own right which, when

taken collectively and part of a pattern amounted to a serious error.

105. Accordingly, the Court finds that the Medical Council has established beyond reasonable

doubt the correctness of the finding that Dr. Siddiqi has been guilty of poor professional

performance in accordance with the statutory requirements set down in the Medical

Practitioner’s Act 2007, as elaborated upon by the Corbally case.

106. The Court must therefore go on to consider the correctness of the Council’s decision in

relation to sanction. In that regard, the Court looks to the case of Hermann v. Medical

Council [2010] IEHC 414 referred to above and the facts of this particular case, the range

of sanctions that are available, and the evidence given by Dr Ellis at this hearing as to the

reasonableness of the sanctions imposed. The Court finds that the sanctions imposed are

107. Accordingly, the Court does not accede to the application made by the appellant for

cancellation of the decision of the respondent, Medical Council, dated the 23rd March,

2016, to attach certain conditions to his ongoing registration following their finding of

poor professional performance.

Result: Appellant's claim dismissed.

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You are here: BAILII >> Databases >> High Court of Ireland Decisions >> Siddiqi v Medical Council of Ireland [2019] IEHC 686 (31 May 2019) URL: http://www.bailii.org/ie/cases/IEHC/2019/2019_IEHC_686.html Cite as: [2019] IEHC 686

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