Mr Michael A Small
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During the course of your employment as an Operating Department Practitioner with the University College London Hospitals:
1. You refused to carry out work related instructions on:
i) 12 November 2012;
ii) 15 November 2012;
iii) 18 October 2013.
2. You behaved inappropriately and/or aggressively, in that:
a. In July 2013:
i) You grabbed the arm of Colleague A;
ii) You stated to Colleague A ‘‘You need manhandling and I know exactly what to do with you’’ or words to that effect.
b. On 30 August 2013, you stated to Colleague B ‘‘Why won’t you go with me when you’ve slept with other members’’ or words to that effect.
c. On 18 October 2013:
i) [HCPC offered no evidence]
ii) Called Colleague B ‘‘A silly fucking cow,’’ or words to that effect.
iii) Said ‘‘don’t be fucking silly I wouldn’t say it in front of people’’ or words to that effect.
d. On 15 November 2012, you said ‘‘Are you taking the piss out of me or what’’ to Colleague B, or words to that effect.
3. Your actions described in 2aii and 2b were sexually motivated.
4. The matters described in Paragraph 1-3 amount to misconduct.
5. By reason of that misconduct your fitness to practise is impaired.
1. The Panel was satisfied that good service had been effected at the Registrant’s registered address.
Proceeding in absence:
2. The Registrant did not attend the hearing. He was not legally represented, although the HCPC had instructed counsel solely for the purpose of cross-examining the principal complainant on the Registrant’s behalf in the event of his attendance.
3. On behalf of the HCPC, Ms Chaker applied for the hearing to be conducted in the absence of the Registrant on the basis that he had been notified of the date, time and location of the hearing at his registered address. Ms Chaker submitted that the allegations related to events that were said to have occurred up to five years ago and it was in the public interest for the hearing to proceed expeditiously.
4. Having considered the revised Practice Note on proceeding in absence and the advice of the Legal Assessor on the case of GMC v Adeogba  EWCA Civ 162 (“the fair, economical, expeditious and efficient disposal of allegations against medical practitioners is of real importance”), the Panel was satisfied that the Registrant had received reasonable notice of the hearing. The Registrant had not applied for an adjournment. There was no indication that he would attend at a later date if today’s hearing were to be adjourned.
5. The Panel noted the overriding public interest in dealing with matters in a timely manner and the fact that witnesses had attended for the hearing. The allegation related to events in 2012 and 2013 and there was no merit in any further adjournment. The Panel therefore decided that the matter should be heard in the absence of the Registrant.
Application to amend the allegation:
6. The HCPC applied to amend the allegation to delete particulars where the evidence no longer supported the charge and to correct dates in another particular. The Panel accepted the advice of the Legal Assessor and allowed the application on the basis that the Registrant had been given sufficient notice of the proposed amendments, some of which were technical in their nature, and because there was no prejudice to his position or other unfairness if the amendments were permitted.
7. Ms Chaker, for the HCPC, gave the Panel an overview of the allegation and the evidence in opening the case. The Registrant was a Senior Band 6 Operating Department Practitioner (ODP) at the Heart Hospital, Barts Health NHS Trust. The case concerned the alleged behaviour of the Registrant towards colleagues in 2012-2013 during the course of his professional duties and at a staff party. The allegation was that he had refused to comply with work related instructions and that he had made offensive comments to colleagues, including remarks towards an agency nurse (Colleague A) and an Operating Department Practitioner colleague (Colleague B) that were sexually motivated.
8. LS, the Director and Interim Project Manager at Stephens Consultancy Ltd, a contract position with the Barts NHS Trust, was the Registrant’s Line Manager from 2011 to 2013. She was made aware of concerns about the behaviour of the Registrant in early 2012. On 21 October 2013, Colleague B reported concerns to LS regarding the Registrant’s behaviour towards her at an office party in August 2013 and on another occasion in October 2013. On 5 November 2013, Colleague A contacted LS by email to report further allegations. A formal disciplinary investigation commenced. Subsequently, MB, a matron at the infection division, was appointed to lead the investigation.
9. The Panel read written statements and heard direct oral evidence from LS, MB and Colleague B. The evidence of Colleague A consisted only of her email of 5 November 2013. The Panel was able to assess each witness and the reliability of their evidence. Whilst LS did not witness any of the key events, the Panel found her evidence credible and reliable and she gave a helpful description of the personalities of those involved. MB was credible, balanced and considered in his evidence. He had met both the Registrant and Colleague B when investigating the allegations. Colleague B gave the primary evidence of the allegations. The Panel found her account to be credible and reliable. Her testimony was also consistent with other documentary evidence. She was fair and balanced in her assessment of events in that she also gave some positive evidence of the Registrant’s character and competence. She was candid when she did not recall events. The Panel therefore concluded that they could place significant weight on the evidence of Colleague B.
10. The first witness was LS. She was the Registrant’s Line Manager from October 2011 to November 2013. She worked for the Barts NHS Trust until 2016. LS found the Registrant to be an excellent ODP in terms of his professional competence, but there were significant problems in his relationships with team members.
11. It was obvious to LS within a month that the Registrant was “a difficult person”. She witnessed him “snapping” at colleagues on occasions and she overheard colleagues expressing concerns. LS held a supervision meeting with the Registrant on 10 February 2012, at which he agreed that his behaviour towards those in authority was sometimes inappropriate. A file note of 21 March 2012 records that the Registrant’s behaviour improved for the six weeks following that meeting.
12. The improvement was not sustained. On 28 June 2012, LS held a further meeting about the Registrant in relation to his refusing reasonable requests and not taking breaks when requested. LS issued him with an improvement notice by a letter dated 4 July 2012.
13. LS described the Registrant as “one of the most difficult people, although not the most difficult, that I have managed”. He was “spikey” in his responses. He would not go for breaks when requested. His body language could be intimidating. He would use his physical size and point his finger as though he was angry during the course of discussions.
14. LS received further complaints from staff by email in relation to incidents on 12 and 15 November 2012. An incident arose in which he refused to clean a TOE (transoesophageal echocardiogram) probe when asked to do so by a colleague. Cleaning the TOE probe was a standard procedure that would have taken only five minutes. It was necessary because of the risk of infection and delay in sterilising the equipment could have resulted in its unavailability for another case.
15. It was, LS said, in the nature of operating theatre practice that it was highly intensive and emotional work with cardiothoracic patients who were seriously unwell and undergoing heart bypass surgery. If team members failed to co-operate or integrate, then that was potentially detrimental to a positive working environment and to overall patient care. She found that the Registrant disturbed team harmony by getting angry, raising his voice, and shouting at other staff.
16. Accordingly, LS found that the Registrant was difficult to manage. She attempted to explain the effect of his intimidating body language on others, but he did not like being given such advice. He did not always follow instructions. There were occasions when he would not go on his lunch break when asked, insisting on taking his lunch break at 1pm, contrary to the policy of lunch break rotation in the operating theatre.
17. LS first became aware of Colleague B’s concerns in 2012 when JW, Senior ODP, told LS that she was concerned about the relationship between the Registrant and Colleague B. LS therefore monitored the Registrant’s actions. She told the Registrant that there were concerns about his personal behaviour towards colleagues.
18. The position deteriorated when Colleague B was promoted to the same Band 6 level as the Registrant. Colleague B eventually put her concerns in writing on 21 October 2013 in relation to the incidents on 15 November 2012 and 18 October 2013.
19. Colleague A, an agency nurse, emailed an allegation in relation to an incident in July 2013 on 5 November 2013. Colleague A said that the Registrant had grabbed her arm and said she needed “manhandling” and that he “knew exactly what do with her.” Colleague A has not been located by the Trust or the HCPC, so she did not give a written statement, other than her email, or attend to give oral evidence. Her evidence was limited to the hearsay content of her email.
20. Colleague B gave direct evidence of various incidents via video link. She adopted her witness statement of 1 November 2015 and answered further questions. She met the Registrant when she started work at the Heart Hospital (later the Barts Heart Centre). She worked with him on a daily basis. There was a large and open anaesthetic area so she worked alongside other practitioners. The working culture was that all were expected to help each other out as and when required. This was important given that the department was often under pressure.
21. The Registrant appeared to resent Colleague B when she challenged certain working practices on the basis of her past experience in another hospital. On 15 November 2012, they had a disagreement over a change in working arrangements that Colleague B had suggested in order to allow her to remain with a particular patient. He became verbally aggressive. Later in the day, Colleague B was present when the Anaesthetist asked the Registrant to clean the TOE probe. The Registrant said to Colleague B, “Are you taking the piss out of me or what?” in a confrontational manner.
22. On Friday 30 August 2013 Colleague B attended a member of staff’s leaving party. The team socialised together approximately once per month. The Registrant could behave pleasantly on social occasions. At the party, the Registrant kept trying to pull Colleague B onto the dance floor. She rejected him, so he asked why she would not “go with him”. His tone of voice was raised and aggressive. She went home shortly afterwards because she was upset.
23. On Monday 2 September 2013, Colleague B told LS about the party incident. Later that day, the Registrant approached her in the Blood Gas Room and asked her if things were going to be awkward between them. She replied “What do you expect?” and he stormed out of the room.
24. On Friday 18 October 2013, Colleague B asked the Registrant to complete a platelet mapping task that she had started on his patient, because it was her lunch break. He lost his temper and said, “Who do you think you are?” and “Don’t speak to me like that”.
25. The Registrant later refused to attend to a particular patient and he behaved aggressively, ranting within the possible earshot of a patient and her son. Once the patient was under anaesthetic, Colleague B made a comment about the Registrant leaving a dirty tray on the side, at which the he lost his temper and called her a “silly fucking cow”. This behaviour frightened and shocked Colleague B. She looked around the theatre to see if anyone else had heard him, at which he said “Don’t be fucking silly, I wouldn’t say it in front of people”.
26. Colleague B regarded this as the worst incident at work. She reported the incident in an email to LS on Monday 21 October. The Registrant was subsequently suspended from his employment on 4 November 2013. Colleague A wrote her email on 5 November 2013.
27. The suspension of the Registrant has relieved the stress upon Colleague B.
28. MB was the Matron for the Infection Division at UCLH. He produced guidance on expected standards of behaviour, including conduct that may constitute bullying and harassment such as unwelcome sexual advances or continued suggestions for social activity after it has been made clear that such suggestions are unwelcome. It was expected that all staff should be familiar with this guidance.
29. MB became involved in December 2013 after the Registrant had been suspended. He had no prior involvement in the investigation and had not met the Registrant. The process of investigation was hampered by the movement and departure of other staff and a lack of clarity about the evidence when MB was first presented with the case file. MB then conducted interviews with the Registrant and Colleague B and requested witness statements from others. Those statements were placed before the Panel, but only Colleague B gave direct evidence.
30. MB tried to conduct an interview with Colleague A. She had sent an email on 5 November 2013 about an incident in July 2013, but she did not attend an internal investigation interview. She worked as an agency locum across London, but she could not be located by the HR department. Her email was sent from her external address. She had described an incident when the Registrant noticed a “hickie” or love bite on her neck and pointed it out to other staff. She stated that the Registrant had grabbed her arm and told her she needed “manhandling” and that “he knew exactly what to do with her”.
31. MB interviewed the Registrant about the allegations. In particular he noted that the Registrant’s behaviour towards Colleague B at the 30 August 2013 leaving party (‘why not go with me when you have been with others’). MB formed the view that his actions were sexual in their nature. The Registrant’s response to this incident was that he was merely asking her for a dance. The Registrant accepted in interview that he said words to the effect of “what’s wrong with me when you’ve slept with others”. MB considered that the Registrant showed a lack of insight into the sexual nature of his alleged remarks and the effect on colleagues.
32. MB found the Registrant’s attitude to the allegations to be both flippant and dismissive when he was interviewed. He did not appear to take the allegations seriously. The Registrant made a written response before his interview in which he rejected the various allegations. MB’s concern was that the Registrant’s conduct suggested a pattern of persistent behaviour that was unacceptable and which demonstrated no insight.
Decision on Facts:
33. The Panel accepted the advice of the Legal Assessor that they should apply the civil standard of proof and should only rely on hearsay evidence if sufficient efforts had been made to locate the witness and if it was fair to rely on such evidence in all the circumstances.
Particular 1(i): refusal to take over care of patient on 12 November 2012 – not proved
34. The Panel had in mind that the only evidence of this particular was contained within an email and that the author of the email was not clearly identified. There was no evidence that the HCPC had made efforts to find or to secure the attendance of the author of the email. There was no witness statement from the maker of the allegation. There was also a degree of ambiguity about whether the Registrant was actually asked to do the work. The Panel took the view that it was not therefore fair to rely on this limited hearsay evidence. The allegation does not appear to have been put to the Registrant. Accordingly, the Panel found that this allegation was not proved to the required standard.
Particular 1(ii): refusal to clean the TOE probe on 15 November 2012 - proved
35. The Panel placed significant weight on the written and oral evidence of Colleague B. The Registrant accepted that he was asked to clean the probe in his statement to the investigation, although he maintained that he thought that Colleague B was ‘‘winding him up’’ in making that request. The Panel took into account that there was a culture of co-operation in which colleagues were expected to comply with instructions or requests. The Panel was persuaded that a request to clean the TOE probe was made by the Anaesthetist, as described by Colleague B. This request was a work related instruction that should have been followed. The Panel therefore found the matter proved.
Particular 1(iii): refusal to complete platelet mapping on 18 October 2013 - proved
36. Colleague B made this request of the Registrant when she needed to take her lunch break. The Registrant accepted in his statement that Colleague B was ‘‘ordering’’ him to complete this work when she went for lunch. The Panel noted that Colleague B complained about this matter within a short time in an email dated 21 October 2013. Colleague B’s evidence was supported by the written statement of NM, dated 24 October 2013. The Panel was satisfied that this was a reasonable work related instruction that Colleague B was entitled to make when she was about to take her lunch break. The Panel therefore found this matter proved.
Particular 2(a)(i): grabbed the arm of Colleague A – not proved
Particular 2(a)(ii): said “you need manhandling and I know exactly what to do with you” – not proved
37. The only evidence in relation to particulars 2(a)(i) and (ii) was that of Colleague A in her email dated 5 November 2013. This was hearsay evidence. There was no acceptance of this conduct on the part of the Registrant, who recalled only an occasion when colleagues were joking about the love bite on Colleague A’s neck. He denied touching her in any way or saying the words alleged. The Panel was satisfied that the Trust had made a sufficient effort to locate Colleague A by sending emails to her external email address, but she did not reply or attend for an internal investigation interview. She was a locum agency nurse who did not work for the Trust. The Panel was satisfied that the email was written in a considered, detailed and reflective way by Colleague A.
38. However, the Panel also noted that Colleague A’s email was written about four months after the alleged incident and that the Registrant emphatically denied the allegation. There was no means of testing the evidence in the absence of Colleague A. The Panel was not therefore satisfied that it was fair to rely on hearsay evidence of this nature, to which less weight should be applied, or that either particular of the allegation within the email was proved to the required standard in the absence of other evidence or admissions by the Registrant.
Particular 2(b): said “why won’t you go with me when you’ve slept with other members” on 30 August 2013 – proved.
39. The Panel accepted the evidence of Colleague B that the Registrant had used the words alleged and that this was inappropriate and/or aggressive behaviour. The Panel also had regard to the fact that the Registrant admitted saying words to this effect, albeit that he claimed they had a more innocent interpretation. The evidence of Colleague B was also supported by the written statement of NM that was submitted as part of the evidence of the internal investigation. The Panel therefore found the facts proved on this particular.
Particular 2(c)(i) – not proved
40. The HCPC offered no evidence on this particular, so it was not proved.
Particular 2(c)(ii): called Colleague B “a silly fucking cow” on 18 October 2013 - proved
41. The Panel accepted the evidence of Colleague B that the Registrant used these specific words to her in the operating theatre and that the use of such words was inappropriate and aggressive. The witness reported this incident in an email within three days and her evidence to the Panel was credible on this matter. The Panel noted that the Registrant had acknowledged that the incident took place but that he denied using these words. The Panel preferred the evidence of Colleague B on this issue and found the matter proved.
Particular 2(c)(iii) – said “don’t be fucking silly I wouldn’t say it in front of other people?” - proved
42. This remark was made on the same occasion as that in 2c)ii) above. The Panel found this particular proved for the same reasons as those stated above.
Particular 2(d) - “Are you taking the piss out of me or what” – 15 November 2012 - proved
43. This comment relates to the TOE probe incident in which the Panel found that the Registrant had refused to carry out a work related instruction. The Panel found the evidence of Colleague B credible on this issue. The Registrant had accepted that this incident occurred, even if he denied the use of the specific words. Accordingly, the Panel found this matter proved.
Particular 3: actions described in 2aii and 2b were sexually motivated – proved in relation to 2b only.
44. The Panel found the Registrant’s words as described in 2 (b) were sexually motivated by the nature of their content. The Panel had regard to the definition of “sexual” in Section 78 of the Sexual Offences Act 2003. The comment was obviously sexual by its nature. The Panel also noted that the Registrant had admitted that his comments related to his belief that the Registrant had slept with black men, so he had himself accepted that there was a sexual connotation in what he had said.
45. This finding of sexual motivation relates only to particular 2b because particular 2aii was not proved.
Decision on grounds:
46. The Panel accepted the advice of the Legal Assessor and was assisted by the written submissions of Ms Chaker on behalf of the HCPC. The Panel therefore had in mind the definition of misconduct in the case of Roylance v GMC  1 AC 311: Misconduct is “some act or omission which falls short of what is proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a medical practitioner in the particular circumstances.”
47. By reason of our findings on the facts as set out above, the Panel found the Registrant to have breached the following standards of the HCPC Standards of Conduct, Performance and Ethics:-
(a) Standard 3: “You must keep high standards of personal conduct”
(b) Standard 7: “You must communicate properly and effectively with service users and other practitioners”
(c) Standard 13: “You must…make sure that your behaviour does not damage the public’s confidence in you or your profession.”
48. Accordingly, the Panel found that the evidence of the Registrant’s conduct, taken as a whole, showed a troubling pattern of disruptive, disobedient and offensive behaviour towards colleagues that amounted to misconduct which was serious.
Decision on impairment:
49. The Panel considered the submissions of the HCPC and accepted the advice of the Legal Assessor. The Panel reminded itself of the public component in NMC v Grant  at paragraph 74 ‘‘in determining whether a practitioner’s fitness to practise is impaired by reason of misconduct, the relevant Panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances.’’
50. The Panel also had regard to the criteria that were set out by Dame Janet Smith in the Fifth Shipman Report, namely whether our findings of fact in respect of the Registrant’s misconduct show that his fitness to practise is impaired in the sense that he has put patients at risk, or is liable to do so in the future, whether he has brought his profession into disrepute or may do so in the future, and whether he has breached the fundamental tenets of his profession or may do so in the future. There was no need to consider whether he has acted dishonestly because this is not such a case.
51. The Panel found that the Registrant’s refusal to comply with reasonable work related instructions in the operating theatre was such as to place patients at risk of harm. The Registrant also placed patients at risk of harm by distracting and upsetting those who were entrusted with life-saving medical procedures. His actions caused turbulence amongst his professional colleagues and undermined the co-operative and collegiate approach that was essential to maintaining the proper functioning of the operating theatre and patient safety. In acting in this way, the Panel found that the Registrant had brought his profession into disrepute. It must also be a fundamental tenet of his profession that patient safety should not be jeopardised by the behaviour of those who are entrusted with their care in the operating theatre.
52. There was no evidence of insight or remediation before the Panel. The Registrant had made no admission or expression of remorse when he was challenged with these matters in 2013. The Panel therefore found that the Registrant’s fitness to practise was impaired at the time of the allegations and, in the absence of any current evidence of insight, remains currently impaired. The Panel also noted LS’ evidence that the Registrant had regressed in his behaviour towards others when not managed carefully on a regular basis.
53. The Panel’s finding of impairment is made on the basis of the need to protect the public and in the wider public interest in order to maintain public confidence in the profession and the regulatory process. The Panel also notes that a reasonable member of the public would expect a finding of current impairment on the facts of this case.
Decision on Sanction:
54. The Panel considered the Indicative Sanctions Policy of the HCPC and the advice of the Legal Assessor. The Panel considered the potential mitigating factors and the aggravating features in this case in reaching its decision on sanction.
55. The Panel had no evidence from the Registrant as to his current position, but it considered a letter that he sent to the HCPC in March 2015 in which he stated that he had not worked as an Operating Department Practitioner since his suspension from employment in 2013, but that he wished to return to the profession in which he had worked hard for 20 years. He said that his attitude had changed when his new line manager (LS) arrived and expressed his view that she “had it in for me”.
56. In mitigation, the Panel took into account of the Registrant’s long service and noted that his professional competence was not called into question. There was some positive evidence as to his professional abilities during the final hearing.
57. The principal aggravating feature in this case was that patients were put at indirect risk of harm by the Registrant’s distraction of colleagues. The Panel was also very concerned about the persistence and duration of the Registrant’s misconduct and the adverse effect, particularly on Colleague B over the period between November 2012 to October 2013.
58. There was no evidence of remorse or insight, so there remains a real risk of recurrence of this misconduct if the Registrant’s attitude and behaviour does not change. The Panel does not draw any adverse inference from his failure to attend the hearing, but the effect of his lack of engagement is that the Panel has no information about his current circumstances and employment.
59. The extent and duration of the misconduct is too serious to make no order or to consider mediation. The Panel considered whether to impose a Caution Order, but decided that it was not in the public interest, because this was not an isolated occurrence and there was no evidence of insight or remediation.
60. The Panel then considered carefully whether a Conditions of Practice Order was appropriate or workable, but concluded that the absence of any information about the Registrant’s current circumstances made such an order impossible to formulate. In any event, the issues in this case went to his attitudinal deficit and failure to understand that his behaviour was offensive, rather than any deficiency in his professional competence or practice. A Conditions of Practice Order also requires commitment on the part of the Registrant, but there has been no such engagement in this case. The Panel also found that such an order would not meet the gravity of the misconduct.
61. The Panel considered that the facts of this case were at the upper end of seriousness for a Suspension Order and that the Registrant’s misconduct came close to the level of gravity appropriate to a Striking-Off Order. However, the Panel ultimately decided that the Registrant’s behaviour was capable of remedy and wanted to give him the opportunity to demonstrate this. The Panel did not think that it was able to conclude that the Registrant’s behaviour was fundamentally incompatible with his continued registration if he is able to gain insight and remediate his failings.
62. The Panel therefore determined that a Suspension Order of 12 months duration was an appropriate and proportionate sanction that reflected the gravity of the misconduct. The Panel is satisfied that this order will protect the public and maintain the confidence of the public in the regulator and the profession. Such an order will give the Registrant an opportunity to develop his insight and thereby reduce the risk of repetition. It was also in the public interest that the Registrant should be able to resume work in his profession if he can engage with his regulator in the review process and overcome his attitudinal deficiencies.
63. The Panel expresses the hope that the Registrant will gain some insight by reading the Panel’s determination.
64. A future Panel reviewing this case would be assisted by the following:-
• A written reflective statement as to the Registrant’s view on the findings in this case and how he might avoid repetition of his misconduct;
• Character and/or employment references;
• Evidence of continuing professional development i.e: evidence that he is keeping up to date with new practices and developments in his profession.
The Registrar is directed to suspend the Registration of Michael Small for a period of 12 months from the date this Order comes into effect.
The order imposed today will apply from 21 June 2017 (the operative date).
This order will be reviewed again before its expiry 21 June 2018.
Right of Appeal:
You may appeal to the High Court of England and Wales against the decision of the Panel and the order it has made against you.
Under Article 29(10) of the Health and Social Work Professions Order 2001, any appeal must be made within 28 days of the date when this notice is served on you. The Panel’s order will not take effect until the appeal period has expired or, if you appeal, until that appeal is disposed of or withdrawn.
European alert mechanism:
In accordance with Regulation 67 of the European Union (Recognition of Professional Qualifications) Regulations 2015, the HCPC will inform the competent authorities in all other EEA States that your right to practise has been prohibited.
You may appeal to the Sheriff against the HCPC’s decision to do so. Any appeal must be made within 28 days of the date when this notice is served on you. This right of appeal is separate from your right to appeal against the decision and order of the Panel.
Interim Suspension Order:
The Panel makes an Interim Suspension Order under Article 31(2) of the Health and Social Work Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest, and is consistent with the Panel’s earlier findings. This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.
No notes available