Mr Ajeesh George
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Allegation
The following allegation was considered by a Panel of the Conduct and Competence Committee at the substantive hearing on 3-6 December 2018.
All the particulars of the Allegation were found proved with the exception of 1(b)(i)(g)(i), 1(b)(i)(g)(ii) and 1(c) (iii) (d), the grounds of lack of competence were established and fitness to practice was found impaired.
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. The Hearings Officer provided the Panel with details of service of the Notice of Hearing and bundle upon the Registrant.
2. The Panel had regard to the HCPTS practice note in relation to Service of Documents and received advice from the Legal Assessor. It was satisfied that the Registrant was notified of the date and time of the hearing via a letter dated 30 October 2019 (the “Notice of Hearing”) which was sent by first class post to his registered address and to his email address. The Panel found that the HCPC had discharged its duty to serve documentation on the Registrant in accordance with the Health and Social Work Professions Order 2001 (“the Order”).
Proceeding in Absence of the Registrant
3. The Presenting Officer invited the Panel to exercise its discretion to proceed with the hearing in the absence of the Registrant. She outlined the chronology of the matter and confirmed that the Registrant had been contacted by the HCPC on 20 November 2019 and she had personally emailed him on 2 December 2019 in relation to the hearing. She had received no response to this communication and invited the Panel to exercise its discretion to proceed with the case in the absence of the Registrant on the basis that he had voluntarily absented himself from the hearing. He had not sought an adjournment and there was no information to suggest that he would attend any re-arranged hearing. Further, this was a mandatory review of a Suspension Order.
4. The Panel noted the provisions of the HCPTS Practice Note “Proceeding in the Absence of the Registrant”. There had been no request for an adjournment received, nor any interest expressed by the Registrant in providing evidence via video or telephone link. The Registrant had not indicated any desire to be represented at the hearing and had not responded in any way to the Notice of Hearing. Included in the Notice of Hearing was confirmation that the hearing could proceed in the absence of the Registrant. He was therefore on notice that the hearing could proceed.
5. The Panel was satisfied that it was appropriate for it to exercise its discretion to hear the matter in the absence of the Registrant. There is an expectation that regulatory matters are dealt with expeditiously. Although proceeding in absence may disadvantage the Registrant, it was satisfied that he was aware of the hearing but had chosen not to attend or be represented. There was no request for an adjournment or any indication that he wished to be represented in the matter, and no evidence that he would attend or be represented in the event that the matter was adjourned to an alternative date. The Panel considered that the public interest in proceeding with the hearing outweighed any potential prejudice which may be suffered by the Registrant. It was satisfied that the Registrant had voluntarily absented himself from the proceedings.
Background
6. The Registrant was employed by Abertawe Bro Morgannwg University Health Board (“the Board”) as a Band 5 Radiographer at the Princess of Wales Hospital from 17 December 2015. Upon commencement of his employment, as was routine, he was monitored and supervised to allow the Board to be satisfied that he was competent to practise autonomously. Concerns were raised about the Registrant’s knowledge of radiation protection and radiographic technique by his colleagues from early 2016. Monitoring and extensive support was provided by the Board to the Registrant to facilitate him becoming an autonomous practitioner. Notwithstanding this support, the Registrant was only able to work under supervision. There being no evidence of improvement in the Registrant’s capability despite the support provided to him, the Board commenced capability processes in respect of the Registrant in accordance with its policy. A formal capability meeting took place on 7 July 2016.
7. The Board informed the HCPC of its concerns about the Registrant following the formal capability hearing on 7 July 2016.
8. A second capability meeting took place on 11 August 2016. It was established that the Registrant continued to fail to meet the objectives set for him and he was therefore granted a further 4 week period to meet the required standard of performance. During this period, his work was observed and recorded, with both the Registrant and the supervising radiographer signing off the records of observations and interventions.
9. The Registrant’s performance was reviewed on 14 September 2016 and it was determined that he still had not achieved the standard of performance expected by the Board, and that significant concerns about his practise remained. He was informed that his employment with the Board would be terminated by reason of his capability.
10. Following a hearing of the Conduct and Competence Committee between 3 - 6 December 2018, which was not attended by the Registrant or a representative acting on his behalf, a number of particulars alleged were held to be well-founded as set out above, and the Registrant’s fitness to practise was assessed as being impaired by reason of his lack of competence. A Suspension Order was imposed by the Panel for a period of 12 months, of which this is the first mandatory review.
11. The Panel was provided with a bundle of documents by the HCPC for the review hearing. The Registrant had not supplied any documentation or representations to the Panel.
Decision
12. The Presenting Officer confirmed that the task of the reviewing panel was to determine whether the Registrant’s fitness to practice remains impaired. The Panel could not go behind the original findings in relation to the allegation but were tasked with assessing the impairment of the Registrant. She addressed at length the issues identified by the substantive hearing panel and invited the Panel to find that the Registrant’s fitness to practise remains impaired. If the Panel was satisfied that his practise remains impaired, she confirmed that all sanctions were open to the Panel save for that of Striking Off, which is not available as the Registrant’s impairment was by virtue of his lack of competence, and he had not been continuously suspended or subject to conditions of practice for a period of 2 years.
13. The HCPC’s position was that the most appropriate Order for the Panel to impose would be a Suspension Order given that it would not be possible to formulate proportionate and workable Conditions of Practice to adequately address the risk posed to the public.
14. The Panel listened carefully to the submissions made by the Presenting Officer, and considered all of the documentation provided to it. It accepted and applied the advice of the Legal Assessor in relation to the proper approach to determining this matter. It also had regard to the policies adopted by HCPC in relation to the approach to take to Fitness to Practice proceedings. It also noted and applied the following practice notes adopted by HCPTS:
a. Review of Article 30 Sanction Orders;
b. Unrepresented Registrants;
c. Finding that Fitness to Practice is Impaired;
d. Drafting Decisions.
And the following documents adopted by the HCPC:
e. Standards of Proficiency for Radiographers;
f. Standards of Conduct, Performance and Ethics;
g. Sanctions Policy.
15. The review process centres around consideration as to whether the Registrant’s fitness to practise remains impaired and if so, whether the existing order or another order needs to be in place to protect the public. A key issue which needs to be addressed is what, if anything, has changed since the current order was imposed. The factors to be taken into account include:
a) the steps which the Registrant has taken to address any specific failings or other issues identified in the previous decision;
b) the degree of insight shown and whether this has changed;
c) the steps which the Registrant has taken to maintain or improve his professional knowledge and skills;
d) whether any other fitness to practise issues have arisen;
e) whether the Registrant has complied with the existing order.
16. The Panel reminded itself that Suspension Orders are imposed only when there is either:
• a serious and on-going risk to service users or the public from the Registrant’s lack of professional knowledge;
• or skills, conduct or unmanaged health problems, or the allegation is so serious that public confidence in the profession or the regulatory process would be seriously harmed if the Registrant was allowed to remain in practice.
17. The Panel which conducted the substantive hearing recommended that the Registrant provide to a reviewing panel evidence of insight, understanding and remediation. It identified the only mitigating factor in the matter before it was that the Registrant had not previously been subject to any regulatory findings. However, it found the following aggravating factors:
a. the breadth of the proven lack of competence, which involved wide-ranging and fundamental failings;
b. the extended duration over which the failings occurred, namely 10 months during which the Registrant had received continuous and extensive support but had failed to progress;
c. 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;
d. the Registrant had failed to engage in the HCPC proceedings and had failed to demonstrate any insight, remorse or remediation.
18. The Panel was obliged to consider whether the concerns summarised above, which led to a finding of impairment at a hearing in December 2018, remain. As the decision in Abrahaem v GMC [2008] EWHC 183 (Admin) indicates, in practical terms this places a “persuasive burden” on the Registrant to demonstrate at a review hearing that he has fully acknowledged the issues which led to the original finding and has addressed them sufficiently “through insight, application, education, supervision or other achievement...”.
19. The Panel noted that the Registrant had provided no information to it in relation to either the findings of the substantive panel or his current situation, despite the recommendation from the substantive panel as to the information which could be beneficial at a review hearing.
20. The Panel reminded itself that when reviewing sanctions under Article 30 of the Order, the Reviewing Panel may:
a) confirm the order;
b) extend, or further extend, the duration of the order;
c) reduce the duration of the order;
d) replace the order with any other order which the Panel could have made (to run for the remaining term of the original order); or
e) revoke the order or revoke or vary any condition imposed by it.
21. The decision reached by the Panel must be proportionate, striking a fair balance between interfering with the Registrant’s ability to practise and the overarching objective of public protection. Of particular relevance to the Panel is whether the concerns raised in the original finding of impairment had been sufficiently addressed, with the burden on the Registrant to demonstrate that he has fully acknowledged the deficiencies which led to the original finding and has addressed that impairment sufficiently. In making its decision the Panel was required to take account of the wider public interest, which includes:
a) the deterrent effect to other registrants;
b) public confidence in the profession concerned; and
c) public confidence in the regulatory process.
It was also mindful of the fact that no registrant should resume unrestricted practice until it is safe and appropriate for them to do so.
21. The Panel concluded that there was insufficient evidence that the risks identified by the substantive panel considering this matter have decreased. The Registrant had submitted no information to the Panel as to his insight into the serious, sustained and widespread failings identified in his practice. He also had provided no information which demonstrated that he had remediated the failings, or expressed remorse for his actions. Accordingly, the Panel found that the Registrant’s fitness to practice remains impaired.
22. Having conducted an assessment of impairment, the Panel went on to consider what, if any, Order was appropriate in the circumstances to manage the risks to the public identified in this matter. It was satisfied that an Order was still necessary and proportionate with regard to the protection of the public and in the wider public interest – a member of the public aware of the circumstances of the failings would be concerned if no Order were made. The Panel determined it would not be appropriate to impose no Order or issue a Caution given the seriousness and extent of the deficiencies found. The Registrant was no longer employed by the Board and therefore mediation was also not an appropriate Order to make. Given the lack of evidence of employment in the profession, and the absence of any evidence of remediation of the failings identified, the Panel did not believe that an adequate level of public protection could be achieved through the imposition of a Conditions of Practice Order – given the breadth of concerns to be addressed, even if conditions could be drafted they would in all likelihood be tantamount to a suspension order. The Panel also concluded that a Conditions of Practice Order would be insufficient to address the issue of trust and confidence in the profession and the requirement to uphold the integrity of the regulatory process. Further, the Registrant had not demonstrated any willingness to engage in the regulatory process and therefore a Conditions of Practice Order would be wholly inappropriate in the circumstances.
23. The Panel was not able to consider a Striking Off Order as the impairment was by reason of lack of competence and the Registrant has not been continuously suspended, or subject to a conditions of practice order, for a period of two years. The Panel was conscious that an Order of Suspension would have a punitive impact upon the Registrant, however it was satisfied that the interests of the Registrant were outweighed by its duty to give priority to the public interest and maintain confidence in the regulator. The Panel was satisfied that no lesser sanction would be appropriate in the particular circumstances of this case.
24. Having determined that an Order was required, and that the most appropriate Order would be that of Suspension, the Panel then considered the length of time for which the Order should be imposed. Given the serious, sustained and widespread failings identified, and the fact that the Registrant has not demonstrated to his regulator any desire or commitment to return to the profession, the Panel concluded that the Order of Suspension should be imposed for a period of 12 months.
25. The Panel considered that a reviewing panel may be assisted by the Registrant:
a. engaging with the regulatory process;
b. providing evidence such as a reflective piece showing remorse, insight and remediation;
c. detailing how he has addressed the key issues the Panel identified, for example through relevant work, paid or unpaid, and supplying details of any relevant training and professional development.
Order
The Registrar is directed to suspend the registration of Mr Ajeesh George for a further period of 12 months on the expiry of the existing order.
Notes
This Order will be reviewed again before its expiry.
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 Articles 30(10) and 38 of the Health Professions Order 2001, any appeal must be made to the court not more than 28 days after the date when this notice is served on you.
Hearing History
History of Hearings for Mr Ajeesh George
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 03/03/2021 | Conduct and Competence Committee | Review Hearing | Struck off |
| 02/12/2020 | Conduct and Competence Committee | Review Hearing | Suspended |
| 03/12/2019 | Conduct and Competence Committee | Review Hearing | Suspended |