Mr Ajeesh George

Profession: Radiographer

Registration Number: RA73105

Interim Order: Imposed on 14 Jun 2017

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 03/12/2018 End: 17:00 06/12/2018

Location: Novotel Cardiff Centre, Schooner Way, Atlantic Wharf

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

 

Whilst registered as a Radiographer and employed by ABM University Health Board, you:

 

1. Between 14 December 2015 and 13 October 2016:

 

a) did not display appropriate knowledge of radiation protection in that you:

 

i. Did not check the pregnancy status of female patients of child-bearing age that were referred for x-rays of the abdominal area on the following dates:

 

a. 5 February 2016;

 

b. 9 February 2016;

 

c. 10 February 2016;

 

d. 20 June 2016;

 

e. 29 June 2016;

 

f. 29 July 2016.

 

ii. Did not consistently demonstrate adequate centering and/or positioning of the detector, including on the following occasions:

 

a. On 20 May 2016, you positioned the detector too high for a chest x-ray;

 

b. On 23 May 2016, you did not move the detector appropriately for an angled-up clavicle x-ray;

 

c. On 27 June 2016, you centred the detector too low for a knee x-ray;

 

d. On 28 June 2016, you centred the detector too low for a knee x-ray;

 

e. On 29 June 2016, you centred the detector too low for an abdomen x-ray;

 

f. On 21 July 2016, you centred the detector too distally for an elbow x-ray;

 

g. On 15 August 2016, you did not centre to the bucky for a pelvis x-ray.

 

b) displayed a limited knowledge of radiographic technique in that you:

 

i. Did not adequately and/or correctly adapt the exposure parameters depending on the patient and/or area being x-rayed, including on the following occasions:

 

a. On 30 March 2016, you increased the mAs from 16 to 100 to account for the use of a grid on a pelvic x-ray;

 

b. On 1 April 2016, you did not adapt the exposure settings for an x-ray of a pelvis on a trolley;

 

c. On 17 May 2016, you did not increase the exposure for a larger patient;

 

d. On 23 May 2016, for an x-ray of a 1 year old, you selected an exposure setting that was suitable for an adult;

 

e. On 25 May 2016, you did not increase the exposure for a patient with large arms;

 

f. On 27 June 2016, you selected the setting for the pelvis instead of hip only for a patient that had been referred for an x-ray of their right hip;

 

g. On 11 July 2016, you conducted an incorrect Antero-Posterior (AP) x-ray for a tibula and fibula in that:

 

i) the exposure was too high;

 

ii) when conducting the lateral view x-ray you did not notice that the sensitivity value was not in range and/or was over exposed;

 

h. On 14 July 2016 when conducting a hand x-ray:

 

i) you did not set the right exposure for the x-ray in that it was too low;

 

ii) when conducting the lateral view x-ray you did not increase the exposure to the correct value;

 

i. On 1 August 2016, for an x-ray of a child’s tibula/fibula, you set a high exposure;

 

j. On 3 August 2016, when conducting a c-spine x-ray;

 

i) did not use the correct exposure;

 

ii) did not notice that the resultant image demonstrated features of over-exposure

 

ii. Did not adequately adapt the Film-Focal Distance depending on the area being x-rayed, including on the following occasions:

 

a. On 26 May 2016, you did not adapt the distance for an x-ray of a tibula/fibula to enable the whole are to be included in one film;

 

b. On 25 July 2016, you used too great a distance when taking a lateral view x-ray of a hip;

 

iii. Did not recognise and/or adapt to the limitations of the patient being x-rayed, including on the following occasions:

 

a. On 12 May 2016, you continued to position a patient for c-spine, chest and shoulder x-rays despite the patient feeling faint and/or looking like they were about to collapse;

 

b. On 12 May 2016, you continued to position a patient for a knee x-ray despite the patient looking like they were about to collapse;

 

c. On 23 May 2016, you physically and/or forcefully lifted the chin of a patient that potentially had a fracture of the cervical spine;

 

d. On 24 May 2016, you started to sit a patient up into an erect position when they potentially had a neck of femur fracture;

 

e. On 24 May 2016, you physically and/or forcefully lifted the chin of a patient that potentially had a fracture of the cervical spine;

 

f. On 27 May 2016, you attempted to raise the arms of a patient with a pacemaker despite the patient explaining he was not allowed to raise his arms;

 

g. On 9 June 2016, while attempting to x-ray the humerus of a post-operative patient, you did not recognise that the patient was struggling to remain standing;

 

h. On 3 August 2016, you tried to move an unsteady, elderly patient onto the bed instead of leaving him in his chair for an x-ray of his foot.

 

c) required clinical supervision at all times in that you:

 

i. Did not consistently position and/or x-ray the correct area, including on the following occasions:

 

a. On 3 May 2016, you positioned the wrong knee for exposure;

 

b. On 24 May 2016, you x-rayed the whole hand of a patient who had been referred for an x-ray of their little finger;

 

c. On 9 June 2016, you x-rayed the hand but missed the little finger of a patient who had been referred for an x-ray of their little finger;

 

d. On 22 June 2016, you x-rayed the right knee of a patient who had been referred for an x-ray of their left knee and marked the image of the right knee as the left knee.

 

ii. Did not demonstrate good infection control practice in that:

 

a. On 3 May 2016, you did not consistently wash your hands and/or the equipment between patients;

 

b. On 18 July 2016, you did not change your gloves before touching the patient and/or equipment.

 

iii. Did not consistently demonstrate effective communication including on the following occasions:

 

a. On 3 May 2016 you gave little or no instructions to patients when positioning them for their x-rays;

 

b. On 26 May 2016, you uncovered a patient’s legs without giving any prior warning to the patient;

 

c. On 10 June 2016, you physically touched and/or moved a patient that had been referred for a chest x-ray without giving any prior warning to the patient;

 

d. On 2 August 2016, you palpated a post-operative patient on their affected side without giving any prior warning or explanation.

 

2. The matters set out at particulars 1 a) – c) constitute misconduct and/or lack of competence.

 

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

 

Finding

Preliminary matters:
Service
1. Notice of the hearing was sent to the Registrant by a letter sent on 21 August 2018 by special delivery post and also by email.  The Panel had sight of a signed Proof of Service certificate confirming the sending of the Notice of Hearing on 21 August 2018 to the Registrant’s address held by the HCPC.  The Panel was satisfied that service had been made in accordance with the HCPC (Conduct and Competence Committee) (Procedure) Rules 2003 (“the Rules”).


Proceeding in absence
2. Mr Millin on behalf of the HCPC submitted that the Panel should exercise its discretion to proceed in the Registrant’s absence. 


3. The Panel considered the submissions on behalf of the HCPC.  It accepted the advice of the Legal Assessor. The Panel referred to the HCPTS Practice Note of September 2018 on proceeding in absence and to the guidance that a hearing panel should consider as provided by the cases of R v Jones (Anthony) [2004] 1 AC 1HL and GMC v Adeogba and GMC v Visvardis [2016] EWCA Civ 162.  Applying that guidance, the Panel was careful to remember that its discretion to proceed in absence is not unfettered and must be exercised with the utmost caution and with the fairness of the hearing at the forefront of its mind.


4. The Notice of Hearing dated 21 August 2018 informed the Registrant of the date and details of the Conduct and Competence Committee hearing, and of his right to attend and be represented.  The Registrant was also advised of the Panel’s power to proceed with the hearing in his absence if he did not attend and of how he could apply for an adjournment of the hearing. He was informed of the sanctions powers available to the Panel, should it find his fitness to practise to be currently impaired.


5. The Registrant had not responded to the Notice of Hearing of 21 August 2018, and had not communicated with the HCPC nor Kingsley Napley Solicitors acting for the HCPC. No request for an adjournment had been received, nor was there any indication that the Registrant wished to attend the hearing but for some reason, such as a health issue, was unable. There was no suggestion that he had sought to instruct a representative.  


6. Taking all the above circumstances into account, the Panel concluded that the Registrant had not engaged with the HCPC process in relation to this hearing.  It was unlikely in all the circumstances that an adjournment would secure his attendance on a future date. The Panel took the view that the Registrant had voluntarily waived his right to attend and adjourning this hearing would serve no purpose. 


7. The Panel was mindful that it must also consider fairness to the HCPC, whose case was ready to proceed today. The HCPC’s witnesses were present and ready to give evidence.  The Panel took account of the public interest in the expeditious resolution of regulatory allegations and the impact of cost and delay caused by an adjournment upon other cases. Following the guidance in the case of Adeogba, given that there was no good reason to adjourn the hearing, the Panel decided it was in the public interest to proceed in the Registrant’s absence.


8. The Panel was reminded that in the Registrant’s absence, it should ensure that the hearing was as fair as circumstances permit.  It would not regard the Registrant’s absence as an admission to the allegations.  The Panel was also mindful that it should ask questions and consider points which may be in the Registrant’s interests and were reasonably apparent from the evidence.


Documentation
9. The Panel received the HCPC hearing bundle, numbered pages 1- 451 and a small bundle of correspondence concerning service.  The Panel also received from Mr Millin on behalf of the HCPC written closing submissions and a chronology of events. 


10. No written submissions or documents had been received from the Registrant for the purpose of the hearing. 


Background:
11. The Registrant is a registered Radiographer.  From 17 December 2015, he was employed as a Band 5 Radiographer by Abertawe Bro Morgannwg University Health Board (“ABMUHB”) in the Radiology Department at The Princess of Wales Hospital.  Information provided as part of his employment application indicated that he had qualified and previously worked abroad and had been practising overseas as a Radiographer for 11 years.  When the Registrant commenced his employment at ABMUHB as a new joiner to the Radiology Department he was monitored and supervised in order that his competencies could be assessed and signed off as safe to practise autonomously. This was standard procedure for all new starters to the department irrespective of experience in order to familiarise staff with local policies, practices and equipment.  Early in 2016, concerns began to be raised by other staff in the Radiology Department that the Registrant was not displaying the expected level of knowledge of radiation protection or radiographic technique.  Monitoring and support continued and informal progress meetings took place in February, March and April 2016 during which similar concerns were identified.  An assessment of the Registrant’s capability and competence was undertaken on 3 May 2016 by a Clinical Lecturer from Cardiff University (KE) and a Band 6 Radiographer from the Radiology Department (OW), both of whom concluded that there was a risk of potentially dangerous practice in relation to a number of issues if the Registrant was left unsupervised.    Following this assessment, it was decided that the Registrant would remain under one to one supervision and that records would be kept of the observations and interventions which were required. ABMUHB’s formal Capability Policy and Procedure was instituted. The first formal capability meeting took place on 7 July 2016, at which time the HCPC was also informed of the concerns.


12. A second formal meeting took place on 11 August 2016.   In the light of the Registrant’s continued failure to meet the objectives set he was placed on the second stage of the capability process for a further four weeks.  It was also agreed at that time that records of observations and interventions would be signed off by both the supervising Radiographer and also by the Registrant, in order to ensure that clear and agreed records were kept.


13. At a review meeting on 14 September 2016, the Registrant was informed that he had still not met the standard of performance required for his role and significant areas of concern remained.  The Registrant was informed he would progress to the next stage of the Capability Policy and accordingly, a termination of employment interview would be arranged.
Summary of evidence of the HCPC’s witnesses


Witness - SR
14. SR confirmed the content of her witness statement signed on 9 September 2018.  SR has been in the role of Superintendent Radiographer in the Radiology Department of the Princess of Wales and Neath Port Talbot Hospitals at ABMUHB for 23 years. She has practised as a Radiographer for 37 years, and had worked in a supervisory role for 30 years.  


15. SR did not work with the Registrant clinically, but oversaw his performance and was responsible for his management. SR confirmed that she regularly saw the Registrant in the department and observed him interacting with staff and patients.  She had a number of discussions with the Registrant about his performance over the course his nigh on 10 month period of employment.   SR gave evidence as to how the initial concerns about the Registrant were dealt with informally and later, she oversaw the formal capability process.


16. SR explained that it was expected that the Registrant would need, as would any Radiographer new to the department, to be introduced to department’s equipment and local Standard Operating Procedures and would be closely supervised until they were deemed as competent to be signed off to work independently.  There was no fixed time period for this, but she would normally expect this to be over a period of 3 to 4 months and a maximum of 6 months even for a new graduate.  It was expected that someone with 11 years’ experience would need no more than a few weeks. SR confirmed that in the case of the Registrant, he was never deemed competent to work without supervision for the whole 10 month period of his employment: it transpired instead that he had to be supervised by a senior Radiographer on a one to one basis for the 7.5 hours of every day he worked at ABMUHB.  SR said she had never before experienced such a situation with any other Radiographer joining the department, whether from the UK or abroad, and whether the new starter had just graduated or had previous experience.


17. SR had instituted a process whereby written records were made by the supervising radiography staff of every observation and intervention into the Registrant’s work which was required.  Later in the process, the Registrant was also required to sign the records to confirm his agreement.  In her evidence, SR produced the records of the daily observations and interventions written by the supervising Radiographers, of whom she said there were some 15 – 18 involved.


18. SR outlined the concerns about the Registrant’s practice in relation to a number of areas, including failure to confirm the identity of patients, to establish pregnancy status of patients, centring and/or positioning of the detector, exposure factors, setting of the film-focal distance, recognising and adapting to patient characteristics and limitations, patient positioning, infection control and communication.


19. SR stated that the support provided to the Registrant had been extensive and the aim had been to bring him successfully into the department as an autonomous practitioner who could undertake a range of work including on-call work. The department had obtained funding for an additional Radiographer and were keen for him to start work. Given his previous experience and employment, SR had expected that the Registrant would be able to “hit the ground running”. However, as the Registrant had to be on one to one supervision by another Radiographer for the whole of his time in the department, there was an impact on the department’s work and resources. SR said that for two Radiographers, the Registrant and the supervising Radiographer, she was getting the work of half a “whole-time equivalent” member of staff because the Registrant was slow at his work and required interventions.


20. SR explained that despite the support provided over the 10 month period, the Registrant never made consistent progress.  Although SR accepted that he made improvements on some occasions, these were not maintained and he would repeat his mistake with subsequent patients.


21. SR said that the Registrant seemed, in the main, simply to accept the concerns relayed to him. At progress meetings he would say he felt he was making progress and was “nearly there”.  However, SR stated that his failings were in fundamental and basic areas of radiography practice, including knowledge of the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R).  SR said it came to the point where she questioned herself as to whether he was in fact a qualified Radiographer.  SR explained it was the Registrant’s fundamental lack of radiographic knowledge which was her greatest concern. 


Witness OW
22. OW is employed by ABMUHB as a Band 6 Radiographer. He explained that he was a colleague of the Registrant, was not part of the senior management team, but was one of the senior Radiographers working in the department.  OW also confirmed he was involved with the Registrant’s induction on joining the Radiology Department and was one of the supervisors who completed diary entries of observations and interventions involving the Registrant. He confirmed he had provided the Registrant with the departmental protocols and a folder of the Radiology Department’s Standard Operating Procedures, copies of which he produced in evidence. 


23. OW said that he was aware that other colleagues had raised concerns about the Registrant. OW confirmed he had his own concerns which he reported to SR and that he had never experienced, in his 8 years, anyone that required such a level of supervision.


24. OW outlined that the clinical assessment of the Registrant that he undertook on 03 May 2016 followed the framework of an undergraduate student assessment which involves a day’s observation to prove the student can manage a diverse range of cases. The only difference was that he did not numerically score the Registrant’s assessment and the Registrant took such a long time with individual patients that he did not cover as many patients as a student would have. OW confirmed in his report that the Registrant displayed dangerous practice which he particularised in the report including the risk of unintended exposure and imaging the wrong anatomy. OW stated that the Registrant therefore could not be left unsupervised. The assessment of the Registrant on 03 May 2016 was undertaken by OW along with KE, an independent clinical lecturer from Cardiff University.


Panel’s consideration of the evidence:
25. The Panel received and accepted advice from the Legal Assessor.  The Panel was reminded that the burden of proof is upon the HCPC which brings the allegations. It was not for the Registrant to prove his innocence.  This remained the case where the Registrant did not attend the hearing.


26. The standard of proof in HCPC proceedings is the civil standard, on the balance of probabilities, meaning that before finding a fact proved the Panel must be satisfied it is more likely than not that it occurred.


27. The Panel was reminded that where the HCPC relied on hearsay evidence, this is admissible in HCPC proceedings but it was for the Panel to consider and determine what weight it could attach to such evidence. 


28. The Panel first considered the issue of witness credibility.


The Registrant
29. The Registrant had not attended the hearing and no submissions regarding the allegations had been received from him.  The Panel treated the allegations as denied and remained mindful throughout that the burden of proof is upon the HCPC. The Panel, as well as the HCPC Case Presenter and the Legal Assessor, ensured during the hearing that they asked the HCPC witnesses questions arising from the evidence which might have assisted the Registrant’s case.   The Panel drew no adverse inference from the Registrant’s absence.


30. The Panel had sight of the information provided by the Registrant to ABMUHB as part of his application, including his CV suggesting 11 years of practice as a Radiographer. However, in the absence of the Registrant and not being able to critically examine those 11 years of experience, the Panel could place little weight on this information.


Witness SR
31. The Panel found that witness SR was objective and professional in her approach.  The Panel found her to be a credible and reliable witness. The Panel also concluded that SR was caring, empathetic and supportive of the Registrant during his employment at ABMUHB.  There was no evidence that she was biased against the Registrant or bore him any ill-will. SR gave evidence that in 30 years of being in a supervisory role she had never previously experienced a Radiographer who was “not progressing” in the way she would have expected and accordingly contacted the HR department. The Panel accepted her account that in initially seeking advice from the Human Resources Department, she was seeking advice about how to support the Registrant, rather than to institute formal capability proceedings.  Her aim was for the Registrant to be able to function as a Radiographer in the department.  The Panel found that SR conducted a fair process.  She emphasised how she had involved the whole department in supervising and supporting the Registrant. She ensured that daily records were kept in order that the Registrant would receive immediate feedback on concerns.    When it was decided that a final capability meeting would have to take place, she was concerned that the Registrant seemed not to understand the process. The Panel noted that she went out of her way to obtain support from a member of the Society of Radiographers for the Registrant, which she was not obliged to do. That person sat with the Registrant and supported him through the two formal capability meetings.


32. The Panel noted that SR considered whether language was an issue in the Registrant’s communication difficulties.  Rather than being critical of his language skills, SR had thought of whether he was having difficulty with her and her colleagues’ accents, or whether they were speaking too quickly. SR also told the Panel that a number of non-UK Radiographers had joined the department in the past and had worked successfully.    


33. The Panel was mindful that SR had not been directly involved in the observation of the Registrant, she had received reports from Radiographers in her team who had observed the Registrant. She had also had discussions with the Registrant and an opportunity to assess him during the various progress meetings, of which she produced the notes. 


34. The Panel was impressed by SR as a witness and was prepared to put significant weight on her evidence.


35. The Panel considered the written records of the observations and interventions undertaken by radiography colleagues whilst supervising the Registrant.  SR produced these in her evidence.  Although most of these records were hearsay evidence (given that OW, who was one of the supervisors keeping the record, gave oral evidence), they were largely contemporaneous with the incidents they described and they were made by senior Radiographers who worked in the Radiology Department and were known to SR. Many were initialled or signed. A significant number were made by OW, who gave oral evidence to the Panel. A number of OW’s diary records identified concerns.  There were entries favourable to the Registrant as well as records of concern and interventions. The records in the final month of the process had also been signed by the Registrant himself as accurate. The Panel noted that it was recorded on just one record, at page D287 of the hearing bundle, that the Registrant refused to sign the entry, suggesting a fair and frank process had been carried out. 


36. The daily records were thorough and detailed.  SR confirmed the records were made by Radiographers at senior Band 6 or 7 level. The large number of radiographers who had been involved reassured the Panel that the concerns were not those of a single or small number of individuals.  SR confirmed she had kept the daily records securely locked in her office. 


37. The Panel was therefore satisfied it would attribute considerable weight to the records produced by SR.


Witness OW
38. The Panel found OW, to be credible and professional in giving his evidence. He also expressed a supportive attitude towards the Registrant.  He referred to having sought to engage the Registrant in the department, both in and out of the work setting.  The Panel was impressed by his evidence and accepted it. 


Decision on Facts:
39. The Panel undertook a careful process of examining the witness and documentary evidence in support of each factual particular and sub-particular in the allegations.
Facts found not proved:


40. The Panel found sub -particulars 1(b)(i)(g)(i) and (ii) not proved.  The particulars referred to an occasion on 11 July 2016 when it was alleged that the Registrant  “conducted an incorrect Antero-Posterior (AP) x-ray for a tibula and fibula in that:


(i) The exposure was too high;
(ii) When conducting the lateral view x-ray, you did not notice that the sensitivity value was not in range and/or was over exposed;”


41. Having reviewed the relevant diary extract (page D271 of the hearing bundle) the Panel noted that it was recorded by the supervising Radiographer that the Registrant took the AP view and then went to take the lateral view without adjusting the exposure.   This was an error by the Registrant but the stem of the allegation related to the AP view, rather than the lateral view. Sub-particular 1(b)(i)(g)(i) was not proved by the evidence, and whilst 1(b)(i)(g)(ii) was proved by the evidence it did not support the stem of the allegation at 1(b)(i)(g). Therefore 1(b)(i)(g) was not found proved.  As indicated below, however, the Panel found the rest of particular 1(b)(i) proved. 


42. The Panel found particular 1(c)(iii)(d) not proved.  1(c)(iii) related to effective communication and1(c)(iii)(d) alleged that “on 2 August 2016, you palpated a post-operative patient on their affected side without giving any prior warning or explanation;”


43. Having reviewed the relevant diary entry for 2 August 2016, at page D227, the Panel noted that there was an issue recorded in the diary concerning the Registrant’s inappropriate palpation of a post-operative patient on that date but it did not concern effective communication.  The Panel therefore found Particular 1(c)(iii)(d) not proved, but found the remainder of Particular 1(c)(iii) proved. 


Facts found proved:
44. The evidence of SR and the documentary evidence she produced was relevant to all the remaining particulars of the allegation.  The Panel accepted her evidence.


45. The Panel also accepted the evidence of OW, which additionally supported the evidence of SR in respect of the particulars 1(a)(ii) and 1(b) and 1(c).


46. On the basis of the evidence of SR and OW and the documentary evidence produced, the Panel found the facts of all the particulars and sub-particulars proved in their entirety, with the exception of 1(b)(i)(g)(i) and (ii) and 1(c)(iii)(d), for the reasons explained above. 


Decision on Grounds - misconduct and/or lack of competence:
47. The Panel considered the submissions of Mr Millin on behalf of the HCPC.  It received and accepted the advice of the Legal Assessor.  The Panel bore in mind that these were matters for its own judgment and took account of the guidance from the case law relating to the meanings of misconduct and lack of competence, both of which were alleged as alternatives in this case. 


48. In respect of misconduct, the Panel bore in mind the guidance of Lord Clyde in Roylance v GMC [No 2] 2000 1 AC 311 and also reminded itself that not every falling short of the expected standard amounts to misconduct: the falling short must be serious and may be considered deplorable by other professionals. Lack of competence is distinct from misconduct and, as per the case of Calhaem v GMC  [2007] EWHC 2606, connotes a standard of professional performance which is unacceptably low and which can usually be demonstrated by reference to a fair sample of a practitioner’s work. 


49. The Panel was mindful that the alleged ground of impairment was in the alternative and the HCPC’s position was that it was for the Panel to determine whether any or all of the particulars proved amounted to misconduct or lack of competence. 


50. The Panel considered whether any or all of the particulars amounted to misconduct rather than lack of competence. The Panel took account of the evidence of witness SR, to the effect that she did not perceive the Registrant’s failings and lack of progress to be in any way “malicious” or “deliberate” but rather were based on his lack of knowledge and inability to understand his failings.  SR’s evidence was that she perceived the Registrant to mean no harm to patients though he did create a risk of harm. This was echoed in the evidence of OW.  Both referred to the Registrant lacking the basic underpinning knowledge of radiographic practice and technique and appeared to have no understanding of his failings. SR referred to him as like “a startled animal in the headlights”. There was evidence that he persisted in trying to perform as a Radiographer but continued to fail to achieve what was required.


51. It was a matter of significant concern that the Registrant had not demonstrated an understanding of the principles of radiography and IR(ME)R.   Although IR(ME)R is UK legislation, the underlying principles reflect the basic principle of radiography that it is necessary to balance the risk of harm which can be caused by radiation against the benefits of obtaining a helpful diagnostic image. Both witnesses gave evidence that the Registrant did not seem to understand this basic aspect of patient safety.


52. Lack of basic knowledge and understanding was a recurring theme of the evidence. The Registrant had not been able to learn and rectify his failings.  It was also a concern to the Panel that he demonstrated no real understanding of his limitations and their impact upon patient care and safety, and on colleagues. 


53. It was evident from the range and number of issues that the Registrant’s standard of performance was unacceptably low.  The Panel was also satisfied that the incidents in the allegation documented in the daily diaries over several months represented a fair sample of the Registrants work, and the 10 month period of his employment at ABMUHB represented an extended period in which the Registrant had failed to demonstrate competence. Rather, he had to be supervised on a one to one basis all day and every day that he had worked during that period. The Panel noted from the record of an early meeting on 5 February 2016 (page D27 in the hearing bundle) that the issues of concern identified at the beginning of the process remained largely the issues of concern at the end of the 10 month period, despite the extensive support given. In a meeting on 14 September 2016, it was noted that interventions by the supervising radiographer were still required every time the Registrant was on duty. 


54. The 44 sub-particulars which the Panel had found proved under heads 1(a), 1(b) and I(c) represented failings across a broad spectrum of fundamental radiographic practice. The findings identified demonstrated fundamental and wide-ranging failings.  The Registrant had been closely and continuously supervised in his practice by a range of radiographic professionals over an extended period of 10 months. The Panel was satisfied that the number of individual examples under each head of the allegation, over an extensive period of time, represented a fair sample of the Registrant’s work and evidenced a wholesale and continuing lack of competence. 


55. The Panel concluded that this was a case of lack of competence rather than misconduct. It was clear that the failings were serious but that they came from the Registrant’s lack of understanding, knowledge and skills rather than his lack of will.


56. The Panel considered in this case that the following paragraphs from the HCPC standards were relevant and were not met: 


HCPC Standards of Proficiency for Radiographers (May 2013 edition):
Registrant radiographers must:
• 1 - be able to practise safely and effectively within their scope of practice
• 2 - be able practise within the legal and ethical boundaries of their profession
• 4 - be able to practise as an autonomous professional, exercising their own professional judgement
• 5 - be aware of the impact of culture, equality, and diversity on practice
• 8 - be able to communicate effectively
• 9 - be able to work appropriately with others
• 11 - be able to reflect on and review practice
• 12 - be able to assure the quality of their practice
• 13 - understand the key concepts of the knowledge base relevant to their profession
• 14 - be able to draw on appropriate knowledge and skills to inform practice
• 15 - understand the need to establish and maintain a safe practice environment
This represents the majority of Standards of Proficiency of Radiographers.


HCPC Standards of Conduct, Performance and Ethics (January 2016 edition)
• 1.1 - You must treat service users and carers as individuals, respecting their privacy and dignity
• 1.2 - You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided
• 2 - Communicate appropriately and effectively
• 2.3 - You must give service users and carers the information they want or need, in a way they can understand
• 6 - Manage risk
• 8 - Be open when things go wrong


57. The Panel found lack of competence established in respect of the facts proved as a whole. 


Decision on Impairment:
58. The Panel next considered whether, by reason of the Registrant’s lack of competence, his fitness to practise is currently impaired.


59. Mr Millin submitted that in the light of its findings on facts and grounds, the Panel should find the fitness of the Registrant to be currently impaired in relation to both the public and private components of current impairment. 


60. No submissions regarding impairment had been received from the Registrant.


61.  In considering current impairment, the Panel accepted the advice of the Legal Assessor and had regard to the HCPTS Practice Note “Finding that Fitness to Practise is Impaired” of March 2017. Impairment is a matter for the judgment of the Pan-el. The Panel kept in mind that not every finding of lack of competence will necessarily result in a conclusion that fitness to practise is currently impaired. The Panel was also mindful that it must consider the currency of the alleged impairment.


62. In this case, the Panel had concluded that the Registrant lacked competence based on findings which demonstrated a serious lack of the knowledge and skills required for the safe and competent practice of radiography. The Panel had found that these failings breached the majority of the HCPC’s Standards of Proficiency for Radiographers.


63. The Panel considered the personal and public components of current impairment. In relation to the personal component, the Panel considered whether there was any evidence that the failings were capable of being remedied, whether there was evidence that they have been remedied and whether there was a risk of repetition.   Failings of a clinical nature are often considered to be potentially capable of remedy. In this case, however, the Panel considered the Registrant’s lack of competence to be so wide-ranging, and sustained despite one to one supervision over many months and so basic that fundamental re-training would be required in order even to attempt to remedy it.  Since the Registrant had not engaged in this hearing and had not put forward any submissions or evidence, there was no information before the Panel demonstrating that he had made any attempt at remediation.


64. Similarly, in the Registrant’s absence, there was no evidence before the Panel at this hearing to suggest that since the events at ABMUHB the Registrant had gained insight into the concerns about his performance there. The Panel had noted that during the period of his employment, when the concerns were being brought to his attention on a daily basis, he appeared to staff not to have insight into their concerns.  It was a notable aspect of their evidence that the Registrant repeated the same mistakes and seemed not to absorb the advice he was being given.  There was no evidence before the Panel that he accepted his failings.


65. In the circumstances of this case, where there was an absence of insight and no evidence of remediation, the Panel concluded that there remained a high risk of repetition. 


66. In considering the public component of impairment, the Panel concluded that the public had been placed at risk of harm by the Registrant’s underperformance, although as a result of the close monitoring of his work by his employer, the opportunity for actual harm had been restricted. The Panel noted in particular the Registrant’s apparent lack of understanding of the risk of over-exposure to radiation, and his lack of understanding of the principles underpinning the IR(ME)R. There had, for example, been incidents where he had x-rayed the wrong body part and needed to re-x-ray, or had over-exposed patients to radiation.  On other occasions he had not set the equipment so that a useful image was obtained and again had needed to re-x-ray. There had been occasions when the Registrant had not undertaken the necessary check on a female patient’s pregnancy status, which could put the developing fetus at risk of over-exposure to radiation. There were also instances of risk of harm by his inappropriate manual handling of trauma patients during the x-ray process.


67. The Panel noted the conclusion reached by OW and KE following their assessment of the Registrant on 3 May 2016, when they concluded that the assessment would, had it been undertaken of a student, have been failed, and that there was a risk of potentially dangerous practice if the Registrant were allowed to work unsupervised.   


68. The Panel was therefore satisfied there was a risk of harm. 


69. The Panel was of the view that public confidence in the profession of radiographers, and in the HCPC as its regulator, would be undermined if a finding of impairment was not made in this case, particularly given the risk of harm that is involved in the clinical use of radiation.


70. The Panel was also satisfied that professional standards would be undermined if a finding of impairment was not made in this case, particularly given the large number of standards of proficiency that he failed to meet.


71. The Panel accordingly found that the Registrant’s fitness to practise is currently impaired.  


Decision on Sanction:
72. Mr Millin made submissions on the issue of sanction.   Mr Millin on behalf of the HCPC did not propose a particular sanction in this matter, but referred the Panel to the HCPC Indicative Sanctions Policy.


73. No information has been received from the Registrant as to his current circumstances, nor have there been any submissions or evidence in mitigation.


74. The Panel accepted the advice of the Legal Assessor.  The Panel was aware that the purpose of a sanction is not to be punitive, though a sanction may have a punitive effect. The Panel bore in mind that its primary function at this stage was to protect the public, while reaching a proportionate sanction, taking into account the wider public interest and the interests of the Registrant. The Panel referred to the HCPC’s Indicative Sanctions Policy and applied it to the Registrant’s case on its own facts and circumstances.

75. The starting point for the Panel was that the Registrant’s lack of competence was serious, wide-ranging and fundamental, demonstrating a lack of knowledge or understanding of even the most basic aspects of Radiography. The Registrant had not met most of the HCPC’s Standards of Proficiency. The Panel had no current information to indicate that the past concerns about his practice have been addressed.  The Panel has concluded that the Registrant continues to pose a current risk of harm to the public and to the wider public interest.


76. The Panel considered mitigating and aggravating factors. 


77. In relation to mitigation, no submissions or evidence had been put forward on behalf of the Registrant.  The Panel took into account the following:


• The Registrant has not previously been the subject of any regulatory findings. 


78. The Panel identified the following aggravating factors in this case:


• The breadth of the proven lack of competence, which involved wide-ranging and fundamental failings;
• The extended duration over which the failings occurred, namely 10 months during which the Registrant had received continuous and extensive support but failed to progress;
• Patients and the public were placed at risk of harm as a result of the Registrant’s actions, particularly in relation to the risk of unnecessary exposure to radiation;
• the Registrant had failed to engage in the HCPC proceedings and had failed to demonstrate any insight, remorse or remediation. 


79. In light of all of the circumstances, the Panel considered what sanction, if any, should be applied, and considered its powers in ascending order of seriousness.
Mediation


80. This was not possible or appropriate, given the Registrant’s lack of engagement with the HCPC and further, the issues proved were too serious to be addressed by means of mediation.


No Further Action
81. A risk of harm to patients had been identified and the safety of the public and the wider public interest would not be protected if the Panel were to take no further action in a case of this seriousness.


Caution
82. A Caution Order would be insufficient to mark the seriousness of the Panel’s findings and to protect the public and maintain public confidence in the Radiographers’ profession.


Conditions of Practice Order
83. In applying the Indicative Sanctions Policy, the Panel considered the lack of engagement by the Registrant in this process, and its concern that there was no evidence of insight or remediation.  In these circumstances, the Panel could not have confidence that the Registrant would be committed to complying with a Conditions of Practice Order, nor could he be trusted to do so.  


84. The Panel also took the view that its findings indicate persistent and general failings which, in accordance with the Indicative Sanctions Policy, indicate that a Conditions of Practice Order is not appropriate. Given the lack of progress the Registrant made when he was receiving one to one support during his employment, the Panel could not have confidence that an order for conditions would be effective.   

  
85. Given the Registrant’s lack of engagement and the serious findings, the Panel decided that a Conditions of Practice Order would not be effective nor would such an order protect the public.  

 
Suspension
86. The Panel considered whether a period of suspension would be appropriate. The Panel has found that the Registrant represents a real and continuing risk of harm to the public and the public interest.  Accordingly, the Panel was satisfied that any lesser sanction than suspension would not adequately protect the public and should be for the maximum period that this Panel can impose of 12 months given the degree of the lack of competence and the extent of the remediation that is required. 


Striking off
87. The Panel accepted the advice of the Legal Assessor in respect of the effect of Article 29(6) of the Health and Social Work Professions Order 2001.  In this case, given that the Panel has made a finding of lack of competence and no finding of misconduct, it is not open to the Panel to impose a striking off order because the Registrant has not been continuously suspended or subject to a Conditions of Practice Order for a period of two years immediately preceding the date of this decision.


88. The Panel heard that the Registrant has been subject of an interim order for over two years.  Initially, in August 2016, interim conditions of practice were imposed. In January 2017, an Interim Suspension Order was imposed and this was extended on application to the High Court in February 2018.  The Panel was referred to the case of Okeke v Nursing and Midwifery Council [2013] EWHC 714 (Admin) which confirmed that interim orders for either conditions of practice or suspension should not be taken into account in relation to the two-year period referred to in Article 29(6): only substantive orders, i.e. orders imposed under Article 29, for conditions of practice or suspension are relevant to the two-year period referred to in Article 29(6). 


89. In all the circumstances of this case, the Panel has determined the appropriate order is a Suspension Order for a period of 12 months.


90. There will be a review of this Order before its expiry.  This Panel considers that a future reviewing Panel will be assisted by evidence from the Registrant demonstrating insight, an understanding of the Panel’s findings and independent evidence that appropriate remediation has been undertaken.  

Order

That the Registrar is directed to suspend the registration of Mr Ajeesh George for a period of 12 months from the date this order comes into effect.

This order will be reviewed again before its expiry.

Notes

Right of Appeal:
You may appeal to the High Court in England and Wales against the Panel’s decision 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 County Court 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 Order:


Application to proceed in the Registrant’s absence with an Interim Order application:


1. Mr Millin made an application for the hearing to proceed in the Registrant’s absence in order to consider an application by the HCPC for an immediate interim order.


2. The Panel was satisfied that the notice of hearing sent to the Registrant on 21 August 2018 had been served in accordance with the Rules.  There had been no change in circumstances since the initial application to proceed in absence on the first day of the hearing, in that there had been no communication from the Registrant. 


3. The Panel noted that the Notice of Hearing informed the Registrant that an application for an immediate interim order may be made in the event that the Panel made a finding and imposed a sanction which suspends his right to practise.  There was no information before the Panel to indicate that the Registrant wished to attend or sought an adjournment for any reason.  The Panel was therefore satisfied it was appropriate to proceed to hear the HCPC’s application in the Registrant’s absence


Application for an Interim Order:


4. Mr Millin made an application for an Interim Suspension Order to cover the appeal period, on the ground that it was necessary for the protection of the public and was otherwise in the public interest.


5. The Panel accepted the advice of the Legal Assessor. It bore in mind that it must consider whether an interim order was necessary in accordance with the test set out in Article 31(2) of the Health and Social Work Professions Order 2001, and that it must act proportionately, imposing the lowest order which would adequately protect the public.


6. The Panel considered the issue of proportionality and balanced the interests of the Registrant with the public interest. 


7. The Panel had determined to impose a substantive Suspension Order. It had made findings that the public were at real risk of harm if the Registrant were able to continue to practise.  Accordingly, the Panel determined that an interim order was necessary in order to protect the public and in the wider public interest.  


8. The Panel was satisfied, for the same reasons as in respect of its substantive decision, that an interim Conditions of Practice Order would not be appropriate.  The Panel therefore directed that the Registrant’s registration should be suspended on an interim basis.

 
9. The Panel concluded that the appropriate and proportionate duration of the interim suspension order was 18 months, as the interim order would continue to be required pending the resolution of an appeal in the event of the Registrant giving notice of an appeal with the 28-day period.


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.  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.

 

 

 

Hearing History

History of Hearings for Mr Ajeesh George

Date Panel Hearing type Outcomes / Status
03/12/2018 Conduct and Competence Committee Final Hearing Suspended