Ronak Malde

Preliminary Matters

Amendments to the Allegation

1. At the outset of the hearing, the HCPC invited the Panel to make some minor stylistic amendments to the Allegation to bring it in line with the HCPC’s current allegation drafting guidance. This was following the Investigating Committee Panel (‘ICP’) not referring dishonesty in respect of two sub-particulars. The Panel was assisted by a Skeleton Argument served in advance, albeit Ms Evans supplemented this orally.

2. The Panel had the chronology of events set out for it. On 19 September 2024, the Registrant was provided with a copy of the draft hearing bundle. This included correspondence which notified the Registrant that the HCPC would be applying to amend the Allegation at the outset of the hearing to reflect the HCPC’s preferred format and to correct some minor typographical errors. The Registrant did not raise any issues with this approach at the time.

3. The Registrant was told that the HCPC would be applying to make the following minor amendment to correct a typographical error:

“5. Your conduct set out at any or all of particular 2(d) was dishonest.”

4. Further, the HCPC would apply to add this charge to reflect the HCPC’s preferred format:

“6. The matters set out at particulars 1-5 above constitute misconduct.”

5. This would require the current Particular 6 to be re-numbered as 7.

6. The Panel accepted the advice of the Legal Assessor that a panel of the Conduct and Competence Committee is permitted to make amendments to an allegation at any point up until findings of fact have been made. The key consideration is fairness to the Registrant.

7. The Registrant had no representations in respect of amendments to the Allegation.

8. The Panel was of the view that it was fair to permit the amendments. No disadvantage was caused by the amendment, and the technical amendments allowed the Registrant to better understand the case against him to allow him to provide a response to the Allegation should he wish to do so. The Panel also considered that permitting the amendments would make proceedings clearer to follow for any member of the public.

Proceeding partly in private

9. The Panel proactively addressed the issue of any specific details of the Registrant’s health, determining that these should be held in private if they arose in the course of the hearing. The Panel accepted the advice of the Legal Assessor and determined that where specific details about the Registrant’s health were concerned, this would fall into an exception to the principle of open justice whereby the public can know about how those healthcare professionals who serve them are regulated. This was because the Registrant has the right to a private life and a fair trial can be heard without private matters needing to become public without any prejudice caused. Accordingly, only those parts of the hearing that dealt with specifics of the Registrant’s health would be held in private.

Background

10. The Registrant is an Operating Department Practitioner (‘ODP’), registered with the HCPC. At the material time, the Registrant was employed by Newham University Hospital, Barts Health NHS Trust (‘the Trust’) as an ODP.

11. On 29 November 2022, the HCPC received a referral from the Trust in respect of the Registrant’s conduct on 8 and 9 July 2022.

12. It is alleged that on 8 and 9 July 2022, the Registrant self-administered Sevoflurane (a halogenated inhalational anaesthetic gas) and that on 9 July 2022, he was found in an unconscious state, passed out on a hospital trolley with circuit anaesthetic tubes found next to his head. Both occurrences were said to have occurred whilst the Registrant was working ‘on shift’ at the Trust.

13. The Registrant was suspended from the Trust on 12 July 2022. An investigation was conducted by the Trust and the findings of the investigation were presented at an internal disciplinary hearing on 25 November 2022. There were multiple witnesses to the Registrant’s alleged misuse of Sevoflurane on consecutive nights (8 and 9 July 2022). The Registrant admitted during the Trust’s investigation to inhaling Sevoflurane on 8 July 2022 (on three occasions) and on 9 July 2022 (on one occasion).

14. During the Trust’s investigation, the Registrant also admitted to returning to patient care after the use of Sevoflurane and acknowledged that this was wrong and unsafe.

Decision on Facts

Admissions

15. The Registrant can admit any of the allegations but is under no obligation to do so. An admission can result in the facts being found proved without the need for the HCPC to adduce any further evidence, in circumstances where the Panel is satisfied that the admissions are being made without duress and the Registrant understands the basis for and the consequences of such an admission.

16. Given that the Registrant was unrepresented, the Panel questioned the Registrant and assured itself that the Registrant comprehended what his admissions meant for the hearing, and that no further evidence needed to be called in order for those factual particulars admitted to be found proved. The Panel specifically questioned the Registrant regarding dishonesty and its potential consequences for impairment and sanction. There was also clarification of whether the Registrant knew he was obliged to report changes to the HCPC in terms of his suspension and his change of character. The Registrant acknowledged that he was aware of this obligation.

Adequacy of the Allegation

17. While the Registrant had not clarified whether he knew of the obligation at the time when he failed to disclose his temporary suspension and investigation at work to the HCPC, the Panel was of the view that his response might be material to dishonesty. The Legal Assessor raised with the Panel and the HCPC whether the Allegation needed to be amended in light of the Registrant’s response. Submissions were sought from parties.

18. The HCPC was of the view that the ICP had not sought to refer dishonesty in relation to the HCPC reporting obligations because of the evidence before it. There was no evidence that the wrongdoing in relation to failing in his reporting allegations to the HCPC was deliberate; the view taken was that the knowledge of the Registrant was such that he was not cognisant of his reporting obligations at the time.

19. The HCPC reconsidered its position in light of the response from the Registrant today. The HCPC view was that the Registrant, while indicating that he was aware of the obligation to report, had not unequivocally stated that this was knowledge he had at the relevant time when the duty was engaged. Further, the Registrant had simultaneously indicated, “There were lots of things going on at the time”. The HCPC decided, having had the benefit of the ICP decision, that this accorded with the view taken by the ICP, which factored in the stress and personal circumstances at the time the duties were engaged. Accordingly, the HCPC declined to apply to amend the Allegation and add any further allegations of dishonesty, these specifically having been considered and discounted by the ICP.

20. The Panel, of its own volition, also had regard to the equivocal nature of what the Registrant had said and came to the same decision as the HCPC that the Allegation did not need to be amended. It did so on a slightly different basis as it was not aware of the detail of the ICP decision or the consideration of factors which it took into account. Nonetheless, the Panel focused on the fact that the Registrant’s answer was not clear cut and, without representation, amending the Allegation at this stage would be unfair. In addressing whether this was a matter of undercharging, the Panel was mindful that an allegation of dishonesty was already alleged and had been admitted.

Acceptance of admissions

21. The Panel returned to consider whether it could formally accept the admissions which the Registrant indicated he was prepared to confirm. It was of the view that the Registrant had, from the earliest point of the HCPC regulatory process, been consistent with his admissions. Ms Evans, on behalf of the HCPC, explained that there had been detailed guidance on the legal tests for dishonesty provided to the Registrant and correspondence between the Registrant and Capsticks Solicitors on this issue. The Panel took this into account in indicating that it would accept any admissions made today.

22. The Registrant made oral admissions to Particulars 1-5. The Registrant had returned the HCPTS Hearing Information Form on 19 March 2025 and admitted all of the factual allegations and impairment at that time. He also agreed to the contents of all of the HCPC witness statements and indicated that he would be attending the hearing.

23. The Panel was mindful that the Registrant was not currently represented in these proceedings but that there had been ongoing correspondence between those who represent the HCPC and the Registrant for some time about his factual admissions and agreeing witness evidence. The Registrant maintained his position regarding the factual particulars of the Allegation, but demonstrated that he was engaging with the regulatory process in a thoughtful manner by indicating that his position in relation to impairment had changed and he considered that he was no longer impaired.

24. The Panel received the advice of the Legal Assessor in relation to the admissions it could accept, referring it to the relevant HCPTS Practice Note on “Admissions”. The Legal Assessor reminded the Panel that the decision on grounds and impairment remained ones for itself, irrespective of the Registrant’s decisions.

25. The Panel accepted the admissions made by the Registrant and found Particulars 1-5 proved.

As a registered Operating Department Practitioner (ODP040526):

1. Whilst working on the night shift from around 8:00pm on 8 July 2022 to 8:00am on 9 July 2022, you:

a. on one or more occasions self-administered Sevoflurane, an inhalation anaesthetic gas;

Admitted and found proved.

b. did not respond promptly or at all to one or more bleep calls;

Admitted and found proved.

c. continued to work and/or provided treatment to one or more patients after the conduct described in particular 1(a) above.

Admitted and found proved.

2. Whilst working on the night shift from around 8:00pm on 9 July 2022 to 8:00am on 10 July 2022, you:

a. self-administered Sevoflurane;

Admitted and found proved.

b. did not respond promptly or at all to one or more bleep calls;

Admitted and found proved.

c. continued to work and/or provided treatment to one or more patients after the conduct described in particular 2(a) above;

Admitted and found proved.

d. when questioned by one or more colleagues about the incident at 2(a) above, stated that you were checking the machine or words to that effect, when this was not the case.

Admitted and found proved.

3. You failed to notify the HCPC as soon as possible that you were suspended by your employer on or around 12 July 2022.

Admitted and found proved.

4. On or around 1 September 2022, when renewing your registration with the HCPC, you failed to declare any changes to the status of your good character, despite the fact you had been suspended by your employer on or around 12 July 2022.

Admitted and found proved.

5. Your conduct set out at any or all of particulars 2(d) was dishonest.

Admitted and found proved.

26. The Registrant took the opportunity to thank the NHS witnesses who had been his mentors for their care and instruction, and to apologise to them for his behaviour.

Decision on Grounds

27. Whether the proven facts amounted to the statutory ground of misconduct was a matter of judgement for the Panel. The HCPC did not present any separate evidence on this point.

28. However, the HCPC did seek to argue that the facts found proved established that the Registrant acted in such a way that fell far short of what would be proper in the circumstances and what the public would expect. The HCPC submissions were placed in writing, confirming that the expectation was that the Panel would first consider misconduct and only consider impairment if misconduct was found. Both grounds and impairment were covered within one document.

29. In relation to misconduct, it was submitted that the Registrant had breached the following standards set out in the HCPC’s “Standards of Conduct, Performance, and Ethics”:

6 Manage risk: Identify and minimise risk

6.2 You must not do anything or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.

9 Be honest and trustworthy

Personal and professional behaviour

9.1 You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.

Important information about your conduct and competence

9.5 You must tell us soon as possible if:

you have had any restriction placed on your practice, or been suspended or dismissed by an employer, because of concerns about your conduct or competence.

30. It was submitted that the Registrant had breached the following HCPC “Standards of Proficiency for Operating Department Practitioners”:

Registrant operating department practitioners must:

3 Be able to maintain fitness to practise

3.1 understand the need to maintain high standards of personal and professional conduct.

9 Be able to work appropriately with others

9.1 be able to work, where appropriate, in partnership with service users, other professionals, support staff and others.

9.4 be able to contribute effectively to work undertaken as part of a multi-disciplinary team.

15 understand the need to establish and maintain a safe practice environment

15.1 understand the need to maintain the safety of both service users and those involved in their care.

31. The HCPC position was that the breaches amounted to misconduct. Further, the HCPC submitted that the Registrant was currently impaired on both public protection and public interest grounds. It was submitted that the Registrant had not provided the Panel with sufficient reassurance that he would not repeat his wrongdoing if placed under pressure, nor how he had remediated his admitted dishonesty. In these circumstances, the HCPC submitted that there remained both a public protection risk and a public interest risk.

32. The Registrant apologised for his behaviour and asked the Panel to consider the evidence he had put before it:

• His admissions at the earliest opportunity to all matters;

• Supervision Records which detailed his performance in a responsible ODP post and commended his care of patients;

• Testimonials that were positive and written in full knowledge of these proceedings;

• Evidence of Continuing Professional Development (‘CPD’) in courses he had undertaken;

• A Reflective Statement.

33. The Registrant acknowledged that he had brought the profession into disrepute and put patients at risk. He said at the time he was extremely stressed. He explained that he knew it was seriously wrong to act as he had done but he failed to appreciate the gravity of his actions. His solution in taking something known to have a sedative effect to calm down was the only thing that occurred to him.

34. The Registrant said that in looking back, he fully comprehended now the trauma that he potentially caused colleagues and was shocked and horrified by his behaviour at the time, which was totally out of character, as the testimonials he provided could evidence. He appreciated that he was “reckless” and “selfish” in putting his needs before others. He said that he and his colleagues were there to work a night shift and he placed added pressure on colleagues, who had to care for him when patients may have needed their attention. In this way, he recognised that he had both negatively impacted his colleagues and put members of the public at risk.

35. The Registrant went on to explain how he considered each breach in turn, explaining, for example, that he did breach paragraph 15.1, in that he failed to appreciate the “need to maintain the safety of both service users and those involved in their care” when he continued to work under the influence of an anaesthetic gas, which he described as an “extremely reckless” thing to do. He admitted that he could clearly see that he had “brought the profession into disrepute” and failed “to uphold the responsibilities” with which he had been entrusted as an ODP.

36. The Registrant said that he had had time to reflect upon his actions and events, which dated back almost three years to July 2022. He was particularly remorseful in being dishonest to his colleagues, in not only compromising his own wellbeing but placing them in a position where they could not provide the help required and make an accurate assessment of his needs. In this way he said that, for example, he recognised that in not telling his colleagues the truth about inhaling the anaesthetic gas he breached Standard 9 above. He reflected in multiple places in his written Reflective Statement that he was dishonest and that this was not acceptable. He was transparent in indicating that he had, in breaching Standard 9.1, failed to justify the public trust in him as an ODP and in the ODP profession. He said that qualities such as compassion and respect are paramount for a good ODP but that he had neglected to demonstrate them in July 2022.

37. The Registrant set out that he could “only imagine the stress and frustration” he caused his colleagues unnecessarily by inhaling the anaesthetic gas and then being dishonest about doing so. He reflected that this was an obvious demonstration that he had breached Standard 3.1 and “did not maintain high standard of personal and professional conduct” at the time. He stressed that this occurred in 2022 and he has since undergone a transformative journey.

38. The Registrant said that he:

• plans regular days off from work to ensure a good work-life balance and to reduce fatigue;

• ensures that he regularly takes exercise and walks outdoors;

• engages in sports such as go-karting with colleagues;

• is conscious not to bottle things up but shares concerns with others;

• has identified and surrounded himself with a good support network who he trusts and can confide in;

• is open with those he works with because he understands the need to do that to remain working in a profession that he loves.

39. The Registrant invited the Panel to look at his Reflective Statement, where he detailed how his insight into everything that he did wrong had developed, the positive testimonials from those who know his work, and the multiple supervision reports commenting on his excellent performance. He said that he had learned his lesson and that he would not let such a situation reoccur. He recognised that his behaviour three years ago was completely unacceptable, placing patients and colleagues at potential risk, but his efforts in the intervening period to understand the reasons for his wrongdoing and to prevent any reoccurrence, in his submission, all evidenced that he is no longer impaired today.

Panel’s decision

40. In relation to misconduct, the Panel noted the advice of the Legal Assessor, who referred to the principles in a number of cases including: Roylance v General Medical Council [2000] 1 A.C. 311, Cheatle v General Medical Council [2009] EWHC 645 (Admin), and Nandi v. General Medical Council [2004] EWHC 2317.

41. The Panel was also provided with specific advice covering multiple allegations, where the following cases were referenced: Shodlock v GMC [2015] EWCA Civ 769; Silver v General Medical Council [2003] UKPC 33, and Hindmarch v NMC [2016] EWHC 2233 (Admin). It noted that it should consider each part of the Allegation individually. It may decide that no one failing amounts to misconduct, or that one or more charges are so serious that these amount to misconduct for the purposes of this hearing. It should consider both the culpability of the Registrant and the threshold of wrongdoing, rather than place reliance only on one or the other. In considering whether the matters should be considered collectively, a multiplicity of allegations does not transform less serious matters into more serious ones. The threshold of misconduct that is serious and related to professional standing can be met either by an individual particular or by multiple particulars, or not at all.

42. The Panel noted that misconduct must be serious and amount to a registrant’s conduct falling far below the standards expected of a registered ODP in such a way that fellow practitioners would find their behaviour “deplorable”. The Panel concentrated first on whether the conduct of the Registrant was serious and whether as such it fell far below the standards expected. It also bore in mind that this was an objective test, although it could take account of all the surrounding circumstances of the case.

43. The Panel noted that there was a breach of the standards cited. However, the Panel reminded itself that a breach of standards does not of itself amount to misconduct. It merely establishes the starting point.

44. The Panel considered all the evidence before it, the submissions of both parties, and the legal advice it had received.

45. The Panel was satisfied that all the matters found proved amounted to the statutory ground of misconduct. It accepted the HCPC submission that inhaling anaesthetic gas at work which was not prescribed to him was a serious matter for multiple reasons, not least of which is that the Registrant would have been performing at a sub-optimal level given he was under the influence of anaesthetic gas which was not prescribed for him.

46. Although there was no information before the Panel that any patient came to harm, the risk of harm was present. Further, the Panel noted that dishonesty in a professional is always regarded as serious, albeit it accepted that dishonesty can appear on a spectrum and this may not be the most serious instance of dishonesty, taking into account the Registrant’s health.

47. The Panel did consider the particulars of the Allegation in turn. In respect of the first particular of the Allegation, it regarded that in self-administering a prescription anaesthetic gas which was not prescribed, the Registrant has not managed well the possible risks to patients. In respect of the second particular of the Allegation, the Registrant put others at risk. The Panel considered how dishonesty had been alleged and the consequences of colleagues not being aware that the Registrant had inhaled an anaesthetic gas; they were put at risk of including him in patient care, being unable to provide him with the care he needed, and, given the presence of the anaesthetic gas being smelt in the room by colleagues DC and EJ, other colleagues could inadvertently have been impacted by the anaesthetic gas and inhaled it also. The Registrant’s dishonesty brought about these risks. He was not transparent in reporting his workplace temporary suspension until December 2022 when it had occurred in September 2022.

48. The Panel considered that the breaches of the relevant Standards of both ethics and proficiency were not minor in nature. The breaches had the potential to harm patients, colleagues, and the Registrant himself. Members of the public would not want to be treated by someone who had just inhaled a prescription anaesthetic gas which had not been prescribed for them.

49. Accordingly, the Panel was drawn to the inevitable conclusion that the Registrant’s actions were, both individually and collectively, serious and that his conduct in 2022 fell far below the standards expected of a registered ODP.

Decision on Impairment

50. In reaching its decision on impairment, the Panel took account of the submissions of parties, the advice of the Legal Assessor, the evidence before it, and the HCPTS Practice Note titled “Fitness to Practise Impairment”. Accordingly, the Panel was conscious that the HCPC’s overarching objective is the protection of the public, and the purpose of fitness to practise proceedings is not to punish registrants for their past acts and omissions but to protect the public from those who are not fit to practise. It does this by:

• protecting, promoting, and maintaining the health, safety, and well-being of the public;

• promoting and maintaining public confidence in the professions it regulates;

• promoting and maintaining proper professional standards and conduct for members of those professions.

51. The Panel was aware that, in determining whether fitness to practise is impaired, it must take account of a range of issues which, in essence, comprise two components, namely the ‘personal’ component (the current competence and behaviour of the individual registrant) and the ‘public’ component (the need to protect service users, declare and uphold proper standards of behaviour, and maintain public confidence in the profession).

52. The Panel appreciated that not every finding of misconduct will automatically result in a panel concluding that fitness to practise is impaired. Moreover, it cannot adopt a simplistic view and conclude that fitness to practise is not impaired simply on the basis that, since the allegation arose, a registrant has corrected matters or ‘learned their lesson’.

53. Although the Panel’s task was not to punish past wrongdoings, it did need to take account of past acts or omissions in determining whether a registrant’s present fitness to practise is impaired. In addition, when assessing the likelihood of a registrant causing similar harm in the future, the Panel should take account of both the degree of harm, if any, caused by a registrant and that registrant’s culpability for that harm. Finally, the Panel was to consider whether a registrant had demonstrated insight into their attitude and failings.

54. The Panel considered that the Registrant had provided evidence of remorse, reflection, and insight into his actions. Further, he had provided references and testimonials which portrayed him in a positive light, commending the care that he takes and the more senior position he currently holds in a private hospital, with additional stresses and responsibilities. The Panel was of the view that while there had been the passage of time without repetition and the Registrant had undoubtedly reflected on his wrongdoing, he had focused on his health rather than his dishonesty.

55. The Panel started by considering the principles set out in the case of Zygmunt v GMC [2008] EWHC 2643 (Admin), where the summary of potential causes of impairment offered by Dame Janet Smith in the Fifth Shipman Inquiry Report (2004) was adopted. This considered that impairment would arise where a healthcare professional:

• Presented or presents a risk to patients;

• Has brought / is likely to bring the profession into disrepute;

• Has breached / is likely to breach one of the fundamental tenets of the profession;

• Has been dishonest / is likely to be dishonest in the future.

56. The Panel considered that the Registrant satisfied all these criteria in terms of his past misconduct, but appreciated that impairment is a current test, looking forward and not back. The Panel was of the view that the Registrant was unlikely to self-administer Sevoflurane in the future, having taken steps to better manage possible stressors. The Panel took into account that the Registrant’s current job involves him managing others alongside his own ODP role and that, with the greater stress and workload he faces, there has been no repetition of events. Further, the Registrant, in his Mental Health First Aider role, will have had training and obtained knowledge about identifying signs of mounting stress and the necessary pathways and sources of support to access.

57. The Panel also received additional legal advice when in the Panel Room during its in-camera discussions. This involved reference to the case of the PSA v (1) GMC (2) Uppal [2015] EWHC 1304, which is authority for the principle that a finding of dishonesty does not necessarily require a finding of impairment in every case. The Panel bore this in mind when arriving at its decision.

58. The Panel was of the view that dishonesty is hard to remediate. It followed the principles outlined in the case of Cohen v GMC [2008] EWHC 581 (Admin), where the identified criteria for assessing current impairment was:

• Is the conduct remediable?

• Has it been remedied?

• Is it highly unlikely to be repeated in the future?

59. The Panel considered that this dishonesty can be remediated and gave thought to what it would expect to see from the Registrant. It noted that the Registrant was of good character before this incident and that the dishonesty appears related to isolated incidents in July 2022 which have not been repeated. It regarded his reflections as genuine and meaningful and noted that he had addressed his dishonesty as wholly unacceptable.

60. In assessing culpability, the Panel did take into account that deliberate and intentional harm is more serious than harm arising from a registrant’s reckless disregard of risk. This is a case where the Registrant is unlikely to have given thought to and foreseen the risk of harm to others. However, the extent to which the Registrant had not addressed his mind to it because a) he was unwell or b) under the influence of an anaesthetic gas needed to be considered.

61. While the Registrant was unable to control his health, he made a deliberate choice to inhale an anaesthetic gas. The extent to which the two are related will also be considered, but not all people with ill health (or even an ODP with access to prescription drugs) take drugs which have not been prescribed for them.

62. While there was no evidence of actual harm occurring, this was down to luck rather than judgement, as the Registrant’s dishonesty could have seen a drug-impaired ODP providing care to a vulnerable patient. Consequently, even though the Panel had been provided with some evidence of how the Registrant now prioritises others over his own interests in his Mental Health First Aider role, it could not be satisfied that the Registrant would not repeat his dishonesty if placed in a difficult position again.

63. Accordingly, the Panel was of the view that while the Registrant has started upon the journey to develop insight, this is incomplete. The Registrant does have the insight to recognise that his failings fell far below the standards required of an ODP and readily admits that, as the Practice Note on impairment makes clear is relevant at paragraph 24a. However, in focusing on tying the dishonesty to health, the Registrant suggests that in taking care of his health he is less likely to be in a situation where he is dishonest. The Panel considered that this was limited in respect of whether he can demonstrate he has taken action to address that failure in a manner which remedies any issue and avoids any future repetition, as is required by paragraph 24b.

64. There was no indication that the Registrant had attended specific courses addressing ethics and appropriate workplace behaviour, nor professionalism in the workplace to address dishonesty. Further, while the Registrant had acknowledged the impact of his dishonesty in respect of both the potential risk to patients and colleagues, he had not provided an explanation for why he was dishonest at the time, save to acknowledge that he was prioritising his own interests over others.

65. The Panel therefore found that, in relation to the personal component, the Registrant is currently impaired.

66. In relation to the public component, the Panel considered that the Registrant’s misconduct was such that the need to declare and uphold professional standards and maintain public confidence in the profession would be undermined if a finding of impairment were also not made in these circumstances. The Panel took into account that this is an isolated incident, without repetition since 2022, and that the Registrant’s colleagues make reference to him as being an “incredible” ODP and “deserving of another chance”. The Panel noted that the Registrant has since obtained a more responsible ODP role and that his current employers commend his performance and report no concerns with how he undertakes his role.

67. The Panel’s opinion mirrored that acknowledged by the Registrant that inhaling a prescription anaesthetic gas which is not intended for one while in a responsible role as a ODP is unacceptable. Being dishonest, perhaps to protect oneself from the consequences of one’s behaviour and face disproval or punishment, while simultaneously making worse the risk for others, is behaviour which needs to be marked as unacceptable. The Panel acknowledged that this dishonesty was not the worst instance of dishonesty it had encountered in professional regulation but it nonetheless arose as a result of the desire to protect oneself, regardless of the risks this then presented to others.

68. The Registrant himself acknowledged that he had breached a position of trust.

69. The Panel took into account that the failures to report a change in good character and promptly notify the HCPC about his temporary suspension at work were not alleged to be dishonest, but it was still a breach of expected duties.

70. The Panel also considered whether these proceedings themselves, along with the intervening period of time it has taken to resolve matters, were sufficient to mark the gravity of the Registrant’s wrongdoing. It was of the view that while this might be sufficient to mark the Registrant’s misconduct in light of his health at the time, insofar as fellow practitioners are concerned, thereby satisfying the need to declare and uphold professional standards, it was insufficient for the public confidence in the profession.

71. The Panel believed that a well-informed member of the public with full knowledge of all of the circumstances of this case would be extremely concerned if a finding of current impairment were not made.

72. Taking all these factors into account, the Panel concluded that the public interest required a finding of impairment against the Registrant.

73. In conclusion, therefore, the Panel found that the Registrant is impaired under both the personal and the public components.

Decision on sanction

74. The Registrant gave evidence under Affirmation. He thanked the Panel for giving him the opportunity to engage. He said that he wanted to share what he had learned from this experience and what he would do differently in the future. The Registrant indicated that he was grateful for the extended period of time that had fallen between the impairment and sanction stages and he had made good use of this to address some of the Panel’s concerns from the impairment stage regarding dishonesty, in particular the issues with regard to why he had been dishonest at the time.

75. He said that he fully acknowledged that by self-administering a prescription-only anaesthetic gas (Sevoflurane), which had not been prescribed to him, and failing to immediately disclose this to his colleagues when questioned, he acted dishonestly. He understood that he had failed to uphold the trust placed in him by his Regulator and employer, letting down the colleagues who had supported him whilst he was a student, and the public, who would expect ODPs to follow the standards set out by the HCPC.

76. The Registrant said that not notifying the HCPC when he was suspended and dismissed by his employer represented a serious lapse in judgement and breached professional expectations. He said that his intentions were not to hide anything from the HCPC.

77. The Registrant acknowledged that he made a deliberate choice to conceal the truth; a decision made due to fear, shame, and to avoid disciplinary action being taken against him. He said that his judgement was absolutely clouded when questioned by his colleagues, indicating that he panicked at the thought of being found out. In doing so, he placed his own needs above the safety and wellbeing of his patients and colleagues, which was professionally and ethically unacceptable. As a healthcare practitioner he recognised that he is always expected to be open and honest. He said that this had been a life lesson and he fully appreciated the importance of being truthful. He said that this valuable lesson will be remembered for the remainder of his life.

78. The Registrant explained that since that time, he has taken meaningful steps to address both the root cause of his actions in inhaling the anaesthetic gas and the dishonesty to cover it up, which he recognised as separate, albeit related to the same incident. These include seeking help from his employer, acknowledging how helpful this had been.

79. The Registrant recognised that while patients are the most important people in the operating theatre, by not looking after himself he failed to look after the patients. This was a new insight to him and had made him look at when he is tired or less than his best. He has a responsibility to be honest with himself and others, which includes colleagues and his employer.

80. The Registrant used, by way of example, where five consecutive days he had worked turned out to be very long shifts which left him feeling physically exhausted and mentally tired. He said that he had put in a request for two days of leave, explaining why he needed these, because he was conscious of the impact of exhaustion on his productivity and, more importantly, on human error which could compromise patient safety. He did not want to be in a position to make such mistakes in the future and would take positive action to prevent this happening.

81. The Registrant said that he had taken advantage of the break between the impairment and sanction stages to reflect on the Panel’s determination and findings. He had therefore completed CPD in relation to being open and honest, undertaking courses focusing on Professionalism and Professional Standards, as well as Ethics and Ethical Standards for HCPC-regulated Health and Care Professionals. He said that as part of his professional development, he has taken time to reflect on what it truly means to demonstrate professionalism in line with the HCPC’s professional standards. He said that he had learned that professionalism is not just about how people look or speak; it is about the values, behaviours, and attitudes that are put into practice every day. There is no place for dishonesty.

82. The Registrant said that he understands that the HCPC’s Standards of Conduct, Performance and Ethics reflect expectations of:

• acting in the best interests of service users;

• maintaining clear and respectful communication;

• keeping high standards of personal behaviour;

• being honest and trustworthy in all professional matters, even when things do not go as planned.

83. The Registrant said that a key takeaway for him had been the importance of accountability. He acknowledged that being a professional means taking full responsibility for his actions, decisions, and the impact they may have on colleagues, patients, and the public. He said that he now recognises his limits and knows when to seek support and why it is important to be open and trustworthy. He said that he now has a far deeper understanding of the implications of dishonesty not just in healthcare but in his personal life. Even though no patient came to harm, he recognised that the risk of harm was significant and that honesty is essential to safe care, team trust, and public confidence.

84. The Registrant said that he deeply regretted the pressure he placed on his colleagues, the trust he betrayed, and the risk he created for others by not being truthful in a critical moment. He said that his insight has developed significantly since 2022 and has continued since the Panel determination on impairment. He now views honesty not as something that is situational or discretionary, but as a non-negotiable foundation of safe and ethical practice. He said that he accepts full responsibility for his actions and is committed to ensuring that they are never repeated.

85. The Registrant reminded the Panel that he has not repeated this behaviour since the incident, despite now working in a more senior and demanding role, which he believes evidences growth, maturity, and sustained commitment to professional conduct. He assured the Panel that he is committed to maintaining the highest standards expected of a registered ODP. He said that he has used this experience as a turning point in both his personal and professional life. He said that he deeply regretted his past actions but has taken them as life lessons for meaningful change. He said that he is determined to continue working in a way that restores trust, upholds professional values, and protects the public.

86. He added that while he has now undertaken several courses to cover professionalism, ethics, and probity, this has embedded the learning that has been developing since 2022. He apologised for not having completed courses which evidenced learning about probity earlier, but said as an unrepresented registrant he had not been clear about the need to evidence his learning in this way until he read the Panel’s determination on impairment. He said that he has now completed two additional courses and undertaken further reflection, completing another Self Reflection document, and is clear that respectful communication is an obligation, particularly when things do not go as planned.

87. In cross-examination, he acknowledged that he had self-administered the anaesthetic gas on two separate occasions in consecutive shifts, which should not have happened. He said that it was very unsafe to do this. That he behaved in this way was a demonstration that his judgement was clouded. He acknowledged that patients could have come to harm and that this was a significant risk. He said that in future, he would self-report to the HCPC promptly if there was ever any reason to do this, given that he understands the priority must always be patients rather than his own interests.

88. In response to Panel questions about the future, he acknowledged that if he was struggling with his health he would speak out, asking to change his rota and being open with directors. He said that he now has regular meetings with IB (Director of Governance and Compliance at his current employer), and has made himself aware of the facilities at his new place of employment for assistance, which he would avail himself of.

89. The Registrant said that he was dishonest because he was scared of losing his job and tried to hide his stress and inhalation of anaesthetic gas, but this dishonesty led to him losing his job. He appreciated that honesty was always the best policy and acknowledged that where his health is concerned, he will take better care of it positively to prevent life stresses from overloading him. He said that in the past he had made a mistake but in the future would be open and honest. He uses the incident reporting system and now knows that errors need to be escalated to higher management and the HCPC, and he would do so. Depending on the seriousness of an incident, he would reflect upon it and write an incident report to inform management. If the incident involved a patient he would also notify the HCPC and, depending on the issue, e.g. for safeguarding, contact the Disclosure and Barring Service (DBS). He knows that he has a duty of candour and recognises the importance of this, and of being open with patients and explaining when things go wrong and apologising.

90. The Registrant said:

“I would act differently in the future. If I did something bad or wrong, I would be open, not just for my own sake ultimately but because it is required to protect patients. I have made changes in the way that I act at work, and this is reflected by the current testimonials. Senior staff have commented on my performance and know about events and have reflected on how I have shared my learning with others. I cannot change the past; but I can impact the future.”

91. Ms Evans, on behalf of the HCPC, confirmed that it was not the practice of the HCPC to make a “sanctions bid”. Nonetheless, she went through the possible mitigating and aggravating factors which she identified may be relevant (which the Panel set out below). Further, she drew the Panel’s attention to various parts of the HCPC Sanctions Policy (which again the Panel considered below).

92. Ms Evans reminded the Panel that, as it had found impairment on both public interest and public protection grounds, it therefore had to address both the risk of harm to the public as well as the wider public interest.

93. The Panel took into account the various mitigating and aggravating factors, including those suggested by Ms Evans, and, in the main, agreed with her assessment but added to the relevant points.

Aggravating factors

94. The aggravating factors were as follows:

• The Registrant had deliberately made the decision to inhale an anaesthetic gas;

• The Registrant breached the standards that he should have upheld;

• The Registrant placed his colleagues and patients at risk of harm by not responding to a call for help with patients promptly, and thereafter doing so when under the influence of a prescription anaesthetic gas not prescribed to him;

• The Registrant had been dishonest, which had brought about an additional risk of harm (albeit the Panel considered that his dishonesty was at the lower end of the spectrum; for instance, the Registrant reminded the Panel that the dishonesty occurred as a spur of the moment decision when caught ‘red-handed’ but was admitted to, rather than being pre-meditated);

• The Registrant was not open with the HCPC by not promptly reporting a loss of good character and his temporary suspension at work;

• The Registrant breached a position of trust in which he had access to a prescription-only anaesthetic gas.

Mitigating factors

95. The mitigating factors were as follows:

• The Registrant had no previous adverse regulatory history;

• The Registrant had made full admissions to all of the allegations at an early stage and not just at the Fitness to Practise hearing;

• The Registrant engaged in the process, making himself available for cross-examination;

• The Registrant apologised to his colleagues at the outset of the hearing, explaining why he had not been able to do that sooner;

• The Registrant acknowledged that his conduct was wrong and therefore demonstrated insight;

• The Registrant had not attempted to deflect responsibility for his actions;

• There was no evidence of any harm to any patients (however, there was the risk of harm to patients in returning to work after inhaling the anaesthetic gas and a risk to colleagues, who would be relying on the Registrant for ODP skills and be hampered by not knowing what was wrong with the Registrant and, accordingly, being able to treat him appropriately);

• There was positive evidence of the Registrant’s abilities as an ODP, and testimonials attesting to his capabilities and of his intentions of acting in the best interests of patients (albeit the Panel would comment that his admitted behaviour, which was found proved by this Panel, was somewhat contradictory to such intentions, even if this occurred in 2022);

• He has continued to work as an ODP for another employer and there has been no repetition of his misconduct;

• The Registrant has been transparent with his subsequent employer and utilised his experience to assist others.

• The Registrant’s current employer has been very complementary about the Registrant’s practice and his openness in making his learning experience one which his colleagues can learn from, and they confirmed that there are no current concerns.

• The Registrant has undertaken CPD for ethics, professionalism, and probity.

• There were health issues at the time of the Registrant’s breach of the standards.

• This occurred in the aftermath of two years of the Covid-19 pandemic, when a huge toll was placed on healthcare professionals;

• This could be regarded as an isolated incident spanning two consecutive shifts.

96. The Panel recognised that the Registrant appeared motivated to remediate his misconduct from the outset by expressing remorse, making admissions, and indicating that in his new job he is continuing to learn and use his experience for others’ benefit.

97. The Panel was assisted by the Registrant giving evidence at this stage. While the Panel recognised that it was the Registrant’s right not to give evidence, by opening himself up to questioning he had availed himself of the opportunity to explain to the Panel what the motivation for his conduct had been and to expand upon it.

Decision

98. The Panel first considered taking no action against the Registrant. The Panel found that because of the seriousness of the misconduct identified this would not be appropriate, since it would not adequately protect the public or reflect the public interest.

99. The Panel next considered a caution order. The Panel noted that a caution order was likely to be an appropriate sanction for cases in which:

• the issue was isolated, limited, or relatively minor in nature;

• where there was a low risk of repetition;

• and where a registrant has shown good insight and has undertaken appropriate remediation.

100. The Panel considered that most of these criteria applied in this case and therefore gave serious thought to whether a caution order was the most appropriate order. The Panel also recognised that a caution order would be an unusual sanction for dishonesty. However, the Panel was assisted by the HCPC Sanctions Policy, which had the following to say about dishonesty:

“Given the seriousness of dishonesty, cases are likely to result in more serious sanctions. However, panels should bear in mind that there are different forms, and different degrees, of dishonesty, that need to be considered in an appropriately nuanced way. Factors that panels should take into account in this regard include:

• whether the relevant behaviour took the form of a single act, or occurred on multiple occasions;

• the duration of any dishonesty;

• whether the registrant took a passive or active role in it;

• any early admission of dishonesty on the registrant’s behalf; and

• any other relevant mitigating factors.”

101. The Panel was mindful that dishonesty is always serious in a healthcare professional, albeit it had determined that these isolated instances of dishonesty did not appear to be reflective of the Registrant’s usual practice and behaviour. The Panel also took into account the health of the Registrant at the time.

102. The Panel did consider whether a conditions of practice order would be the more appropriate order. It noted the guidance, which states that a conditions of practice order is likely to be appropriate in cases where:

• a registrant has insight;

• the failings or deficiencies are capable of being remedied;

• there are no persistent or general failures which would prevent the registrant from remediating;

• appropriate, proportionate, realistic, and verifiable conditions can be formulated;

• the Panel is confident the Registrant will comply with the conditions.

103. The Panel noted that, in its view, the Registrant’s insight had developed since 2022. He had been able to evidence that it had developed even further during the hearing. Some of the deficiencies (for instance, dishonesty) were not easy to remediate but the Panel had nonetheless received evidence not just of courses the Registrant had attended but his reflection upon them as to what he has learnt, and how he has applied this to past events and what it would mean for his future conduct.

104. The Panel did not consider that the Registrant’s failings had been persistent and wide-ranging and, although it might have been possible that appropriate conditions could have been formulated to deal with practise issues, it recognised that conditions do not lend themselves to marking dishonesty. The Panel noted the positive testimonials and reports from the Registrant’s current employer and his more senior position held for over two years without concern. Conditions did not appear to be appropriate in these circumstances.

105. The Panel even considered whether suspension was the more appropriate sanction and was assisted by the guidance available on sanctions. It noted that a suspension order is likely to be appropriate where there are serious concerns which cannot reasonably be addressed by a conditions of practice order but which do not require the registrant to be struck off the Register. These types of cases would typically exhibit factors such as:

• the concerns represent a serious breach of the Standards of Conduct, Performance and Ethics;

• the registrant has insight;

• the issues are unlikely to be repeated;

• and there is evidence to suggest that the registrant is likely to be able to resolve or remedy their failings.

106. The Panel reminded itself of the esteem in which the Registrant is held by his colleagues, who described him as having the best interests of his patients at heart. Furthermore, the Panel noted that he had insight and that there had been no repetition of his conduct since his referral to the HCPC in 2022. Most significantly, the Panel gave serious consideration to the fact that the Registrant had engaged with this process. He had demonstrated his insight and his desire to undertake every opportunity to remediate and to evidence that this was a single incident in his life which was out of character for him, as his character witnesses confirmed. He now addresses his health very deliberately and has evidenced his continued learning, with regular evaluation of how poor health can impact performance.

107. The Panel was conscious that it was only considering suspension on the basis that dishonesty cannot readily be addressed by conditions. However, it acknowledged that depriving the public of a good ODP is contrary to the public interest. Accordingly, it was of the view that the Registrant had learned his lesson and recognised both the importance of looking after one’s health and the need to always be honest.

108. The Panel was of the view that these regulatory proceedings and the finding of impairment mark the gravity of these incidents and will be a salutary lesson to the Registrant, will protect the public, and will mark the profound unacceptability of the Registrant’s actions. The Panel had regard to the impact of two years of the Covid-19 pandemic on healthcare workers. The Panel was clear that the Registrant’s behaviours were serious departures from the standards he should have upheld but that the likelihood of repetition was negligible, with the Registrant’s latest insights evidenced.

109. The Panel did consider that the wrongdoing had to be marked and considered that a Caution Order struck the right balance between imposing a sanction that would appear on the Registrant’s record and could be taken into account if there was future wrongdoing, and preventing a good ODP from continuing to practise without restriction, or at all. The Panel was of the view that the Caution Order needed to run for a longer period than one year to remind the Registrant that this incident may be in his past but it would have a real impact on his future and any other post he might apply for.

110. The Panel therefore determined to make a Caution Order in relation to the Registrant for three years.

That the Registrar is directed to annotate the register entry of Mr Ronak Malde with a caution which is to remain on the Register for a period of three years from the date this Order comes into effect.

No notes available

History of Hearings for Ronak Malde

Date	Panel	Hearing type	Outcomes / Status
14/04/2025	Conduct and Competence Committee	Final Hearing	Caution
28/01/2025	Conduct and Competence Committee	Interim Order Review	Interim Conditions of Practice
23/10/2024	Investigating Committee	Interim Order Review	Interim Conditions of Practice
18/04/2024	Investigating Committee	Interim Order Review	Interim Conditions of Practice
15/01/2024	Investigating Committee	Interim Order Review	Interim Conditions of Practice
16/10/2023	Investigating Committee	Interim Order Review	Interim Conditions of Practice
17/07/2023	Investigating Committee	Interim Order Review	Interim Conditions of Practice
20/01/2023	Investigating Committee	Interim Order Application	Interim Conditions of Practice