A General Medical Council disciplinary panel today ruled Dr Freddy Patel, the pathologist who carried out the first autopsy on Ian Tomlinson who died at last year's G20 protest, acted in a way that amounted to misconduct during two earlier post-mortem examinations and his fitness to practise is impaired.
The panel also ruled that Dr Patel had displayed deficient professional performance in a third post-mortem.
The panel had already concluded that Dr Patel was "irresponsible" and failed to meet professional standards during his examinations of the bodies of a five-year-old girl in 2002, a four-week-old baby in 2003 and a woman who died in 2005.
Panel chairman Richard Davies told Dr Patel: "The panel is not satisfied that there is no risk of the relevant conduct being repeated."
Dr Patel, 63, was said by the panel to have behaved irresponsibly, failed to meet standards expected of a Home Office pathologist and acted in a way liable to bring the profession into disrepute when he changed the woman's cause of death in 2005.
He carried out a post-mortem examination on January 5, and decided she had died due to a blood clot in the coronary arteries.
A month later, following a second post-mortem by another pathologist, he prepared an addendum to his report, changing the cause of death to a brain haemorrhage in line with the new findings.
Dr Patel told an inquest into the woman's death he had changed the primary cause of death "to satisfy the family" but Mr Davies said the pathologist's assumption that the change made no difference from the coroner's viewpoint, as the death was not suspicious, and merely allowed an inquest to proceed was not an adequate explanation.
During today's ruling Mr Davies said Dr Patel's "acts and omissions were very serious" and amounted to misconduct.
He said pathologists "must not set aside their professional judgment for any of the parties involved during or after a post-mortem examination for reasons of expediency or anything else".
Dr Patel's failure to note the weights of individual organs examined, as is recommended by Royal College of Pathologists' guidance, also showed deficient professional performance.
Dr Patel was also found to be guilty of misconduct in a post-mortem examination on a four-week-old baby in August 2003.
The panel had earlier decided his failure to obtain full skeletal X-rays prior to the examination, as recommended by the Royal College of Pathologists' guidelines, was irresponsible and failed to meet professional standards.
The hearing previously heard Dr Patel carried out the post-mortem examination at 7.20am, prior to the radiologist's 9am start time.
Today, Mr Davies told the pathologist: "The panel has concluded that you deliberately ignored the guidelines so as to carry out the post-mortem examination simply at a time of your own convenience, and very shortly before radiographers would have been readily available.
"Against that background the panel has concluded that your acts and omissions amount to misconduct."
The panel earlier found Dr Patel had been "irresponsible" and not met the standard expected of a Home Office pathologist when he failed to identify marks on the body of a five-year-old girl which suggested she had been violently attacked prior to her death in 2002.
Mr Davies said the panel considered it "probable" Dr Patel "performed only a cursory external examination of the body" and failed to spot a damaged shoulder blade.
The panel ruled today that Dr Patel's conduct in the case amounted to deficient professional performance but not to misconduct.
The girl's body was exhumed to allow a second post-mortem examination to take place and Mr Davies said: "It is noted that in this case if the body had been cremated then critical evidence would have been lost.
"Had you allowed your suspicions greater scope, then the exhumation of a child and the attendant potential distress might have been avoided."
Adrian Hopkins QC, representing Patel, had argued that the two cases involving children should not reflect on Dr Patel's current fitness to practise as post-mortem examinations are now carried out by specialist paediatric pathologists and he had not undertaken one since 2004.
Mr Davies said the issues of record-keeping and adherence to guidelines were still relevant.
Mr Davies said the panel believed there were "fundamental weaknesses" in Dr Patel's conduct and professional performance.
"It does not consider that the limited extent to which you have accepted criticisms and offered assurances for the future show genuine insight into the character and range of your shortcomings."
He said the panel was not satisfied there was no risk of the conduct being repeated "particularly against a background of evidence that you have been willing to jeopardise your professional independence by complying with the wishes of others".
The panel is not expected to make a decision on sanctions until later this week.
Dr Patel, whose full name is Mohmed Saeed Sulema Patel, has already been suspended from the Home Office register of forensic pathologists amid questions about his post-mortem examination of Mr Tomlinson.
The 47-year-old newspaper seller died during London's G20 riots in April last year after being pushed to the ground by a police officer.
Dr Patel's competency was called into question after two other pathologists agreed that Mr Tomlinson, who was an alcoholic, died as a result of internal bleeding, probably from his diseased liver, after falling on his elbow.
The shortcomings in Dr Patel's examination of Mr Tomlinson's body were revealed by prosecutors as they announced that no charges would be brought over the death.
The panel heard submissions about appropriate sanctions from Simon Jackson QC, representing the GMC.
He said Dr Patel had "made no admissions that he had failed in any way".
"He made no concessions that he had learned anything from these matters."
Mr Jackson said Dr Patel had not learned from the examination of the young girl in 2002 and failed to follow guidelines when he came to examine the baby the following year.
"The panel could not be satisfied that Dr Patel does not pose a significant risk in terms of repeating behaviour that was committed in 2002, 2003 and 2005," he said.
Mr Jackson said sanctions, including striking off the register, were not designed to punish but to protect the public and maintain confidence in the profession as a whole.
Dr Patel was found guilty of serious professional misconduct by a GMC hearing just months before the post-mortem examination on the young girl, Mr Jackson told the panel.
He was given copies of Roger Sylvester's medical records when he carried out a post-mortem examination on his body in January 1999.
An inquest into Mr Sylvester's death was adjourned for further investigations and Dr Patel breached patient confidentiality when he told journalists the medical records showed the dead man had been a crack cocaine addict.
Mr Jackson said the GMC hearing in January 2002 had considered it a "lapse" in Dr Patel's usual high professional standards while he felt under pressure.
Following the hearing Dr Patel would have been fully aware of his professional obligations yet failed to comply with them in the 2005 case when he altered the woman's cause of death, Mr Jackson added.
The hearing will resume at 9am tomorrow.
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