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FITNESS TO PRACTISE PANEL OF THE
MEDICAL PRACTITIONERS TRIBUNAL SERVICE
5 - 8 AUGUST 2013
7th Floor, St James’s Buildings, 79 Oxford Street, Manchester, M1 6FQ Name of Respondent Doctor:

Registered Qualifications:

Area of Registered Address:

Reference Number:

Type of Case:
Panel Members:

Legal Assessor:

Secretary to the Panel:
Representation:
GMC: Mr E Morgan, Counsel, instructed by GMC Legal Doctor: Present and represented by Mr J Leonard, Counsel, instructed by Berrymans
EXCLUSION OF PRESS AND PUBLIC

The Panel passed a resolution, under Rule 41 of the General Medical Council (Fitness
to Practise) Rules 2004, that the press and public be excluded from those parts of the hearing where they considered that the particular circumstances of the case outweighed the public interest in holding the hearing in public. ALLEGATION
“That being registered under the Medical Act 1983, as amended: 1. Between August 2007 and December 2011 you: acted as Patient A's General Practitioner, when you knew this was Admitted and found proved
b. made decisions about Patient A’s management including prescribing Admitted and found proved
Admitted and found proved
d. took blood from Patient A on 2 July 2010; Admitted and found proved
administered a flu vaccination (‘the vaccination’) to Patient A on 5 Admitted and found proved
issue a prescription for the vaccination; Charge withdrawn by GMC under Rule 17(3)
g. failed to make notes in Patient A’s records beyond recording Admitted and found proved
2. Between April 2011 and December 2011, as set out at Schedule 1, you prescribed, to Patient A, excessive quantities of: Bronchodilator inhalers (salbutamol or terbutaline); Admitted and found proved
b. Qvar steroid inhalers (beclomethasone dipropionate); Admitted and found proved
Symbicort combination steroid/long acting beta agonist (budesonide Admitted and found proved
Admitted and found proved
3. Between April 2011 and December 2011 you failed to refer Patient A: a. to another General Practitioner for assessment of her respiratory Found not proved
b. for specialist investigation of her respiratory problems. Found not proved
And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct.” Found not proved

Determination on facts
Dr Bowen: As you are aware, at the start of the proceedings, the Panel passed a resolution, under Rule 41(2) of the General Medical Council (Fitness to Practise) Rules 2004, that this hearing be held in private. This determination wil , therefore, be read out in private but a public version, with appropriate redactions, wil be made available at the close of the hearing. Mr Leonard, on your behalf, made a number of admissions in relation to the facts al eged, as set out in the al egation. These have been announced as admitted and In reaching its decision, on the outstanding paragraphs, the Panel has considered al the evidence placed before it, both oral and documentary. It has also considered the submissions from Mr Morgan, on behalf of the General Medical Council (GMC), The Legal Assessor reminded the Panel that the burden of proof rests on the GMC and that the standard of proof to be applied is that applicable to civil proceedings, namely the balance of probabilities. He advised the Panel in relation to expert evidence, the approach to be taken to your own evidence at this stage of the proceedings, and the construction to be placed on paragraph 3 of the al egation. The Panel has made the fol owing findings on the facts: Paragraphs 1(a), 1(b), 1(c), 1(d), 1(e): Between August 2007 and December 2011 you: acted as Patient A's General Practitioner, when you knew this made decisions about Patient A’s management including took blood from Patient A on 2 July 2010; administered a flu vaccination (‘the vaccination’) to Patient A on
have been admitted and found proved.

Paragraph 1(f) in its entirety was withdrawn following an application
under Rule 17(3) by the GMC.

Paragraphs 1(g), 2(a), 2(b), 2(c), and 2(d):
failed to make notes in Patient A’s records beyond recording Between April 2011 and December 2011, as set out at Schedule 1, you prescribed, to Patient A, excessive quantities of: Bronchodilator inhalers (salbutamol or terbutaline); Qvar steroid inhalers (beclomethasone dipropionate); Symbicort combination steroid/long acting beta agonist
have been admitted and found proved.

Paragraph 3(a):
Between April 2011 and December 2011 you failed to refer Patient A: to another General Practitioner for assessment of her respiratory
has been found not proved.
The Panel first considered Mr Leonard’s submission that any obligations to Patient A could only derive from your status as her General Practitioner (GP), and that, as you should not have been performing that role (as al eged and admitted in paragraph 1(a)), the obligations could not apply to you. The Panel has rejected that submission. It considers that you were as a matter of fact performing the role of her GP and that, even though this is contrary to Good Medical Practice, you were stil obliged to perform that role properly, acting in the patient’s best interests. The Panel then went on to consider the substantive al egation. The Panel accepted the thrust of the definition of referral put forward by Mr Morgan, namely, that in a clinical context, the concept of a referral means more than the mere sharing of information. A referral should involve the direction of a question or issue from one medical practitioner to another, and a request for some action or treatment that is recognised as such by the recipient of the referral. The Panel accepted the expert evidence that in general practice such a referral could take the The Panel accepted that you had a conversation with Dr A about Patient A, and that you had arranged for blood tests results to be sent to him. As a result of these actions, and as evidenced by the entries in the patient’s medical records made by Dr A, on 15 and 17 June 2011, it is clear that he assessed the blood test results, conducted a telephone consultation with Patient A, recorded her then current condition, and noted that she should be monitored closely. The Panel considered that it had not been presented with sufficient evidence to find that you failed to refer Patient A to another General Practitioner for assessment of
Paragraph 3(b):
for specialist investigation of her respiratory problems.”
has been found not proved.
The Panel accepted the expert evidence that specialist respiratory investigations It considered that Dr A was the specialist GP in the practice in respiratory medicine, and could therefore, appropriately receive referrals for such investigations. Given the observations concerning Dr A’s involvement as set out in relation to paragraph 3(a), the Panel was not satisfied that you had failed to refer the patient for specialist investigation of her respiratory problems. Determination on impaired fitness to practise
Dr Bowen: This determination wil be read out in private but a public version, with appropriate redactions, wil be made available at the close of the hearing. At this stage of the proceedings, the Panel must decide, under Rule 17(2)(k) of the General Medical Council’s (Fitness to Practise) Rules 2004, whether, on the basis of the facts found proved, your fitness to practise is impaired by reason of your In reaching its decision, the Panel has given consideration to al the evidence adduced, both oral and documentary, and has taken account of the submissions of Mr Morgan, on behalf of the GMC, and those made by Mr Leonard, on your behalf. Mr Morgan invited the Panel to find that your fitness to practise is impaired by reason of misconduct. Whilst recognising the extenuating circumstances operating in this case and the fact that you have made no attempts to conceal your conduct, he submitted that you acted as Patient A’s General Practitioner (GP) knowing that you were wrong to do so and despite there being alternative routes available to manage her care. He also submitted that you were not compel ed to act as you did and that you have yet to develop full insight into your conduct. Mr Leonard invited the Panel to find that the facts of your case do not amount to misconduct. He submitted that, if the Panel did find misconduct, it need not necessarily find that your fitness to practise is impaired by reason of it. Mr Leonard stated that he was not suggesting, on your behalf, that you had no choice but to act in the way that you did, but he did stress that you were under considerable pressure to do so. He emphasised the isolated nature of this episode, your otherwise unblemished record, and the evidence of remediation, insight and remorse. Mr Leonard also submitted that this is not a case involving moral y culpable behaviour, but that it relates primarily to the exercise of your professional practice, a view that Whilst the Panel has noted the submissions made, it has exercised its own judgment in considering whether your fitness to practise is impaired. The Panel has approached its task in two stages. Firstly, it needed to determine whether the facts found proved were sufficiently serious to amount to misconduct. Secondly, only if misconduct was found, would it need to go on to consider whether your fitness to practise is impaired on the basis of that misconduct. Throughout its deliberations, the Panel has borne in mind its responsibility to protect the public interest. This includes the protection of patients, the maintenance of public confidence in the profession, and the declaring and upholding of proper In relation to misconduct, the Panel noted that you have admitted, and the Panel has found proved, that you acted inappropriately by performing the role of Patient A’s GP, XXX. In that role you proceeded to manage her complex medical condition and to prescribe a range of medication which, although clinical y indicated, was excessive in quantity. You have also admitted failing to make appropriate entries in The Panel has noted that you performed this inappropriate role over a period of several years, XXX, there were times when you lost the objectivity and independence necessary to ensure that she received optimal care. You have accepted that your actions were not always in her best interests. The Panel has heard that, in relation to your prescribing, there was a risk – albeit a smal one – of harmful side effects arising from over-prescription. The Panel has also noted that your performance of this role was only brought to an end by the intervention of the PCT. The Panel accepts that you were under very considerable pressure from Patient A to act as her GP and that refusal to do so would have caused her considerable distress. Nonetheless, you have conceded that you did have a choice in the matter and that there were others available to treat her. The Panel has also noted that, in your account of events given to the PCT, you admitted that external financial and professional pressures had contributed to the delay in dealing with the situation. The Panel has concluded that you were not under irresistible pressure to treat Patient A and that you could have done more to avoid doing so. The Panel considers that the relationship between the profession and the public is based on the expectation that medical practitioners wil act appropriately at al times. As a doctor you are expected to ensure that your judgement is not clouded XXX, that your record keeping is adequate to support his or her future care and that you prescribe in a responsible and appropriate manner in al circumstances. The Panel considered that you breached those principles as set out in Good The Panel has noted the view of the GMC expert that your conduct fel seriously below the standards expected of a registered medical practitioner. In al the circumstances, the Panel was in no doubt that the facts found proved are sufficiently serious to amount to misconduct. The Panel then went on to consider whether your fitness to practise is currently impaired by reason of your misconduct. The Panel is aware that a finding of misconduct may frequently lead to a finding of impaired fitness to practise but that each case turns on its own facts and particular circumstances. In coming to its decision on impairment, the Panel has considered the context in which your misconduct occurred. It has also considered the issues of remediation, Whilst the Panel has noted that the events referred to span the period from 2007 to 2011, it considered that they amounted to a series of linked actions concerning one patient which were triggered by exceptional circumstances. More specifical y, Patient A was someone whose personal circumstances made it very difficult, both physical y and psychological y, for her to engage with standard GP services. The Panel is in no doubt that XXX, she placed you under extraordinary pressure to act as her GP and that, had you not done so, she would have experienced additional, significant distress. Whilst the Panel does not condone, and is indeed highly critical of your decision to succumb to this pressure, it cannot ignore the exceptional features of this case when considering whether there is any risk of repetition of your Further, with regard to that misconduct, the Panel has noted that you tried to get your col eagues to re-engage with the patient, and that you attempted to persuade the patient to see your col eagues. At times you were successful in this regard. Thus whilst your treating of Patient A was a serious failing, it cannot be said that you were taking sole responsibility for her care. The Panel has borne in mind that, with the exception of the facts which were withdrawn or found not proved, you admitted al the facts of your case at the outset of the hearing. It has also borne in mind that no evidence has been placed before it to suggest that you have acted in this way in any other circumstances, or have repeated the behaviour since. On the contrary, the evidence before the Panel, including the testimonials, suggests that your professional conduct is otherwise You have been open and honest about your actions from the time they were discovered. You made it clear to the Panel that you understand why your actions were wrong and have expressed genuine remorse for your behaviour. You explained that Patient A is now in a supportive and constructive clinical relationship with a GP in another practice. In any event, were that not the case, you assured the Panel that you would never repeat the errors of judgement that gave rise to this case. The Panel has noted that the Primary Care Trust chose not to remove you from their Performers’ List, and that their subsequent actions suggest that they consider you to have remedied your failings. It has borne in mind that the GP practice where you were working at the time as a partner chose to offer you a salaried position after Bearing al the evidence in mind the Panel has concluded that, you have remedied your conduct, have good insight into your actions, and that the risk of your repeating your behaviour, even if the exceptional circumstances were to reoccur, is The Panel considers that you have learned a salutary lesson from these proceedings. It is satisfied that the findings of fact, together with its finding of serious misconduct, which are significant in themselves, wil send out a clear message to the public, the profession, and to you, that your actions were unacceptable. The Panel has determined that, in the exceptional circumstances of your case, a decision to al ow you to continue in unrestricted practice would not undermine the public’s confidence in the profession, nor would it place patients at risk. In al the circumstances, the Panel has determined that your fitness to practise is not currently impaired by reason of your misconduct.
Determination on a warning
Dr Bowen: This determination will be read out in private but a public version, with appropriate redactions, will be made available at the close of the hearing. Having found that your fitness to practise is not impaired by reason of your misconduct, the Panel has considered whether to issue a warning in your case. In reaching its decision, the Panel has given consideration to all the evidence adduced in this case, both oral and documentary, and has taken account of the submissions made by Mr Morgan, on behalf of the General Medical Council (GMC), and those of Mr Leonard, on your behalf. Mr Morgan invited the Panel to impose a warning in your case. He submitted that the Panel’s findings as set out in its determination on impairment satisfy the guidelines for the issuing of a warning. Mr Leonard accepted that the findings would al ow the Panel to impose a warning in your case. However, before doing so, he suggested that the Panel might want to consider whether it is necessary to issue a warning in the light of its comment that the findings of fact, together with the finding of serious misconduct, wil send out a clear message to the public, the profession, and to you, that your actions were unacceptable. He made submissions in relation to the potential wording of the warning should the Panel chose to impose one. Whilst the Panel has noted the submissions made, it has exercised its own judgment in considering whether to issue a warning in your case. The Panel has already given a detailed determination in relation to impairment and it has taken those matters into account during its deliberations at this stage of the proceedings. The Panel has also taken into account the GMC’s Guidance on Warnings (dated May 2012) and the Indicative Sanctions Guidance (dated April 2005 and updated in August 2009). Throughout its deliberations, the Panel has borne in mind its responsibility to protect the public interest. The public interest includes the protection of patients, the maintenance of public confidence in the profession, and the declaring and upholding of proper standards of conduct and behaviour. The Panel has applied the principle of proportionality and has balanced the public interest with your interests. In reaching its decision, the Panel has noted, amongst other things, your previous good character, that you have shown remorse for your actions, and that the evidence before it suggests that your professional conduct is otherwise exemplary. It has borne in mind that you have been open and honest about your actions, and that you have accepted that they were wrong. As noted previously, the Panel considers that you have remedied your conduct, have good insight into your actions, and that the risk of your repeating your behaviour is negligible. Nonetheless, the facts found proved in your case were serious, represented a significant departure from Good Medical Practice, in particular paragraphs 3(b), 3(f) and XXX, and amounted to misconduct. That misconduct is sufficiently serious that, if there were a repetition, it would be likely to result in a finding of impaired fitness to practise. In all the circumstances, the Panel has determined that it is appropriate and proportionate to impose a formal warning as follows: “Dr Bowen: Between August 2007 and December 2011 you acted as a
General Practitioner to a patient when it was inappropriate to do so. You then
made decisions about the patient’s management and medication without
appropriate recording in the patient’s record. In 2011 you also prescribed
wasteful amounts of medication to that patient.

The Panel recognises that there were exceptional circumstances that led to
your conduct in this particular case and that they are very unlikely to recur.
Nonetheless, your conduct did not meet the standards required of a doctor, as
set out in Good Medical Practice and associated guidance. It is, therefore,
necessary in response to issue this formal warning. Your misconduct is
sufficiently serious that, if there were a repetition, it would be likely to result in
a finding of impaired fitness to practise.
This warning will be published on the List of Registered Medical Practitioners (LRMP) for a period of five years and will be disclosed to any person enquiring about your fitness to practise history. After five years, the warning will cease to be published on LRMP; however, it will be kept on record and disclosed to employers on request.” Any breach of the warning may be taken into account by the GMC in the future. That concludes this case. Prescription
Loratadine Tablets 10 mgR bd (ranbaxy60 table Co-Amoxiclav 250/125 Tablets C tds42 table Mepilex Border- Dressing 10 cm x 20 craC asdlS dress Miconazole Org] Gel Sugar Free 24 mg/mC asdBO grams Co-Amoxiclav 250/125 Tablets C tds21 table Paracetamol Caplets 500 mgC 2 qds asdlOO capi Co-Amoxiclav 500/125 Tablets C 1 tds21 table Warfarin Sodium Tablets 1 mgR asd56 table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbinafine Hydrochloride Tablets 250 R od28 table Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Montelukast Sodium Tablets 10 mgR Id28 table Fexofenadine Hydrochloride Tablets 1B0R ld30 table Esomeprazole Gastro-Resistant Tablets R 1 nocte2B table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Budesonide And Formoterol Dry Powder InR use asd2 inhale Warfarin Sodium Tablets 1 mgR asd56 table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbinafine Hydrochloride Tablets 250 R od2e table Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Montelukast Sodium Tablets 10 mgR ld28 table Loratadine Tablets 10 mgR bd (ranbaxy60 table Fexofenadine Hydrochloride Tablets 180R ld30 table Esomeprazole Gastro-Resistant Tablets R 1 nocte28 table Budesonide And Formoterol Dry Powder InR use asd2 inhale Mepilex Border Dressing 10 cra x 12.5 cC asdlO dress Co-Amoxiclav 500/125 Tablets C 1 tds42 table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Budesonide And Formoterol Dry Powder InR use asd2 inhale Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Chloramphenicol Eye Drops 0.5 IC one drop 4 10 ml Budesonide And Formoterol Dry Powder InR use asd2 inhale Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Co-Amoxiclav 500/125 Tablets C 1 tds21 table Budesonide And Formoterol Dry Powder InR use asd2 inhale Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Warfarin Sodium Tablets 1 mgR asd56 table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbinafine Hydrochloride Tablets 250 R od28 table Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Montelukast Sodium Tablets 10 mgR ld28 table Loratadine Tablets 10 mgR bd (ranbaxy60 table Fexofenadine Hydrochloride Tablets 180R ld30 table Esomeprazole Gastro-Resistant Tablets R 1 nocte2B table Co-Amoxiclav 500/125 Tablets C 1 tds42 table Budesonide And Formoterol Dry Powder InR use asd2 inhale Warfarin Sodium Tablets 1 mgR asd56 table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Miconazole Oral Gel Sugar Free 24 mg/mC asdBO grams Budesonide And Formoterol Dry Powder InR use asd2 inhale Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbinafine Hydrochloride Tablets 250 R od28 table Qvar 100 Autohaler Cfc-Free Breath-ActuR a5d4 inhale Montelukast Sodium Tablets 10 mgR ld28 table Fexofenadine Hydrochloride Tablets 180R ld30 table Esomeprazole Gastro-Resistant Tablets R 1 nocte2B table Budesonide And Formoterol Dry Powder InR use asd2 inhale Tubigrip Elasticated Support Bandage StC asd2 bandag Co-Amoxiclav 500/125 Tablets C 1 tds42 table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 23/07/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR a5d4 inhale Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs prnl inhale Budesonide And Formoterol Dry Powder InR use asd2 inhale Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 30/07/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs prnl inhale Budesonide And Formoterol Dry Powder InR use asd2 inhale Erythromycin E/C Tablets 250 mgC 2 od56 table Warfarin Sodium Tablets 1 mgR asd56 table Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 07/08/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Montelukast Sodium Tablets 10 mgR ld2e table Loratadine Tablets 10 mgR bd (ranbaxy60 table Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs prnl inhale Fexofenadine Hydrochloride Tablets 180R ld30 table Esomeprazole Gastro-Resistant Tablets R 1 nocte28 table Budesonide And Formoterol Dry Powder InR use asd2 inhale Ventolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 15/08/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs prnl inhale Budesonide And Formoterol Dry Powder InR use asd2 inhale Ventolin Evohaler Cfc-Free Inhaler 1O0R asd4 inhale Terbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 20/08/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs qds2 inhale udesonide And Formoterol Dry Powder InR use asd2 inhale 102. W arfarin Sodium Tablets 1 mgR asd56 table entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 26/08/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale 106. M ontelukast Sodium Tablets 10 mgR ld2B table Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs qds2 inhale 108. Fe xofenadine Hydrochloride Tablets IBOR ld30 table someprazole Gastro-Resistant Tablets R 1'nocte28 table 110. Er ythromycin E/C Tablets 250 mgC 2 od56 table udesonide And Formoterol Dry Powder InR use asd2 inhale entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbinafine Hydrochloride Tabieta 250 R od28 table erbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 03/09/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs qds2 inhale uticasone Propionate Nasal Drops (Unie 6 drops int28 unit udesonide And Formoterol Dry Powder InR use asd2 inhale entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbutaline Sulphate Breath-Actuated DrC inhale 1 dol inhale 12/09/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs qds2 inhale udesonide And Formoterol Dry Powder InR use asd2 inhale 125. W arfarin Sodium Tablets 1 mgR asd56 table entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbutaline Sulphate Breath-Actuated DrC 2 puffs prn2 inhale 20/09/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free inhaler 2C 2 puffs qds2 inhale someprazole Gastro-Resistant Tablets R 1 nocte28 table 131. Er ythromycin E/C Tablets 250 mgC 2 od56 table udesonide And Formoterol Dry Powder InR use asd2 inhale entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbutaline Sulphate Breath-Actuated DrC 2 puffs prn2 inhale 05/10/2011 albutamol Nebuliser Solution 2.5 mg/2C asd20 singl Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2C 2 puffs qds2 inhale uticasone Propionate Nasal Drops (UniR 6 drops int28 unit udesonide And Formoterol Dry Powder InR use asd2 inhale erbinafine Hydrochloride Tablets 250 R od28 table erbutaline Sulphate Breath-Actuated DrC 1 -2 puffs 3 inhale 10/10/2011 Ipratropium Bromide Cfc-Free inhaler 2C 1 -2 puffs 3 inhale Co-Amoxiclav 500/125 Tablets C 1 tds21 table entolin Evohaler Cfc-Free Inhaler 100R asd'l inhale erbutaline Sulphate Breath-Actuated DrR 1 -2 puffs 3 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale 148. Mi conazole Oral Gel Sugar Free 24 mg/mR asdBO grams Ipratropium Bromide Cfc-Free Inhaler 2R 1 -2 puffs 3 inhale Budesonide And Formoterol Dry Powder InR 2 puffs bd3 151. Mi conazole Oral Gel Sugar Free 24 mg/mC apply tdslS grams 13/10/2011 152. W arfarin Sodium Tablets 1 mgR asdB4 table entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbinafine Hydrochloride Tablets 250 R od28 table erbutaline Sulphate Breath-Actuated DrR 1 -2 puffs 3 inhale 20/10/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale 157. M ontelukast Sodium Tablets 10 mgR ld2a table Ipratropium Bromide Cfc-Free Inhaler 2R 1 -2 puffs 3 inhale uticasone Propionate Nasal Drops [UniR 6 drops int28 unit 160. Fe xofenadine Hydrochloride Tablets 180R ld30 table someprazole Gastro-Resistant Tablets R 1 nocte28 table Co-Amoxiclav 500/125 Tablets C 1 tds21 table Budesonide And Formoterol Dry Powder InR 2 puffs bd3 entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbutaline Sulphate Breath-Actuated DrR 1 -2 puffs 3 inhale 27/10/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2R 1 -2 puffs 3 inhale Budesonide And Formoterol Dry Powder InR 2 puffs bd3 entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbutaline Sulphate Breath-Actuated DrR 1 -2 puffs 3 inhale 03/11/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale Ipratropium Bromide Cfc-Free Inhaler 2R 1 -2 puffs 3 inhale udesonide And Formoterol Dry Powder InR 2 puffs bd3 entolin Evohaler Cfc-Free Inhaler 100P. asd4 inhale erbutaline Sulphate Breath-Actuated DrR 2 puffs prn4 inhale 09/11/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale 177. Mi conazole Oral Gel Sugar Free 24 mg/mR asdSO grams Ipratropium Bromide Cfc-Free Inhaler 2R 2 puffs prn4 inhale Clotrimazole Cream And Pessary 2 % + 5C use as per 1 Budesonide And Formoterol Dry Powder InR 2 -4 puffs 4 181. W arfarin Sodium Tablets 1 mgR asdS4 table entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale erbinafine Hydrochloride Tablets 250 R od28 table erbutaline Sulphate Breath-Actuated DrR 2 puffs prn4 inhale 16/11/2011 Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale 186. M ontelukast Sodium Tablets 10 mgR ld28 table Ipratropium Bromide Cfc-Free Inhaler 2R 2 puffs prn4 inhale uticasone Propionate Nasal Drops (UniR 6 drops int28 unit 189. Fe xofenadine Hydrochloride Tablets 180R ld30 table someprazole Gastro-Resistant Tablets R 1 nocte28 table Budesonide And Formoterol Dry Powder InR 2 -4 puffs 4 entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbutaline Sulphate Breath-Actuated DrR 2 puffs p m 4 odium Chloride Nebuliser Solution 0.9C qds20 ampou Qvar 100 Autohaler Cfc-Free Breath-ActuR asd4 inhale 196. Pr ednisolone E/C Tablets 5 mgC 40 mg as ne56 table Ipratropium Bromide Cfc-Free Inhaler 2R 2 puffs prn4 inhale Co-Amoxiclav 500/125 Tablets C 1 tds21 table 199. Cl arithromycin Tablets 500 mgC 1 bdl4 table Budesonide And Formoterol Dry Powder InR 2 -4 puffs 4 ubigrip Elasticated Support Bandage StC asd2 bandag entolin Evohaler Cfc-Free Inhaler 100R asd4 inhale Terbutaline Sulphate Breath-Actuated DrR 2 puffs p m 4 Qvar 100 Autohaler Cfc-Free Breath-ActuK asd4 inhale 205. Pr ednisolone E/C Tablets 5 mgC 40 mg as ne56 table Ipratropium Bromide Cfc-Free Inhaler 2R 2 puffs p m 4 inhale 29/11/2011 Budesonide And Formoterol Dry Powder InR 2 -4 puffs 4 erochamber Plus Spacer Device standarC asdl device

Source: http://www.mpts-uk.org/static/documents/content/Bowen.pdf