Elizabeth Israel

Background

1. In May 2021, the Registrant registered with PSL Recruitment Services Limited (PSL Recruitment), an agency which recruits physiotherapists for both the NHS and private providers. Mr AT, the managing director of PSL Recruitment and the Registrant had a phone conversation, and arrangements were made for the Registrant to attend for an interview. This was originally scheduled for 20 May 2021, and in the event was postponed by a day, and took place on 21 May 2021. According to Mr AT, the Registrant had said she wished to start work as soon as possible as she needed money.

2. Part of the compliance process undertaken by PSL Recruitment is to obtain at least two references for candidates, covering their last three years of employment. The Registrant provided PSL Recruitment with contact details for three referees; KD at Homerton University Hospital, JP at Excellent Health Physiotherapy, and KC at TRP Physio.

3. PSL Recruitment received an ‘out of office’ from KD’s email in response to attempted contact on 21 May 2021. When PSL Recruitment were able to speak to her on 24 May, she advised that the request should be sent to the Human Resources department. No response was received to that request.

4. The second referee, Mr JP, could not be contacted on the business email provided by the Registrant. Mr AT therefore spent some time on 21 May 2021 attempting to locate him through online searches. The closest match he found was ‘Excellence Physiotherapy and Osteopathy London’. He called the practice and was informed that no-one by the name of Mr JP worked there. When Mr AT asked about the Registrant, he says he was told by the Practice Manager that the Registrant had worked at the clinic for about a month. Mr AT noted that according to the Registrant’s CV, she had worked there considerably longer.

5. Later on 21 May, PSL Recruitment received an email purporting to be from Mr JP, to say that the Registrant had informed him that PSL Recruitment were trying to get in touch with him. A reference request form was sent to the outlook email address that Mr JP had used to contact PSL Recruitment. The reference was returned on 24 May 2021.

6. The third referee was Mr KC of TRP Physio. According to Mr AT, emails sent to the address the Registrant had provided kept bouncing back. On 25 May 2021 PSL Recruitment received an email purporting to be from Mr KC, sent from a gmail address. The email said that he had been informed that PSL Recruitment were attempting to contact him for a reference in relation to the Registrant. He asked for the reference request to be sent to the gmail address. Later the same day, an email was received from Mr KC’s gmail account attaching a reference for the Registrant.

7. On 25 May 2021 Mr AT called KC in order to verify the reference. Mr KC informed Mr AP that his physiotherapy practice had closed down around a year previously, and that KC, at that time, ran a cake shop. Mr KC subsequently confirmed that he did not write the reference that PSL Recruitment had been sent in his name, for the Registrant.

8. Mr AT then suspected that the Registrant was writing the references herself. During a call later on 25 May 2021 between Mr AT and the Registrant, she admitted she had done so, after Mr AT said that he would need to report the matter to the police. There was then a discussion about notifying the HCPC, and the Registrant said she needed time to think things through. She called Mr AT back and informed him that she would self-refer to the HCPC.

9. The Registrant emailed the HCPC using the ‘registration’ email address at 5.29pm on 25 May 2021. She wrote:
I am contacting you regarding my registration as a physiotherapist. My name is Elizabeth Israel (PH105956).
I have been under immense stress in regards to finding work and proving food and money for my family.
As a result I created an email address and provided a reference for myself. I understand the implications and unlawfulness in doing so and I would like to offer my sincere deepest apologies. It has been brought to my attention by a previous employer and I believe that it is the best decision to contact you to let you know. I acted outside of my character and I am very remorseful.
I value my professional title as a physiotherapist which I have worked so hard to maintain and understand the implications in doing so.
Please let me know how this can be resolved. I look forward to hearing from you soon

10. On 26 May 2021 PSL Recruitment also submitted a referral to the HCPC. That referral includes reference to the HCPC address to which the Registrant’s self-referral had been made, and states that it appeared to have been sent to the incorrect place.
Hearing

11. At the outset of the hearing, the Registrant admitted particulars 1 and 2 of the allegation.

12. Ms Stockdale on behalf of the HCPC opened the case and set out the background. She called witness AT, Managing Director of PSL Recruitment, who confirmed the contents of his statement dated 29 July 2022. Mr AT outlined PSL’s process for obtaining references. He explained that PSL have a compliance team who carry out the checks. In his statement, he noted that he was surprised to receive a reference from Mr JP, as his attempts to locate this person had been unsuccessful, and Mr AT had concluded that JP did not exist. In relation to Mr KC, Mr AT thought it was strange that a gmail address would be used, so he called Mr KC following receipt of the reference. Once he had spoken to Mr KC, who had confirmed that he had not written the reference sent to PSL Recruitment, Mr AT spoke to the Registrant, who eventually admitted to having written the reference herself.

13. Ms Stockdale called witness KC. He confirmed his statement dated 29 September 2022. Mr KC stated that his physio business, TRP, closed around late August 2018. This was shortly after he opened his Cakebox franchise in June 2018. Around a year later he went back to part-time physiotherapy practice. He was self-employed and worked for another company until early 2020, when coronavirus hit.

14. Mr KC confirmed that he was the clinical director of TRP Physio, and that at the time of his conversation with Mr AT he was on the HCPC register. When it became apparent during his call with Mr AT that the Registrant had used an email address purporting to be his, and when he discovered that the Registrant had written a reference purporting to be from him, he was shocked and confused. Mr KC stated that he had previously provided a reference for the Registrant in November 2020, and would have written another one for her if this had been requested.

15. Mr KC stated that he advertised for the position which the Registrant was appointed to, in May 2018. He confirmed, as set out in his statement that she was employed for around four to six months. As to the content of the reference, he would have rated her ‘excellent’ in each criteria save for punctuality and reliability which he would have said were ‘good’. Finally, Mr KC stated that the phone number at the end of the reference form was not his.

Decision on Facts

16. The Panel accepted the advice of the Legal Assessor. It was aware that the burden of proof lies with the HCPC, which must satisfy the Panel, on the balance of probabilities, that the matters alleged occurred. It was aware that contemporaneous documents are generally a more reliable source of evidence than memory (Dutta v GMC [2020] EWHC 1974). It was further aware that hearsay evidence is admissible either where it is admissible in accordance with the Civil Evidence Act 1995 or where the Panel is satisfied that admission of the evidence is necessary in order to protect members of the public. Finally, in relation to dishonesty, the Panel was aware it is to apply the two stage test set out by the Supreme Court in Ivey v Genting Casinos Ltd [2017] 3 WLR 1212.

17. In respect of particular 1, the Panel began by considering the contemporaneous documents. Starting with Mr KC, it had seen an email purporting to be from him, to PSL Recruitment, dated 25 May 2021 at 13.42pm, which read:
“…Elizabeth has informed me that you have attempted to send me an email regarding a reference but the emails are bouncing back. All seems to be working well from my end. Please reply to this email…”

18. It had seen a second email also dated 25 May 2021 sent at 14.39, in response to PSL Recruitment resending the reference form to the gmail address used in the above email, attaching the completed reference form. In addition, the Panel had sight of the reference purportedly written by Mr KC. That stated that the dates of employment were January 2018 to September 2018, and that the Registrant was ‘excellent’ in relation to each criteria on the form. Mr KC’s name was printed and a phone number was set out.

19. In his evidence, Mr KC confirmed that he did not write the reference and that the phone number was not his. In his witness statement Mr KC confirmed that the email address from which the reference had been sent to PSL Recruitment was not his. The Panel found his evidence to be reliable and consistent with the documentary evidence. The Panel was satisfied, on the evidence of Mr KC, combined with the documentary evidence referred to above, that he did not write the reference and that the email address used was created by the Registrant.

20. The Panel then considered the documentary evidence relating to Mr JP. It noted a similar pattern, in that on 21 May 2021 at 19.00pm an email was sent from an outlook address to PSL Recruitment, in the name of Mr JP, which read:
“…Elizabeth Israel has contacted me to request a reference for her time working with us at Excellence Health. She mentioned that you had tried to get in contact with me but I am yet to receive an email. Please do forward any reference requests to myself at this email address.”

21. The Panel had also seen an email from PSL Recruitment to Mr JP at the same outlook address sent on Monday 24 May 2021, attaching the reference form, and an email in reply sent at 5.23pm on 24 May, purportedly from Mr JP, attaching a completed reference. The Panel additionally had sight of that reference, which stated that the Registrant had worked at Excellent Physio Health from 6 January 2019 to October 2020. It ranked her ‘excellent’ in relation to each criteria save for ‘Interaction with colleagues’ and ‘Punctuality’, which were ranked ‘good’.

22. Whilst the Panel had not heard evidence from Mr JP, and indeed, there was a lack of clarity as to who he was or whether he had ever worked with the Registrant, the Panel accepted the evidence of Mr AT with regard to the due diligence carried out. The Panel found Mr AT to be a balanced witness with no axe to grind. The Panel was aware that some of his evidence was hearsay, and as such was conscious that it could not give that part of his evidence the same weight as if the Practice Manager had been called to confirm his account. Mr AT had spoken to the Practice Manager at Excellence Physiotherapy and Osteopathy London, who had no knowledge of Mr JP, but did know of the Registrant, who was said to have worked there for around a month. The Panel took this into account alongside the documentary evidence.

23. The Panel noted the similarities between the approach used in both cases. In each case, emails to the address provided by the Registrant for her referees had bounced back, the ‘referee’ had then directly contacted PSL Recruitment from a personal email address, requesting a reference form, and had then returned the reference from the same personal email account. The Panel therefore found that the Registrant had adopted the same tactic in relation to each referee, and that the Registrant had again fraudulently written the reference purporting to be from Mr JP, as well as creating an email account in his name.

24. These findings were consistent with the Registrant’s admission to particular 1. The Panel found particular 1 proven.

25. Moving to particular 2, that the Registrant’s actions above were dishonest, the Panel applied the two-stage test set out in Ivey v Genting Casinos. It first considered the Registrant’s actual state of knowledge or belief as to the facts. The evidence before the Panel was that the Registrant had adopted a sophisticated plan to deliberately mislead PSL Recruitment. She had gone to the time and effort of creating two email addresses in the names of other people. She had contacted PSL Recruitment from those emails, purporting to be her referees, and had requested that the reference forms be sent to those email addresses. She had then completed the references in the names of the referees, and sent them to PSL Recruitment with the intention of making it appear that the references had been written and sent by the named individuals. The Panel found that the Registrant had planned to deceive PSL Recruitment and make them believe that genuine references had been provided.

26. The Panel went on to consider whether these actions coupled with the Registrant’s intent to mislead would be considered dishonest by ordinary decent people. The Panel found that this would absolutely be the case. Ordinary decent people would have no difficulty in concluding that the Registrant’s conduct was dishonest. This finding was supported by the Registrant’s admission to particular 2. She readily accepted that her actions had been dishonest. The Panel found particular 2 proven.

Decision on Grounds

27. The Panel heard evidence from the Registrant in relation to both misconduct and impairment. The Registrant said that she was deeply remorseful for her actions, and she understands the gravity of lying and the impact of this in people’s trust and confidence in her as a physiotherapist. She recognised that she had made errors of judgement and her actions were a departure from the expected ethical standards.

28. The Registrant stated that she had reflected on the factors which had led to her acting in this way, which was out of character. She had identified that stressors and external pressure clouded her decision-making ability.

29. The Registrant informed the Panel that since the events of May 2021 she had been entrusted with leadership roles and managing clinics. In terms of professional development, she had undertaken reading on medical ethics in preparation for a medical law degree which she plans to commence in September 2023. This has reinforced her dedication to the principles which underpin the profession. She had spent time with clinical educators and undertaken training around integrity and honesty, however she had not undertaken formal courses. In her role volunteering in a care home, the Registrant had undertaken training with a senior nurse and mental health support worker in decision-making relating to long term care needs and ethics around end of life support.

30. Since the incident in May 2021, the Registrant had worked at the Homerton Hospital in a band 7 role from December 2021 to May 2022 managing the long covid team, and had worked in a community team between May and October 2022. She was currently working in the West Byfleet Medical Centre managing a private physiotherapy clinic. This was both a clinical and managerial role. The Registrant stated that the clinic was not aware of these proceedings as it was her understanding she was under no obligation to inform them. The Registrant said the learning from the incident was evidenced by the way she had responded to requests for references for her subsequent roles. She has been honest with agencies about her difficulties in getting references where people had not responded or had moved on.

31. The Registrant stated that she has received overwhelming support from colleagues, and through her church, which has in turn motivated her to regain people’s trust. The incident had served as a profound wake up call. She had undertaken counselling which she felt had helped her manage stress and make good decisions. She has learnt to think before making decisions and thus avoid rash decisions.

32. As part of the reflective process that the Registrant has gone through since the incident, she stated that she had written reflective journals. She had developed insight through reflecting on what had happened. She had written practical steps around what she should have done, what she will do in the future, and how she will implement change. A GP was acting as a professional mentor to her. He was aware of these proceedings. They had had conversations about the importance of honesty and integrity as well as the need to recognise stress levels.

33. Finally, the Registrant stated that she accepted her conduct fell below the standards expected, and that it amounted to misconduct.

34. In response to a question from the Panel, she confirmed that Mr JP did not exist; she had made him up.

35. Ms Stockdale submitted that the Registrant’s actions clearly qualified as misconduct. Her conduct breached principle 9 of the HCPC’s Standards of Conduct, Performance and Ethics, which require Registrants to be honest and trustworthy. The Registrant was in breach of standard 9.1; ‘to make sure that your conduct justifies the public’s trust and confidence in you and your profession’.

36. Ms Stockdale submitted that dishonesty is always serious as it involves a breach of the fundamental tenets of the profession. Damage caused by the Registrant’s dishonesty was demonstrated though the evidence of Mr AT, who stated he was concerned that the Registrant would fraudulently use PSL Recruitment’s letterhead. It was further demonstrated by Mr KC saying that he ‘felt used’. This evidence, it was submitted, in turn shows that the public’s trust in the profession of physiotherapy had been damaged.

37. The dishonesty here, it was submitted, was particularly serious for a number of reasons:

a. The dishonesty involved repeated fraudulent acts by the Registrant, including the provision of a false name and false email addresses of ‘Mr JP’, and the false contact details (email address and phone number) of Mr KC; the setting up of email accounts based on those false email addresses; the writing of emails to PSL Recruitment purporting to be from ‘JP’ and KC; the completion of the written references purporting to be signed by ‘JP’ and KC the latter of which contained incorrect information about the Registrant’s period of employment;
b. The dishonesty involved pre-meditation and planning;
c. The dishonesty lasted for several days between 21 and 25 May 2021;
d. The Registrant did not disclose her dishonesty, and it would have continued but for its discovery by Mr AT at PSL Recruitment;
e. The dishonesty occurred within professional practice as part of the Registrant’s recruitment into a new physiotherapy role;
f. The dishonesty was for the Registrant’s own personal gain, namely, to commence a new role as a physiotherapist as quickly as possible; and
g. The dishonesty involved a flagrant disregard for recruitment procedures designed to protect the safety of patients.

38. The Panel accepted the advice of the Legal Assessor namely that misconduct is a matter for the Panel’s independent judgment, and there is no burden or standard of proof. It was aware that there is no statutory definition, but guidance is given by the caselaw, including Roylance v GMC (No 2) [2000] 1 AC 31 where Lord Clyde said “Misconduct is a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed.....in the particular circumstances”. It was further aware that the falling short should be serious: Doughty v General Dental Council [1988] AC 164.

39. The Panel determined that dishonesty is always serious as it reflects a serious departure from professional standards, breaches a fundamental tenet of the profession, has a significant impact on trust and undermines public confidence in the profession. The Panel had already found that the Registrant’s actions were calculated, planned and sophisticated. She had executed her plan and would have succeeded in misleading PSL Recruitment, were it not for Mr AT attempting to contact ‘Mr JP’ and then following up the reference purportedly received from Mr KC.

40. Whilst the Panel was cognisant of the mitigation put forward by the Registrant, that did not detract from the seriousness of her actions. Whilst significant stressors in the Registrant’s life may have affected her judgement, this was not a momentary lapse, but a calculated intention to deceive.

41. The Panel endorsed all of the submissions of Ms Stockdale as set out above, and noted that the Registrant accepted that her actions fell below what was expected of her as a registered professional. The Panel found that the Registrant had seriously breached Standard 9 and 9.1 of the HCPC’s Standards of Conduct, Performance and Ethics. The Panel concluded that the Registrant’s actions were particularly serious for the reasons set out at paragraph 25, and those articulated by Ms Stockdale in paragraph 36. It found that the Registrant’s conduct fell far below the standards required and that it amounted to misconduct.

Decision on Impairment

42. Ms Stockdale, on behalf of the HCPC, submitted that in making its determination on the question of current impairment, the Panel should have regard to the test set out by Dame Janet Smith in the Fifth Shipman Report. It should consider whether its findings meant that the Registrant’s fitness to practise is impaired in the sense that she:

a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or
b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or
c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or
d. has in the past acted dishonestly and/or is liable to act dishonestly in the future.

43. It was submitted that grounds (b) – (d) applied in this case. Ms Stockdale submitted that in determining current impairment, the Panel needs to take into account the way the Registrant has acted in the past, and then look forwards and consider whether her ability to practise safely is compromised and/or whether public confidence in the profession would be undermined in the absence of a finding of impairment.

44. Ms Stockdale submitted that the Registrant’s fitness to practise is impaired under the personal component. She referred the Panel to her previous submissions with regard to the seriousness of the Registrant’s conduct, and noted that dishonesty is difficult to remediate, suggesting an underlying attitudinal issue. Ms Stockdale drew the Panel’s attention to the lack of documentary evidence behind the reflective journey that the Registrant referred to in her evidence and also the lack of any formal courses undertaken.

45. In relation to insight, Ms Stockdale submitted that this had not been fully achieved. The Registrant had referred to acting ‘quickly’ and ‘not rationally’, however this did not reflect the ongoing and repeated dishonesty. Whilst the Registrant had expressed remorse, Ms Stockdale drew a distinction between regret for one’s wrongdoing, and regret for the consequences following the discovery of one’s wrongdoing.

46. In Ms Stockdale’s submission, there remained a risk of repetition, notwithstanding that the Registrant is otherwise of good character, due to the limited evidence of remediation and lack of full insight.

47. In addition, it was submitted on behalf of the HCPC that the Registrant’s fitness to practise is impaired under the public component. The serious nature of the dishonesty meant that the Registrant had brought the physiotherapy profession into disrepute. Public confidence in the profession would be undermined if a finding of impairment was not made in this case.

48. The Registrant did not make submissions, having already given evidence in relation to impairment. She had said in her evidence that she does not believe she is currently impaired. She asked the Panel to take into account that she is very insightful and very remorseful.

49. The Panel accepted the advice of the Legal assessor, namely that:

 Impairment is a matter for the Panel’s independent judgement;
 Misconduct and impairment are separate stages in the decision-making process, and it may be that misconduct having been found, a panel may decide that fitness to practise is not impaired; Cheatle v GMC [2009] EWHC 645 (Admin);
 The question for the panel was whether the Registrant’s fitness to practise is currently impaired by reason of misconduct. Accordingly, in assessing impairment, the panel was looking at the past to assess the present; Meadow v GMC [2007] 1 QB 462;
 The Panel may be assisted by the three-fold test set out in the case of Cohen v GMC [2008] EWHC 581 (Admin): Is the conduct remediable? Has it been remedied? Is it highly unlikely to recur?
 The Panel should also take into account the guidance on the interpretation of the Cohen test, as provided in CHRE v NMC and Grant [2011] EWHC 927 (Admin), as formulated by Dame Janet Smith in the report into the Fifth Shipman Inquiry, and set out at paragraph 41 above;
 Finally, the Panel should consider the public component, and whether the need to uphold professional standards and maintain public confidence in the profession would be undermined if a finding of impairment were not made in the circumstances of this case.

50. The Panel first considered whether the Registrant is currently impaired on the personal component. It was of the view that, to the Registrant’s credit, she had admitted what she had done, and that it was dishonest, at an early stage (in her conversations with Mr AT on 25 May 2021). She had maintained that admission subsequently. She had admitted the facts, including dishonesty, before the Panel at the outset of this hearing. The Panel found her apology, including the apology to Mr KC made during the course of the hearing, and her remorse, were genuine. Since the incident in May 2021, the Registrant had obtained and worked in three locum roles, and there had been no repetition of her misconduct.

51. However, the Panel was of the view that the Registrant had not demonstrated full insight. Indeed, her insight was, at best, developing. Her evidence had been given in general terms. She had not been able to give specific or concrete examples, either of courses she had undertaken, conversations she had had with her GP mentor, or the learning she had gained from the preparatory reading for her planned studies commencing in September 2023. Despite requests from the Panel, the Registrant had not provided any evidence of the development and reflection she said she had undertaken. She had not provided evidence of CPD, or extracts from the reflective diary she had referred to in her evidence. The Panel would have been assisted by such material, as well as character references. The Panel noted that the Registrant had referred to a range of people from whom she has received support, including people at her church, and in the care home where she had undertaken voluntary work. She had referred to conversations with her GP mentor and clinical educators in her professional role. Yet none of these had attested to her character.

52. Against this background, the Panel worked through the three-stage test set out in the case of Cohen v GMC. It considered that that whilst dishonesty is inherently difficult to remediate, it can be remediable.

53. In terms of whether the Registrant’s misconduct had been remedied, the Panel considered that, had the Registrant provided evidence of what she said she had done by way of reflection, learning and personal development, that would have been persuasive. However, on the information and evidence before it, the Panel found that the Registrant had not fully grasped the gravity of her actions. She had not demonstrated an understanding of how serious the multi-dimensional deception she had planned and executed was. She had not clearly articulated how dishonesty of this nature seriously undermines a) the trust that the public, patients and fellow professionals should be able to put in her, and b) public trust in the profession of physiotherapy. She had not touched on the risks posed to both employers and service users if fraudulent references are provided and relied on when physiotherapists are recruited. The Panel concluded that the Registrant’s misconduct had not been remedied, as she had not demonstrated fully developed insight.

54. It followed that there remained a risk, at some level, of repetition of dishonest conduct. Whilst the Registrant had set out in her evidence how she had reacted when there were difficulties or delays in references being sourced for the three locum roles she has held since May 2021, and she may well not, in the future, provide fraudulent references having learnt from this experience, the Panel had concerns as to the extent to which the Registrant’s actions demonstrated an underlying attitudinal issue. This was because, whilst on one level, the events between 21 and 25 May 2021 could be described as a discrete instance of dishonesty, there were multiple facets. The Registrant did not make a momentary error of judgement, but invented a referee, gave false email addresses, emailed PSL Recruitment pretending to be both ‘Mr JP’ and Mr KC, wrote references purporting to be from the referees, and sent them by email making it appear that the references were being sent by those referees. She then only admitted to her actions when Mr AT said that he would get the police involved.

55. The Panel was not satisfied, given what it had heard from the Registrant in terms of reflection as to the impact of these actions on those directly affected, and the wider public and the profession, that she would not resort to dishonest conduct in the future if she were under pressure to achieve a particular outcome.

56. The Panel determined, for these reasons, that the Registrant is currently impaired on the personal component, and it agreed with the submission of Ms Stockdale that she is impaired in relation to limbs (b) – (d) of the test set out in CHRE v NMC and Grant. She has in the past, and is liable in the future to:

 Bring the profession into disrepute;
 Breach a fundamental tenet;
 Act dishonestly

57. The Panel went on to consider whether a finding of impairment is also required in the circumstances of this case to uphold professional standards and maintain public confidence in the profession. It had found that the Registrant had fallen far below the conduct expected in accordance with Standard 9 (Be honest and trustworthy) of the HCPC’s Standards of Conduct, Performance and Ethics. A finding of impairment was required in order to uphold standards. Further, an informed member of the public would expect a finding of impairment in these circumstances. Trust in the physiotherapy profession has the potential to be seriously damaged if people are recruited to roles based on fraudulently given references. The process of independent verification of skills is thereby subverted. Whilst there was no evidence of risk to the public, as a consequence, in this case, there is an obvious risk if people who act in this way are not held to account by the regulator. Public confidence would, the Panel determined, be seriously undermined were a finding of impairment not made. The Panel found that the Registrant is currently impaired on the public component.

Decision on Sanction

58. Ms Stockdale on behalf of the HCPC made no particular submission as to the sanction the Panel should impose in this case. However, she referred it to some caselaw which she submitted may assist in their determination, and relevant sections of the HCPC’s Sanctions Policy.

59. Ms Stockdale referred the Panel to Khan v General Medical Council [2015] EWHC 301 (Admin), which is authority for the proposition that cases of dishonesty lie at the top end of the spectrum of dishonesty. She additionally referred them to two cases where registrants had provided false references; Hosney v General Medical Council [2011] EWHC 1355 (Admin) and Abiodum v Nursing and Midwifery Council [2015] EWHC 434 (Admin).

60. Ms Stockdale submitted that the primary function of sanction is to protect the public, however proportionality is a critical factor, which requires a balance to be struck between the competing interests of the Registrant and the HCPC’s overriding objective. She submitted that mitigating factors in this case included the Registrant’s previous good character, the personal mitigation she had referred to, and the insight and remediation she had demonstrated. However, there were also aggravating factors, including that the allegation involved repeated fraudulent acts, pre-meditation and planning, and that the dishonesty was ongoing between 21 and 25 May 2021. She submitted that there had been a failure to disclose the dishonest conduct; that it was for personal gain; it took place in a professional context and demonstrated disregard for recruitment procedures designed to protect patients.

61. Ms Stockdale referred the Panel to the factors which, according to the Sanctions Policy, it should take into account when considering both a suspension order and an order for strike off. Ultimately, the decision rested with the Panel.

62. The Registrant submitted that a caution order would be appropriate as it would not restrict her ability to practise. This was an isolated incident and there was a low risk of repetition. Indeed, she had shown through her appointment to subsequent roles that she had not repeated her misconduct. Further, she had admitted fault, she had apologised to Mr KC, and would have apologised to Mr AT if she had been able to, but could not due to these proceedings.

63. The Panel accepted the advice of the Legal Assessor, that it should:

 Consider whether there are any particular mitigating or aggravating features;
 Have regard to the Sanctions Policy, and work through the sanctions starting with the least restrictive;
 Have regard to the HCPC’s over-arching objective of protecting the public, maintaining public confidence in the profession and upholding proper professional standards
 Impose the minimum sanction necessary to meet the regulatory objective, bearing in mind that the purpose of sanction is not to punish; Sir Anthony Clarke MR in Meadow v GMC [2007] 1 QB 462
 Ensure that any sanction is proportionate, whilst bearing in mind that the interests of the profession take precedence. Bolton v Law Society (1994) 1 WLR 512, endorsed in the context of health regulation in The Council for the Regulation of Health Care Professionals v General Dental Council (Fleischmann)[2005] EWHC 87 (Admin):
 Bear in mind that remediation carries little weight at the sanction stage; Yeong v GMC [2009] EWHC 1923 (Admin); GMC v Patel [2018] EWHC 171 (Admin);
 Be aware that there is generally considered to be a ‘scale of dishonesty’ and there is not an automatic presumption of strike-off; Hassan v GOC [2013] EWHC 1887 (Admin); Lusinga v Nursing and Midwifery Council [2017] EWHC (Admin) 1458; Watters v Nursing and Midwifery Council [2017] EWHC (Admin) 1888.

64. The Panel began by considering aggravating and mitigating factors. It considered these in the context that this had been a single act of dishonesty, albeit multi-faceted and which extended over a period of 5 days.

65. The Panel considered that the aggravating features were that the Registrant’s actions:

 Were pre-meditated and calculated, as set out above;
 Involved the invention of a referee;
 Involved a pattern of conduct over the five days, which included sending a number of fabricated emails;
 Were for personal gain;
 Would not have been admitted but for Mr AT confronting her and making reference to calling the police.

66. The Panel then considered mitigating factors to be:
 The Registrant was under an extreme form of personal stress at the time;
 She had accepted her actions and that they were dishonest early in the HCPC’s process, and had been open with the Panel;
 She had self-referred to the HCPC at the earliest opportunity;
 She had apologised to Mr KC, and the reason she had not apologised to Mr AT was that she had been unsure if she was allowed to contact him due to these proceedings;
 She had shown some insight and a willingness not only accept her misconduct, but to try to put matters right;
 No previous regulatory concerns had been raised and she was otherwise of good character;
 There had been no risk of harm to patients as Mr KC confirmed that there were no concerns about the Registrant’s clinical abilities (he would have given her a positive reference);
 There had been no repetition of the conduct, the Registrant having been recruited, through locum agencies, to three subsequent roles.

67. With the above in mind, the Panel went on to consider the appropriate sanction in this case, which would uphold confidence in the profession and maintain standards. It considered that the Registrant’s misconduct was not at the lower end of the scale, but nor was it at the top, as it had persisted for a limited period of time, and thereafter had not been repeated. Further, there had been no risk of harm to patients.

68. The Panel bore in mind the serious nature of the misconduct, and that dishonesty undermines public confidence in the profession. It bore in mind the factors set out at paragraph 58 of the Sanctions Policy, specifically the active role the Registrant played in deceiving Mr AT and PSL Recruitment, and the duration of the dishonesty.

69. Noting that dishonesty is always at the serious end of the spectrum of misconduct, as it goes to the heart of the values of a regulated professional, and given the aggravating factors set out above, the Panel could not take no further action or impose a caution order, as these would not meet the regulatory objectives of upholding standards or maintain public confidence in the profession and the regulatory process.

70. The Panel then considered a conditions of practice order. It noted paragraph 108 of the Sanctions Policy, that conditions are less likely to be appropriate in more serious cases such as those involving dishonesty. It further considered that acting dishonestly is not something which conditions can effectively mitigate against. They are, in the Panel’s view, appropriate in cases relating to clinical practice, but here, there were no practice issues. The Panel concluded that a conditions of practice order was not suitable in the current case, as conditions to deal with the attitudinal concern could not be formulated, and in any event, such an order would be insufficient to uphold public confidence or maintain standards.

71. The Panel moved to consider a suspension order. It considered that the majority of the matters set out at paragraph 121 of the Sanctions Policy applied. The conduct represented a serious breach of the HCPC’s Standards of Conduct, Performance and Ethics; the Registrant had some insight, and whilst the Panel had not been able to conclude that there would not be repetition, it deemed the risk to be low, in view of the Registrant’s actions since the date of this incident. Further, the Registrant had demonstrated a willingness to put things right, to further remediate and develop both personally and professionally. The Panel considered that suspension was a very serious sanction, as it will prevent the Registrant from practising as a physiotherapist, impacting on both her personally and her children. It took this into account when considering proportionality. It bore in mind that its primary concern lies with upholding the overriding objective of the HCPC, and in accordance with Bolton v Law Society, the interests of the individual come second. The Panel was of the view that a suspension order will give a clear signal to the profession as to the importance of upholding standards, and that such an order would also sufficiently mark the Panel’s strong disapproval of the Registrant’s conduct, such that it will enable public confidence in the profession to be maintained.

72. In reaching this position, the Panel looked to the next sanction, a striking off order, to satisfy itself that it had reached the appropriate balance in the matters it had taken into consideration. The Panel was aware that a striking off order may be made in cases involving serious dishonesty, but only where no lesser sanction would adequately meet the regulatory objective. As the Registrant had shown some insight, and a willingness to develop this further, combined with the fact that she is a competent physiotherapist, it considered that there was a public interest in enabling her to return to practice in due course. As such, a striking off order would be disproportionate.

73. Finally, the Panel gave consideration to the appropriate duration of the suspension order. It had determined that the dishonesty was at the mid to high part of the ‘scale’ of dishonesty, but that dishonesty at the top end would, in all likelihood, result in strike-off. It reminded itself of the aggravating features outlined above, and asked itself what was required in order for public confidence in the profession to be maintained. It considered that a suspension order for 10 months, i.e. towards the top end of the period it could impose, would reflect the seriousness of the dishonesty and enable the public to maintain confidence in the profession and the regulatory process. This would also send the appropriate message to the profession as to the importance of professional standards.

74. In reaching this decision, the Panel further considered that this would be an appropriate period of suspension to enable the Registrant to further reflect on the impact of her actions on the profession and the public, and fully remediate. It determined that this order should be subject to a review, and that a reviewing panel is likely to be assisted by:

 A reflective statement from the Registrant, dealing with the impact of her dishonesty on the public and the profession;
 Evidence of CPD demonstrating learning in relation to the importance of professional standards specifically relating to Standard 9 of the HCPC Standards of Conduct, Performance and Ethics ;
 Testimonials or references as to her character from paid or voluntary work

The Registrar is directed to suspend the registration of Ms Elizabeth Israel for a period of 10 months.

Interim Order

1. The Panel next considered an application by Ms Stockdale for an interim suspension order to cover the appeal period before the final order becomes effective, and the time taken to dispose of any appeal made.
2. Ms Stockdale had submitted that an interim order should be made in light of the panel’s finding that a suspension order is necessary to maintain standards and to uphold confidence in the profession and the regulatory process. She submitted that an interim order is necessary in the public interest. She asked for an interim order for 18 months.
3. The Registrant was neutral on the matter.
4. The Legal Assessor advised the Panel that it could make an interim order if doing so was necessary for protection of the public, otherwise in the public interest or in the interests of the Registrant. She reminded the Panel that imposition of an interim order on the public interest ground alone is rare, and the question is whether public confidence would be seriously undermined if no order were imposed to cover the period of any appeal. The Panel should bear in mind its previous findings and also consider the appropriate form and duration of any interim order.
5. The Panel was mindful of its earlier findings. Whilst it had not excluded a risk of repetition of the misconduct, it had imposed the sanction of a suspension order as the need to uphold public confidence and professional standards demanded this. It was cognisant that it had not found a risk of harm to patients. It also bore in mind that there had been no interim order restricting the Registrant’s practice prior to this hearing. However, it considered a relevant factor to be that, until this week, no findings of misconduct or impairment had been made. The position was now very different. The message to the public and the profession as to the seriousness of this matter would be diluted if the Registrant appealed the Panel’s decision and was allowed to practise unrestricted until her appeal was heard. The panel concluded that it would be wholly incompatible with those earlier findings if there was no interim order in place.
6. Accordingly, the panel determined that an interim suspension order is necessary to uphold the public interest. It made the interim order for 18 months, to allow for any appeal to be dealt with. When the 28-day appeal period expires, this interim order will come to an end unless an appeal has been filed with the High Court. If there is no appeal, the final order shall take effect when the appeal period expires.

History of Hearings for Elizabeth Israel