The treating doctor deals with Mr Carrim's business affairs only in a facilitative role and is not directly involved in running the businesses; paragraph 53 on page 45 explains this role and the context of the doctor's intervention.
“The doctor himself never says that he gets involved in the business per se. He has a facilitative role, where it is appropriate to play a facilitative role... paragraph 53.1 on page 45 gives you the context of how the doctor enters the equation.”
The doctor himself must make a clinical assessment before relaying matters to Mr Carrim, not just relay a telephone message or question.
“the doctor himself says that whatever matter has to go to Mr Carrim through the doctor is not just simply relaying a telephone message or relaying a question, but that the doctor himself has to make a clinical assessment at that moment in time”
Mr Carrim was allowed to bring a substantive application for a postponement to address his movements, supported by affidavits from his second wife and doctor describing restrictions on his movement and interactions.
“Mr Carrim was then afforded the opportunity to bring a substantive application for the postponement and in that application an opportunity was provided to address the latest information regarding Mr Carrim's movements around the Cape and this is addressed in two affidavits. The one... is by his second wife and the second affidavit is by his doctor”
There was a medical incident requiring Mr Carrim to return quickly, accompanied by a deponent who took him to the doctor and was with him during the consultation.
“because there was a medical incident ... That was the deponent who took Mr Carrim to the doctor and accompanied him and was with him during the consultation”
Mr Carrim was given an opportunity to bring a substantive application for postponement and responded with affidavits from his second wife and his doctor detailing the restrictions on his movements.
“Mr Carrim was then afforded the opportunity to bring a substantive application for the postponement and in that application an opportunity was provided to address the latest information regarding Mr Carrim's movements around the Cape and this is addressed in two affidavits. The one... is by his second wife and the second affidavit is by his doctor.”
There was a medical incident that led to Mr Carrim's return from Mafikeng, which required a consultation accompanied by the deponent.
“there was a medical incident ... and it was the deponent who took Mr Carrim to the doctor and accompanied him and was with him during the consultation”
Mr Carrim's movements to North West became contentious and the doctor’s affidavit confirms the 14 July incident lasted 4 hours for purchasing toiletries and medication, with precise times recorded in facility's records.
“The doctor's version on the 14th of July in his first affidavit ... the description of the 14th of July incident ... confirmation that it was 4 hours ... for the purpose of purchasing toiletries, over the counter flumedication”
The doctor states the facility's records show Mr Carrim departed at approximately 1:30 pm and returned at approximately 5 pm on 14 July, and such excursions are not unusual.
“the facility's records reflect that he departed at approximately 1:30 and returned at approximately 5... these kind of excursions are not unusual”
The facility is not a place where a patient may enter and leave at will; leaving requires a pass from the treating doctor or self-discharge.
“I deal next with the facility's leave regime because I understand that an impression may exist that the facility is a place a patient may enter and leave at will. That impression would be false.”
The doctor’s medical assessment and report to the Commission were based on flawed factual foundation due to lack of full knowledge of Mr Carrim's comings and goings from the facility.
“the doctor’s own medical assessment and the report that was furnished to the Commission appears to have been based on a flawed factual foundation”
A patient may lawfully leave the facility only in one of two ways: by pass issued by doctor or if patient discharges themselves.
“a patient may lawfully leave the facility only in one of two ways. But later ... the doctor ... tells us about the possibility of nurses also issuing passes”
The doctor changed the account on how passes are issued, including nurses issuing passes, which was not in the first affidavit and came only after being presented with different evidence.
“which is a very fundamental change from the first affidavit. You do not need to have been presented with this data ... to make an accurate statement ... that in fact what he said was not correct because the facility protocol is not followed, that in fact the practice of keeping records is that it is just not honoured”
The facility protocol for recording patient pass-outs is not followed; there are no records, and the doctor does not keep his own notes about when he issues or authorizes pass-outs.
“the facility protocol is not followed, that in fact the practice of keeping records is that it is just not honoured, that there are not any records. The doctor also tells us that he himself does not keep records”
The doctor gave reports to the Commission based on information given by Mr Carrim, which is now known to be false, thus the reports do not hold true anymore.
“The doctor ... is relying on what Mr Carrim tells him about his movements ... Those reports do not hold true anymore”
The doctor made a categorical statement that people go out of the facility only in two lawful ways: pass by doctor or self-discharge, which contradicts later statements about nurses issuing passes.
“a patient may lawfully leave the facility only one of two ways. But later ... the doctor ... tells us about the possibility of nurses also issuing passes”
The treating doctor's report is in breach of professional guidelines because it involves the treating doctor providing an independent assessment, which should not be done according to the guidelines referenced by the doctor's affidavit.
“the argument that the doctor's report is definitive is also extraordinary for another reason, because it itself is a breach of the professional guidelines that are referred to by our doctor in his affidavit”
The doctor's report is not definitive and breaches professional guidelines by being provided by the treating doctor who is inherently subjective and an advocate for the patient, thus the assessment of capacity should be independent and forensic.
“the argument that the doctor's report is definitive is ... a breach of the professional guidelines ... the treating doctor should not be the person to provide an independent assessment ... the individual's capacity ... the objective determination of the capacity”
The medical opinion given regarding Mr. Carrim's movements is based on flawed factual information as the doctor was not fully informed of the true movements.
“the doctor's own medical assessment and the report that was furnished to the Commission appears to have been based on a flawed factual foundation.”
In a supplementary affidavit, the doctor stated that if he is not available to authorize passes, then nurses will do so, which is a fundamental change from the first affidavit.
“if he is not available then the nurses will authorise. So which is a very fundamental change from the first affidavit.”
The doctor does not keep records or notes of when he issues or authorizes pass-outs, and the facility protocol of record-keeping is not followed and not honoured.
“the facility protocol is not followed, that in fact the practice of keeping records is that it is just not honoured, that there are not any records. The doctor also tells us that he himself does not keep records. He does not keep his own notes of when he issues or authorises pass-outs.”
The doctor relied on information from Mr. Carrim about his movements when giving reports, but later it was found that he was being given untruthful information and hence reports no longer hold true.
“the doctor, he is relying on what Mr Carrim tells him about his movements. He now knows that he is not being told the truth about the movements. ... Those reports do not hold true any more.”
It is quite telling that the doctor and the second wife move and change their allegations once confronted by objective facts about Mr. Carrim's movements.
“it is quite telling that you have these movements in the allegations on Mr Carrim's side, not by one person only. The second wife also moves or changes her allegations once confronted by facts that contradict what she says ... this is happening with the doctor as well.”
The doctor provided a new account on how the pass system works only after being presented with different evidence, which was not in the founding affidavit.
“So we did not ask for the specific question of passes to be addressed in the founding affidavit. That was done of the doctor's own volition. ... Why did it come up only when presented with different evidence?”
The doctor admits that the facility protocol for issuing passes is not followed and no records are kept as required, which he only disclosed in the second affidavit.
“at paragraph 18 is where the doctor explains that in fact what he said was not correct because the facility protocol is not followed, that in fact the practice of keeping records is that it is just not honoured, that there are not any records.”
The expert was not tasked to assess Mr Carrim's paper and could not do so based only on the doctor's affidavit provided.
“this expert was not asked to do an assessment on paper of Mr Carrim, nor could he have been able to do so because all that he was provided with was their doctor's affidavit”
The doctor's affidavit did not set out clinical details such as the treatment protocol, meaning the expert could not give a meaningful opinion based on it.
“their doctor, which is something that I should actually point out, because it does go to the reliability of that report, does not set out the details of things like the treatment protocol, etcetera. And I do not want to say too much more about that, but there is not that kind of detail in any event. So it would not have even been possible for our expert to give a meaningful opinion based on that affidavit”
The expert was only asked to comment on whether the objection to not having an independent medical examination is clinically appropriate, specifically focusing on objections made by the doctor about the interposition.
“So what he was asked to do instead was to comment on whether the objection, on whether it is clinically appropriate not to have an independent medical examination. That is what he was asked to comment on, and specifically to comment on the objections that were made by their doctor about the interposition or whatever the interposition is defined as.”
The expert attached his CV and is the former Chair of the professional association regulating the field in which the doctor practices. He is highly experienced and co-authored the guidelines referenced in the report.
“this expert has attached his CV. He is the former Chair of the professional association that regulates the very field in which their doctor practices. He is extremely experienced, and he is the co-author of the guidelines that he refers to in this report”
The expert was not asked to assess Mr Carrim's paper and could not do so because only the doctor's affidavit was provided, which lacked details like treatment protocols.
“this expert was not asked to do an assessment on paper of Mr Carrim, nor could he have been able to do so because all that he was provided with was their doctor's affidavit . And their doctor ... does not set out the details of things like the treatment protocol”
The expert was asked to comment only on whether an independent medical examination should have been required, particularly regarding the objections made by the doctor's affidavit about the interposition.
“what he was asked to do instead was to comment on whether the objection , on whether it is clinically appropriate not to have an independent medical examination . That is what he was asked to comment”
The expert respectfully disagrees with the objections made by the doctor's affidavit related to the interposition and the need for an independent medical examination.
“And in paragraph 7 , you will see that he respectfully disagrees”
The expert explains that requiring the treating doctor to provide the opinion threatens the therapeutic relationship between doctor and patient.
“he says not to do so , to require the treating doctor to provide the opinion threatens that therapeutic relationship between the doctor and his patient”
No reply has been given to the expert's affidavit and the doctor's so-called expert has not challenged the affidavit besides what was heard from Mr Premhid.
“there is no reply to our expert . ... other than what we have heard from Mr Premhid , their doctor , their so-called , their expert has not challenged the affidavit”
The doctor's view is that the long-term medical issue observed and treated after coming on board as treating doctor may have arisen and materially impacted the client prior to diagnosis and treatment, implying a condition predating treatment involvement.
“the doctor observed, diagnosed, and treated after he came on board as the treating doctor suggests that actually the condition could have arisen and materially impacted Mr Carrim even prior to when it was diagnosed and treated thereafter”
Commissioner Khumalo says the doctor only saw the client from a certain period and thus cannot express an opinion on the earlier period due to lack of knowledge.
“this doctor only saw your client from when, because the period from March until 13 April, he cannot express an opinion on that. He simply does not know what the position was. He was not there.”
The point of the doctor's view is that the medical condition observed after coming on board may have a longer-term impact from before that time, though this cannot be taken further.
“And the point of the matter is the doctor's view is that what I have observed from the incident when I came on board onwards suggests to me a long-term medical issue which may have impacted things before. I cannot take it further than that.”
There is ongoing pressure related to events starting from 4 May, involving a medical expert whose credibility is being questioned but who has volunteered to give evidence under oath at the Commission.
“the phenomenon only started on 4 May onwards... This doctor has made himself available to the Commission in numerous instances”
Mr Carrim is accused by the Evidence Leaders of avoiding accountability by using affidavits and clinicians to support his position rather than directly addressing medical evidence, and the Commission has not cross-examined the doctor who has volunteered to confirm the evidence.
“In their view, the Evidence Leader's view, Mr Carrim is avoiding accountability at all costs... the one thing they have not done is they have not called the doctor to be cross-examined by them, and he has volunteered himself to do so”
The Evidence Leaders do not purport to impugn the medical opinions of the doctor but seek an independent doctor's assessment due to their layperson status.
“They are lay people... They could never pretend to do that... That is different to speaking to the facts alleged by the doctor...”
There has been shifts in the factual positions regarding Mr Carrim's medical evidence, and the Evidence Leaders are entitled to challenge these shifts.
“there has been a shifting of the goal posts, even by the doctor himself... the Evidence Leaders are perfectly entitled to challenge the doctor on that”
Clinical conclusions drawn solely from factual inaccuracies about movements can be misleading and must be carefully considered to avoid impugning clinical diagnosis, as warned by the medical doctor in the affidavit.
“the danger in analysing the facts of those movements would potentially lead you to draw an inaccurate clinical conclusion ... and that is what the doctor warns the Commission”
Subpoenas will be issued today to hospitals where Mr Carrim has been receiving treatment to establish admission and discharge dates, and to his doctor in Cape Town to establish dates of medical consultations.
“we are going to issue a subpoena later today to the hospitals at which he has been receiving treatment, to establish when he was admitted and when he was discharged ... also going to be issuing a subpoena to his doctor, who is based in Cape Town, to establish the dates on which he has seen Mr Carrim”
A doctor was allegedly assassinated after operating on a patient, and the allegation involves interference by a father who lost his son.
“A father loses his son in hospital when a doctor was operating on that son. It is alleged that father goes and says to his friends he has shot the doctor because he lost his son through the hands of the doctor.”