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Decision No: 98/20C
Practitioner: Dr Paul Francis Silvester
Charge Characteristics: Inadequate care
Additional Orders: Doctor granted interim name suppression (majority decision):
Doctor's interim name suppression order vacated:  9820cfindingslaw
Full Decision: 9820cfindingslaw



A CAC charged that Dr Silvester, in the course of his management of his patient for a de-gloving laceration over the anterolateral aspect of the distal left thigh:

  1. Carried out a surgical procedure in Accident and Emergency under local anaesthetic; rather than in theatre under general anaesthetic;
  2. Carried out an immediate closure of the wound rather than a delayed closure;
    thus exposing the patient to greater risk of infection and complications, such conduct constituting conduct unbecoming a medical practitioner which reflects adversely on the practitioner's fitness to practice medicine.



The patient was a pillion passenger on a motorcycle involved in an accident with a truck. She suffered a degloving injury of the left leg involving "a forty centimetre irregular laceration". Dr Silvester irrigated the wound with a dilute local anaesthetic. The wound was then closed and a dressing applied. The patient was transferred to another hospital the following morning. The following day the patient was unwell and x-rays showed the presence of a gas-forming organism. At operation the necrotic tissue was removed and multiple further procedures were required.



Dr Silvester was found not guilty of conduct unbecoming a medical professional, which reflects adversely on his fitness to practice medicine.

The Tribunal found that the surgical procedure carried out by Dr Silvester in A & E under local anaesthetic on the facts of the case did not expose the patient to greater risk of infection and complications. The Tribunal was not prepared to substitute its judgement for that exercised by Dr Silvester to perform the procedure under local anaesthetic because his judgement depended on his own assessment of the wound, time, place and circumstances. However, the Tribunal accepted the evidence of experts that such wounds are generally best explored under general anaesthetic.

The Tribunal found as a fact Dr Silvester undertook a primary closure of the wound. The Tribunal was satisfied that it was an error on Dr Silvester's part to have undertaken a primary closure rather than a delayed closure of the wound. However the Tribunal concluded that the problems the patient experienced developed because of the difficulty in assessing the extent of tissue damage from ischaemia, and the complicating factor of a division of care because of the patient's transfer to another hospital. In closing the wound prior to the patient being transferred the Tribunal concluded that Dr Silvester may have exposed the patient to a greater risk of infection. The Tribunal considered that this error was not sufficient to warrant a finding of conduct unbecoming.