Mary C Pelopero

Profession: Physiotherapist

Registration Number: PH90446

Hearing Type: Final Hearing

Date and Time of hearing: 09:00 16/06/2015 End: 16:00 18/06/2015

Location: Health and Care Professions Council, Park House, 184 Kennington Park Road, London, SE11 4BU

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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As amended at the final hearing:

1. On or around 25 June 2013, you administered a heat treatment to Patient A, and you:

a. did not assess and/or record whether this was an appropriate treatment for Patient A's condition;

b. did not assess and/or record Patient A's skin sensation prior to commencing the treatment;

c. did not monitor and/or record the effects of heat treatment on Patient A during treatment;

d. continued to administer the heat treatment which resulted in Patient A developing a blister on his left hip.

2. Between 04 February 2013 and 26 September 2013, you:

a. Retained initial evaluations pertaining to the following patients at your home

i. Patient A;
ii. Patient B;
iii. Patient C;
iv. Patient D;
v. Patient E;
vi. Patient F;
vii. Patient G;
viii. Patient H;
ix. Patient I;
x. Patient J;
xi. Patient K;
xii. Patient L.

b. Did not record the initial evaluations for the patients referred to above in Particular 2a in the electronic care system.

3. An audit of your caseload was undertaken, and it was found that, you:

a. Did not consistently complete and/or record patient assessments on the electronic care system, for:

i. Patient M;
ii. Patient N;
iii. Patient O;
iv. Patient P;
v. Patient Q;
vi. Patient R;
vii. Patient S;
viii. Patient T;
ix. Patient U;
x. Patient V;
xi. Patient W;
xii. Patient D;
xiii. Patient X;
xiv. Patient Y;
xv. Patient Z;
xvi. Patient I;
xvii. Patient Ai;
xviii. Patient Bi;
xix. Patient Ci
xx. Patient Di;
xxi. Patient Ei.

4. The matters set out in paragraphs 1, 2, and 3 constitute misconduct and/or a lack of competence.

5. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.


Preliminary matters

1. The Panel heard an application made on behalf of the Council to amend the charges. The Panel noted that the Registrant had been notified of the proposed changes and that the application was not opposed. The Panel was satisfied that the proposed amendments could be made without any unfairness or prejudice to the Registrant. Accordingly, the Panel granted the application.

2. The Registrant admitted all of the charges save for Allegations 3a(vi), 3(xii) and 3(xiv). The Registrant accepted that her conduct amounted to misconduct and a lack of competence and that her fitness to practise is currently impaired on the basis that she has been unable to demonstrate remediation due to her not being able to practise as a physiotherapist.


3. The Registrant was initially employed as a night care assistant for Eastleigh Care Homes (ECH) between 3 April 2009 and 4 February 2013 when she became a company physiotherapist upon completion of conversion of her overseas qualification.  This was, therefore, her first post as a qualified physiotherapist in the UK.

4. ECH provide residential and nursing home accommodation and services across three homes in separate locations. The residents in the homes include the elderly and vulnerable with varying degrees of cognitive and communication abilities.  As company physiotherapist, the Registrant was responsible for working with the vulnerable residents who were based across all three sites.

Allegation 1

5. Relates to the Registrant’s provision of a heat treatment to Patient A on 25 June 2013. Patient A was a 94 year old male resident who had been in the Minehead residential home for some time. He was blind, hard of hearing, had restricted range of movements and had a left sided weakness following a stroke. He also had some cognitive impairment and at times had an inability to communicate and had variable capacity to give consent.

6. The Registrant appears to have carried out an initial assessment/evaluation on him on 19 March 2013 in which, among other things, she noted he was experiencing severe left shoulder pain.  Within the assessment the treatment plan includes reference to the use of a hot water bottle to the shoulder for 10-15 minutes.

7. Following this, the Registrant then treated Patient A regularly up until 27 June using heat therapy by way of a hot water bottle to the left shoulder and arm on a number of occasions with no negative effect.  However, on 25 June 2013 Patient A was complaining of pain to his left hip and so, as well as applying a hot water bottle to the left arm and shoulder, it was applied to the left hip.

8. This treatment took place at around 1.23pm, however when Patient A was moved back to bed by one of the care assistants after lunch at 2.23pm it was noticed that there was a red mark on his hip.  By the next day this had become a blister which developed to the size of a ten pence piece and took some time, in view of his age and health, to heal. The blister can be seen in photographs which were taken on 26 and 27 June 2013.

9. As a result of this incident there was an internal investigation conducted by the Deputy Matron, KH. The investigation involved an initial investigatory meeting with the Registrant on 7 August 2013 after which she was suspended.  There were also two disciplinary hearings on 17 and 26 September 2013 after which the Registrant was dismissed from her role as a physiotherapist but was kept on as a care assistant. 

10. As ECH had no other physiotherapist in their employment they instructed an external physiotherapist, KS, to write a report providing her opinion as to the standard of care provided and appropriate practice in the circumstances.  In summary her conclusions were that:

• there should have been an assessment as to whether heat treatment was appropriate for Patient A and that there was no record that such an assessment had taken place;
• all assessments and findings should be recorded;
• prior to applying heat treatment it is necessary to assess a patient’s temperature sensation and thus a physiotherapist must carry out a hot and a cold test.  Further, that the use of a physiotherapy hammer with a brush and skin prick adaption was not an appropriate way of doing this;
• it is necessary to monitor the effects of heat treatment whilst it is being applied;
• Patient A had not been adequately examined and the heat treatment was the cause of the blister;
• given Patient A’s history of stroke the use of heat treatment with Patient A was unwise and risky at best;
• The standard of care provided was below what could reasonably be expected of a physiotherapist in the circumstances.

Allegation 2

11. Over the course of the first disciplinary meeting on 17 September 2013 the Registrant was asked whether she had conducted an initial assessment/evaluation for Patient A and whether she had recorded it. Her answer was that she had recorded it in a notebook which she kept at home. She explained that the reason for this was that she had had difficulties uploading onto the system due to IT problems.  This raised two concerns. Firstly, that the notes were not on the system and so other care professionals would not have access to them.  Secondly, the potential issues of breach of data protection and confidentiality in that they were stored at the Registrant’s home rather than onsite in the patients’ files. It was expected by ECH that all patient initial assessment/evaluations would be recorded, regularly updated and for paper copies to be scanned onto the electronic system, iCare.

12. At the conclusion of the meeting, shortly after 2pm, it was agreed that the Registrant would provide all copies of any notes she had by 4pm that day. KB says that she received a phone call from the Registrant at 4pm in which she said that the notes were packed in boxes and that she was struggling to find them. KB agreed to extend the time by a further 45 minutes. However, when she was unable to get through by phone at 4.45pm she went to the Registrant’s home address only to find that there was no one there. As she was leaving KB saw the Registrant and her husband returning home in their car. The Registrant explained that she would find the notes that evening and that her husband would deliver them by 7am the next day.

13. Ultimately twelve initial assessments/evaluations were provided in respect of Patients A through to L. When Ms B examined both iCare and the paper files she found that these assessments/evaluations were not stored in either location.

Allegation 3 a

14. Upon receiving and reviewing the initial assessments/evaluations there were concerns that there were only twelve provided. There was capacity across the three sites for 182 patients and JW, the disciplinary officer, was aware, through her own experience, that the Registrant had been treating in excess of twenty patients. 

15. It was, therefore, decided to carry out an audit of the Registrant’s work to look into her recording practice. Therefore, on 25 September, KB, having identified a sample of cases on which the Registrant had worked, carried out this task.  The results appear in her statement. 

16. In summary, but for Patient D, Patient R and Patient Y, there was no assessment or evaluation on the system and, in many of the cases, there was not even reference to there having been any assessment despite treatment being provided by the Registrant.

Decision on facts

Allegation 1

17. The Panel notes that the Registrant has admitted this allegation and has not challenged the evidence presented by the Council. It has had regard to Patient A’s notes, the Incident Report and the photographs of the injuries.

18. Having considered all of these matters, the Panel is satisfied, on the balance of probabilities, that this allegation has been proved.

Allegations 2 (a) & (b)

19. The Panel notes that the Registrant has admitted this allegation and has not challenged the evidence presented by the Council.

20. It has considered with care and accepted the evidence of KB whom it found to be a credible, consistent and experienced witness. KB confirmed that she was told by the Registrant that the initial evaluations for the patients in question were being kept by her at her home. The Panel accepted the evidence she gave about being provided with them by the Registrant at her request and then examining the iCare system. KB confirmed that no copies were present on the system. The Panel accepted her evidence that the policy was that these assessments should have been scanned onto the system and that the Registrant would have known this.

21. With regard to the notes relating to Patient D, the Panel accepted that, whilst there were differences between the entry on the system and the handwritten notes of the initial examination, the entry on the system represented the notes relating to the initial examination.

22. For these reasons, the Panel is satisfied, on the balance of probabilities that allegation 2(a) has been proved as has 2(b) save for the allegation relating to Patient D.

Allegation 3 a

23. The Panel notes that the Registrant has admitted this allegation and has not challenged the evidence presented by the Council. It accepted the results of the audit carried out by KB and the other documentary evidence submitted in support.

24. The Panel considered that this allegation was, however, not about the timeliness of recording or how often the assessments should have been carried out.

25. Consequently, the Panel found this allegation proved on the balance of probabilities save in relation to Patients D, R and Y where it was satisfied that initial assessments had been carried out and recorded on the electronic care system.

26. As the other assessments were not completed, there was no way in which they could have been recorded and to this extent, the allegation of a failure to record is proved.

Decision on grounds

27. The Panel considered that those matters found proved in allegations 1(a) – 1(d) related to aspects of the Registrant’s practice that should have been within her scope of training. The treatment required the basic level of competence from a physiotherapist and would have been covered in training. The Panel was satisfied that the Registrant’s actions demonstrated a lack of care on her part both in her administration of the treatment and her failure to monitor it appropriately.

28. The Panel was satisfied that these matters fell far below the standard expected of someone in the Registrant’s position and therefore constituted misconduct on her part.

29. In respect of those matters found proved in allegation 2(a), the Panel was satisfied that the Registrant would have been aware of the requirements and policies that prohibited the keeping of this type of material at her home. She would have known of the requirements and guidelines relating to confidentiality and data protection. The Panel notes that the Registrant has referred to her home being owned by the company but nevertheless it is satisfied that this is no excuse and these acts fell far below that expected of someone in her position and consequently also amount to misconduct by her.

30. In respect of allegation 2(b) the Panel noted the difficulties with the computer system mentioned by the Registrant and also verified by Mrs P in her evidence. The computer system restricted the amount of information that could be entered into a particular cell and there were difficulties with trying to retrieve information already entered. The Registrant had reported these problems but nothing appeared to have been done to resolve them.

31. In the light of this evidence the Panel was not satisfied that the matters found proved amounted to either misconduct or lack of competence on the part of the Registrant.

32. In respect of allegation 3a, the Panel was satisfied that patient assessments had been carried out with regard to Patients D, R and Y. However, the failure to consistently complete patient assessments for the other patients mentioned in this allegation amounted to a failure by the Registrant to perform one of the most fundamental roles in her practice. Consequently, the Panel was satisfied that her failures in this aspect fell far below that expected of someone in her position and amounts to misconduct on her part.

33. In respect of the failure to record such assessments, as these had not been completed this was not possible. Consequently, the Panel makes no findings about misconduct or lack of competence in this regard.

34. In the case of those matters that the Panel has found to amount to misconduct, it has not, in view of the serious nature of those findings, made any further findings as to lack of competence.

35. The Panel was satisfied that there were breaches of the following relevant standards as set out in the Standards of proficiency for Physiotherapists: 4.1 (being able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem); 4.2 (being able to make reasoned decisions to initiate, continue, modify or cease techniques or procedures and record the decisions and reasoning appropriately); 7.2 (understanding the principles of information governance and being aware of safe and effective use of health and social care information) and 15.1 (understanding the need to maintain the safety of service users).

36. Furthermore, the Panel was satisfied that the matters found proved also amounted to breaches of the HCPC Standards of conduct, performance and ethics – 1. You must act in the best interests of service users and 10. You must keep accurate records.

Decision on impairment

37. As regards allegation 1, the Panel noted that the injury caused was a superficial burn that led to the production of a blister. Whilst unpleasant, this injury was not of the most serious kind.

38. The Registrant has acknowledged her failings in this regard in that she made full admissions from the start and has done so before the Panel at the start of this hearing. To this extent, the Panel is satisfied that she has shown a degree of insight. 

39. The Panel is satisfied that this misconduct is remediable and has to a degree been remediated. In her current role as a generic therapy assistant, the Panel accepted the evidence of Mr A (Senior Physiotherapist), that she has been performing to a competent level and has been administering heat treatment. Mr A was satisfied that there were no concerns whatsoever about her performance. Equally, Mr A told the Panel that he had no concerns whatsoever about the Registrant’s recordkeeping.

40. However, the Panel notes that in her current role, the Registrant has not been able to work as a physiotherapist and consequently her ability to demonstrate full remediation has not been possible. Therefore, the Panel is satisfied that, whilst the risk to service users may be low, the personal component is satisfied and the Registrant’s fitness to practise is currently impaired to that extent.

41. The Panel had regard to the Registrant’s early recognition of responsibility and her current level of skill and performance, as demonstrated through the evidence of Mr A and the Appraisal dated 25 February 2015, in which her performance is described as either significantly strong or exemplary. The Panel does not find that her fitness to practise is currently impaired as far as the public component is concerned.

Decision on sanction

42. The Panel has considered what is the appropriate sanction with care.

43. The Panel heard submissions from both parties and took into account the advice from the Legal Assessor. It has considered all the evidence with care.

44. The Panel considered the range of options available in ascending order of seriousness. It had regard to the HCPC Indicative Sanctions Policy. The Panel notes that it has a responsibility for the protection of the public and in particular patients, for the maintenance of the reputation of the profession and public confidence in the regulatory process. The Panel had regard to the principle of proportionality.

45. The Panel has taken account of those matters of mitigation, including the Registrant’s full admissions from the outset and her admissions at this hearing. The Panel has indicated that the Registrant has consequently demonstrated a degree of insight.

46. The Panel started by considering whether it was appropriate in this case to take no action or make an order for mediation but does not consider either appropriate. The Registrant’s actions resulted in physical injury to her patient and were failures in fundamental aspects of her practice. Consequently, the Panel was satisfied that the matters were too serious to result in either of these disposals.

47. Next, the Panel considered with care the option of imposing a Caution Order. However, in light of the fact that, as of today, the Registrant has not fully remediated her actions, it was not satisfied that this was an appropriate sanction.

48. The Panel next considered the making of a Conditions of Practice Order. It was satisfied that it could impose conditions that would be appropriate, proportionate, workable and measurable.

49. Furthermore, this Panel is satisfied that a future review panel will be assisted by a log of assessments where the Registrant has shadowed a qualified physiotherapist together with a reflective piece which refers to those assessments and includes any learning points gained. The piece should also include reference to and demonstrate other ways in which the Registrant has sought to remediate her failures.

50. The Panel is satisfied that the order should last for a period of 12 months which is an appropriate period in which to achieve the degree of remediation required.




The Panel imposed a 12 month Conditions of Practice Order. Ms Mary C Pelopero, must comply with the following conditions of practice:

1. You must place yourself and remain under the supervision of a qualified physiotherapist registered with the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within 28 days of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations.

2. You must promptly inform the HCPC if you cease to be employed by your current employer or take up any other further employment.

3. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

4. You must inform the following parties that your registration is subject to these conditions:
(i) any organisation or person employing you or contracting with you to undertake professional work;
(ii) any agency you are registered with or apply to be registered with (at the time of application); and
(iii) any prospective employer (at the time of your application).


An Interim Conditions of Practice Order was imposed to cover the appeal period.

The Order will be reviewed on/around 16 July 2016.

This was a Conduct and Competence Committee Final Hearing held at the HCPC between the 16 - 18 June 2015.

Hearing History

History of Hearings for Mary C Pelopero

Date Panel Hearing type Outcomes / Status
16/06/2015 Conduct and Competence Committee Final Hearing Conditions of Practice