Not guilty verdict in FGM case - what do we think?

[Amethyst24]

www.bbc.co.uk/news/uk-england-31138218

It did seem like an intractable case with which to test the legislation, and it does appear the doctor was put in a position in which he had no idea how best to proceed. But I think it's encouraging that other medical staff are reacting when they see victims of the crime.

It's weird that being a consultant you would call a junior reg (who was very shortly afterwards promoted to a senior reg - so clearly not new to the game) a "very junior doctor." I would consider an FY1 or FY2 to be "very junior." I would also expect someone who's working as a junior reg in obs to know something about the injuries they could encounter (given they will be required to stitch vaginal/labial tears) and what to do in those circumstances.
I would consider understanding of how to stop labial bleeding, no matter what the cause, to be very basic knowledge for an obs doctor. I had labial damage having my DS and the midwife did the stitching. I'd find it very odd for a junior reg not to have that knowledge, such that he simply closes up an old area of scar tissue.

I'm sure he did know how to repair a normal labial tear. It sounds to me like he didn't know the legalities about resuturing an FGM lady. So he should have put some stitches in one labia on one side. Then with a new thread stitched the other side to stop any bleeding. Instead it sounds like he sewed them back together.

The hospital should have covered this on induction if it's an area with a high rate of FGM which it sounds like it is.

But Viva, don't you think it's odd that rather than doing what you described, which is what the normal approach to a typical labial tear would be, he just stitched the infibulation back together? It seems odd for a doctor to see an obviously poorly stitched wound, to open it, as necessary, and to then just close that poor stitched wound again rather than going about repairing the old wound (or at least packing the wound to help stop bleeding until a further consult could be obtained).

It seems sloppy and unprofessional to me.

What I'm saying is, he might not be au fait with FGM (although as a doctor with any interest in obs, lack of knowledge of FGM seems ridiculous to me) but he would be able to see with his own eyes the state the woman's vulva was in, and I would expect a competent doctor to deal with the immediate emergency and then go about solving the more long term issue of the labial damage, rather than just sticking a stitch in and moving on. I know he alerted his supervisor at a later stage but still it seems very odd that he didn't consider the whole issue serious enough at the time to warrant immediate and proper treatment.

When I was a student I rememebr a mentor saying that a confident, experienced practitioner will reflect in practise, so at the time but a less experienced person will reflect on practise, so afterwards.

Sounds like he was still at the stage of reflecting on practise. Which may well have been exacerbated by working in a busy labour ward and feeling under pressure to be at another emergency.

Ive see senior registrars who are incompetent at more basic stuff than an unusual tear so this doesn't suprise me that a junior reg might have struggled here. If he'd taken a few minutes to think this through there may have been a different outcome, but that doesn't warrent prosecution.

Caillin - from the Guardian report linked to upthread, it sounds like his workload that day was enormous - he was needed to attend to an emergency CS immediately after, did what he genuinely (if mistakenly) believed to be the best repair he could at the time, then afterwards, when he had a moment to think about it, realised it probably wasn't the best course of action and raised it with a supervisor.

I would have thought that, in an inner London hospital, FGM should be pretty high up on the list of subjects that any member of staff in oby/gyn should be fully briefed and educated in?

Oh yeah I don't think he should have been prosecuted at all, he was clearly targeted. But the only positive outcome is that it will make doctors vigilant and hopefully dramatically increase detection and awareness of FGM.

Horrible thought though - will some women be forced to labour at home for fear FGM will be discovered? If a woman has FGM the chances of a risky delivery are very high.

"I would have thought that, in an inner London hospital, FGM should be pretty high up on the list of subjects that any member of staff in oby/gyn should be fully briefed and educated in?"

I'm not sure, and would be interested to know. My completely un-educated guess would be that they should definitely be well briefed, but I'd be surprised if the briefing was put into practise enough to have the all doctors be experienced enough to make 100% correct judgement calls in high pressure situations. If that makes sense.

My general experience is that HCPs have appallingly poor knowledge of even the basics of female reproductive health so it doesn't surprise that the extra knowledge about FGM isn't being passed on.

I was just wondering how apart from girls/coming forward is there no other way that you are going to catch perpetrators?

I'm not sure Breaking. I mean, I suppose if someone learns that a person is carrying out FGM they can report them but I'd imagine that's well covered up.

The only time I've ever had a vaginal exam is when in labour. I've had smears but it was up to me to attend them, if I was trying to hide FGM I wouldn't go.

Many women who've undergone FGM live in extremely misogynistic cultures where their movements are very restricted. A lot may not understand English very well and so may not know how to report. They may also be told by the people around them that they will be in trouble if the FGM is found.

This was clearly a desperate attempt to bring a prosecution, any prosecution. The real disgrace is that no-one has been prosecuted for undertaking an initial FGM, not a post partum stiching.

The law here is clearly not fit for purpose, since it seems to rely on girls giving evidence against their families. The French law seems better. As I understand it, if one has custody of a child and that child is (on inspection; and there are inspections) found to have suffered FGM then the person with custody is automatically guilty of an offence. The French are less squeamish about idenitifying girls at risk and overtly monitoring them

I lived in Nigeria for a couple of years. FGM was common in my area (don't know what type but pretty extreme). It was sometimes discussed b/w the ex-pat midwifery/medical community (never amongst Nigerian women in my hearing - very taboo subject). Certainly I was left with the impression that there was no choice after childbirth but to restitch the incision. Maybe that was due to the basic facilities available but I must admit I can't envisage a straightforward alternative. When the labias etc are gone how/what do you reconstruct with? I imagine a series of surgeries would be required and for full consent from the woman (the important bit) you'd need a more detailed discussion about possible outcomes etc than is possible in the immediate aftermath of birth.

I heard the DPP on the radio this morning talking about this case and found her unconvincing. Having read the article posted above, the whole thing seems even less satisfactory.

The CPS invariably seems to take a defensive stance about the rightness of its decisions and processes, which is worrying, particularly given that Rotherham council has just been criticised for refusing to consider they could be at fault over anything, ever. The CPS seems to take the same stance whenever they are asked about any of their decisions.

For example, recently there was a case where the DPP carried out a review into their decision making when a woman they were prosecuting killed herself. Surprise surprise, it was found the CPS was blameless. Various victim groups complained.

The CPS has been criticised by its own inspectors for how it deals with complaints and set up something they call an independent assessor, but if a complaint is made to the independent assessor the CPS writes the terms of reference, which hardly seems independent to me. In some cases people can complain under the victim's code but the criteria for that are narrow and not always relevant. The Attorney General's office is supposed to be responsible for the CPS but any complaints to them get forwarded to the CPS to draft the answer, and most of the AG's lawyers are seconded from the CPS anyway. The CPS is not covered by the Parliamentary Ombudsman either, so there is no check or balance there.

Sorry if this is at a bit of a tangent to the case under discussion but I think it is quite dangerous to have an organisation today that basically is allowed to regulate itself.

I agree with the poster who said it is interesting the DPP was to attend a select committee meeting shortly after the decision to prosecute was made. Maybe that is cynical, but the CPS is pretty keen on doing PR in the media to make itself look good. I was a victim and was treated terribly by them, despite there being an eventual conviction, and I have noticed for years and years that how they present themselves in the media bears no relation to how they behave as an organisation when no one is looking. I think they need to concentrate a bit less on defending themselves or trying to make themselves look good and a bit more about their competence, decision making, being answerable, how to behave when something goes wrong, and how to improve from now on with the currently disgraceful situation regarding the lack of FGM prosecutions.

Why was the Dr prosecuted? From what I can gather he was repairing an existing FGM after the patient had given birth. Albeit he may not have carried out the procedure completely correctly, but he obviously did not set out to mutilate the patient. He flagged the issue to a colleague, so he wasn't trying to cover it up. This incidence is a training issue, not a criminal one IMO.
I agree the French law /system seems better. Action needs to be taken in communities in which FGM is prevalent when potential victims are young girls / babies (e.g. random inspections of potential victims). Anything else is too late.

The woman had said that she had had FGM performed but she had surgery to allow her to get pregnant. It appears that in the time between that & labour, the scar had healed up again. She was not examined prior to labour despite her caregivers knowing this and was not referred her to the relevant consultant or antenatal clinic to allow for repeat surgery/planning.

www.bbc.co.uk/news/uk-england-31138218

cailindana, you have called Dr Dharmasena "unprofessional" twice.

I'd be interested to know what you, with your training in obs and gynae, would have done in those busy few minutes of helping one mother deliver her distressed baby and then bleed from a wound before having to dash off to perform/assist with an emergency section on another mother with a distressed baby.

He made the best decision he could at the time.

He agrees that he could have done better but the patient, surely one of the best judges here, was not harmed and does not believe herself to have been harmed.

shaska, "I did read that he had denied a couple of motions to dismiss, or something - does anyone know why?"

One of the Guardian articles says:

"During the trial process the judge rejected two attempts by the defence to dismiss the prosecution on the grounds that, under the Female Genital Mutilation Act 2003, a doctor is exempt from prosecution if a surgical procedure was carried out on a woman in labour or after childbirth and was medically necessary."

www.theguardian.com/society/2015/feb/05/cps-chief-alison-saunders-fgm-case-doctor-acquitted-30-minutees

It is a real shame that this was the first case. Certainly the media impression I was left with when he was first charged was that he had done this at the instruction of the husband and wasn't it awful etc. Which seems to be far from true.

Also, I don't think it's fair to say the hospital hung him out to dry. I assume there are strict protocols when an injury in the course of medical treatment needs to be reported to police and I imagine the hospital expected the report to be filed, maybe a couple of questions, then the case put away.

The hospital did not report the case to the police. They conducted an inquiry which said that the doctor and some other staff needed retraining and some time to reflect.

Clearly this wasn't enough for someone with an axe to grind who leaked it to the police.

The police then sat on it for 2 years after a rubbish initial inquiry - they didn't look at the notes or interview the woman with an interpreter.

Until suddenly the CPS was under intense pressure to have a prosecution and they remembered this one gathering dust in a cupboard - and hey, presto! A prosecution.

Strict protocols? Ha ha ha.

Ah, thanks Kundry.

I've never known "strict protocols" in any hospital I've worked in either, Kundry!

The Guardian though does say that the hospital did report it to the police:

"In the aftermath of the incident, a hospital inquiry examined what had taken place, labelling the event a “serious untoward incident”. The inquiry recommended more training for the doctor and a period of reflection. Five months after the incident, he was made a senior registrar.

Meanwhile, the hospital had referred what had taken place in the delivery room to the Metropolitan police as a matter of course because of its concerns."

www.theguardian.com/society/2015/feb/04/first-female-genital-mutilation-prosecution-dhanuson-dharmasena-fgm

It isn't clear how or particularly why in this case it was reported to the police though.

The timing of the announcement of the prosecution and Saunders' appearance at the select committee are very interesting...