Mr Inderjit Singh Sagar

Profession: Chiropodist / podiatrist

Registration Number: CH13419

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 23/01/2020 End: 13:00 23/01/2020

Location: Health and Care Professions Tribunal Service, 405 Kennington Road, London, SE11 4PT

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

The following Allegation was considered by a Panel of the Conduct and Competence Committee at a Substantive Hearing on 15 – 17 November 2017 and 12, 29 and 30 January 2018.
 
In March 2011, whilst registered as a Chiropodist, you: 
1) Did not complete an adequate assessment of Patient A prior to undertaking a nail ablation by not or not adequately: 
(a) Assessing Patient A’s vascular supply;
(b) Obtaining Patient A’s medical history. 
2) Did not complete adequate records in respect of Patient A. 
3) Provided inappropriate treatment to Patient A’s right toe nail in that: 
(a) You used phenol for the nail ablation when this was contra-indicated for Patient A; 
(b) You did not refer Patient A to a GP or vascular consultant for assistance. 
4) Did not obtain informed consent from Patient A prior to undertaking a nail ablation by not: 
(a) Providing Patient A with a sufficient explanation of the treatment options; 
(b) Providing Patient A with sufficient explanation of the risks and benefits of each of the treatment options. 
5) Your actions described in paragraphs 1-4 amount to misconduct and/or lack of competence. 
6) By reason of that misconduct and/or lack of competence, your fitness to practise is impaired.

The panel at the substantive hearing found the facts proved and the statutory ground of misconduct established. The panel found the Registrant’s fitness to practise to be impaired and a Conditions of Practice Order, for a period of 12 months, was imposed as a Sanction. This decision was reviewed on 18 January 2019 and that panel varied the Conditions of Practice Order for a further period of 12 months.

Finding

Preliminary Matters:

Hearing in Private

1. Mr Rowe made an unopposed application that those parts of the hearing that affected the private life of the Registrant should be heard in private. After receiving advice from the Legal Assessor, the Panel granted this application. 

Background:

2. The Registrant, the owner of ‘The Chorley Chiropody Practice’, has practised as a sole practitioner as a Registered Chiropodist/Podiatrist for over 20 years. In March and April 2011, the Registrant gave treatment to Patient A that resulted in a complaint made three years later to the HCPC about its poor standard.

3. At a Substantive Hearing that ended on 30 January 2018, a panel of the HCPC’s Conduct and Competence Committee found proved the Particulars that the Registrant had not completed adequate assessments of Patient A’s vascular supply before he undertook a nail ablation. Nor had he adequately obtained Patient A’s medical history. The panel also found proved that the Registrant had not completed adequate records, had not referred the patient to a GP or Vascular Consultant and had provided inappropriate treatment to Patient A’s right toenail. The Registrant, it was also found proved, had not obtained informed consent from Patient A before he performed a nail ablation. 

4. That panel judged that these failures amounted to misconduct, that the Registrant’s fitness to practise was impaired and that the appropriate sanction to impose was a Conditions of Practice Order for a period of 12 months as set out below: 

1) You must place yourself and remain under the supervision of a workplace supervisor registered by the HCPC and supply details of your supervisor to the HCPC within 28 days of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations.

2) You must promptly inform the HCPC if you cease to be in self-employment or take up any other or further employment.

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

4) You must inform the following parties that your registration is subject to these conditions:

(a) any organisation or person employing or contracting with you to undertake professional work;
(b) any agency you are registered with or apply to be registered with (at the time of application); and
(c) any prospective employer (at the time of your application).

5) You must work with your supervisor to formulate a Personal Development Plan designed to address the deficiencies identified in this hearing, including:

- vascular assessment and clinical reasoning
- record keeping
- obtaining informed consent

6) Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.

7) You must meet with your supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.

8) You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.

9) You must maintain a record of reflective practice detailing every occasion when you undertake a procedure using local anaesthesia and must provide a copy of that profile to the HCPC on a monthly basis or confirm that there have been no such occasions in that period, the first profile or confirmation to be provided within 2 months of the Operative Date.

10) You must arrange an independent audit of your record-keeping every 4 months to demonstrate progress on remediating the record-keeping deficiencies identified in this hearing and provide details of each audit to the HCPC.

11) You will be responsible for meeting any and all costs associated with complying with these conditions.

12) Any condition requiring you to provide any information to or obtain the approval of the HCPC is to be met by you. You must send the information required to the offices of the HCPC, marked for the attention of the Director of Fitness to Practise or Head of Case Management.

5. This order was reviewed on the 18 January 2019 and the reviewing panel considered that the Registrant’s fitness to practise remained impaired on both public protection and public interest grounds. The reviewing panel considered that the conditions had not been fully complied with and the Registrant had not demonstrated full insight and remediation. The reviewing panel considered that a suspension order would be disproportionate at this time and determined to provide the Registrant with a further opportunity to demonstrate he could return to safe practice. The reviewing panel made the following conditions of practice order for a further period of 12 months:

1) You must only perform partial or total nail avulsion under local anaesthetic whilst under the direct physical supervision of a Chiropodist/Podiatrist registered with the HCPC with a minimum of five years post graduate qualification experience.  You must supply details of your supervisor to the HCPC within 28 days of the Operative Date. You must follow the advice and recommendations of this supervisor and provide the HCPC with their feedback before the next review hearing.

2) You must work with a supervisor, who is a Chiropodist/Podiatrist registered with the HCPC  with a minimum of five years post graduate qualification experience, who may or may not be your direct clinical supervisor referred to in Condition 1, to formulate a Personal Development Plan designed to address the deficiencies identified in this hearing, including:

- vascular assessment and clinical reasoning
- record keeping
- obtaining informed consent

3) Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.

4) You must meet with the supervisor referred to in Condition 5 [sic] above on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.

5) You must allow your supervisor referred to in Condition 2 above to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.

6) You must maintain a record of reflective practice detailing every occasion when you undertake a procedure using local anaesthesia and must provide a copy of that profile to the HCPC on a monthly basis or confirm that there have been no such occasions in that period, the first profile or confirmation to be provided within 2 months of the Operative Date.

7) You must arrange an independent audit of your record-keeping every 4 months to demonstrate progress on remediating the record-keeping deficiencies identified in this hearing and provide details of each audit to the HCPC within 14 days of completion.

8) You must promptly inform the HCPC if you cease to be in self-employment or take up any other or further employment.

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

10) You must inform the following parties that your registration is subject to these conditions:

(a) any organisation or person employing or contracting with you to undertake professional work;
(b) any agency you are registered with or apply to be registered with (at the time of application); and
(c) any prospective employer (at the time of your application).

11) You will be responsible for meeting any and all costs associated with complying with these conditions.

12) Any condition requiring you to provide any information to or obtain the approval of the HCPC is to be met by you. You must send the information required to the offices of the HCPC, marked for the attention of the Director of Fitness to Practise or Head of Case Management.

6. That panel determined that it would assist this Reviewing Panel for the Registrant to provide the following:

1) Reports from the workplace supervisor(s) referred to in Conditions 1 and 5 above evidencing;

i. the extent to which you have demonstrated that you have achieved the aims set out in your Personal Development Plan.
ii. that all aspects of nail surgery have been carried out to a satisfactory and competent professional standard

2) Copies of the results of your record-keeping audits.

3) Evidence of reflection which demonstrates tangible assurance of relevant learning embedded in your practice.
 
Decision:

7. Ms Simpson for the HCPC set out the relevant background to the matter and submitted that the Registrant had breached a number of the conditions. She submitted that it was arguable that condition 1 had been breached, condition 2 had not been fully complied with, condition 4 and 5 had been breached and condition 7 had not been fully complied with. In the circumstances she submitted that the Registrant had been unable to demonstrate insight and remediation of the concerns. She submitted that the HCPC’s position was that a suspension order may be appropriate given the Registrant’s continued failure to comply with the conditions.

8. Mr Rowe on behalf of the Registrant informed the Panel that the conditions were not clear and that there was no breach of conditions 1 and 5. He accepted that there had been partial compliance with condition 2. Mr Rowe explained that the Registrant had made efforts to address the concerns and comply with the conditions. Mr Rowe set out that the supervisor he had chosen moved away from the area very soon after the last order was made, and this caused considerable difficulties. Nevertheless, the Registrant still worked with the supervisor and identified another individual to supervise him on an informal basis. Mr Rowe set out the personal and financial difficulties encountered by the Registrant and submitted that he has not had the benefit of any professional assistance with these matters until relatively recently. Mr Rowe conceded on behalf of the Registrant that his fitness to practise remained impaired, but he invited the Panel to consider a further conditions of practice order to give the Registrant a final chance to remedy the concerns.

9. The Registrant provided a number of documents setting out the courses he had attended, notes of discussions and learning, and one record keeping audit. The Registrant also provided a completed PDP verified by his supervisor but no notes of any meetings with the supervisor setting out the Registrant’s progress.

10. The Panel considered the submissions of the parties together with all of the evidence it had before it. The Panel accepted the advice of the Legal Assessor and had regard to the HCPTS Practice Note ‘Finding that Fitness to Practice is Impaired’.

11. The Panel noted that the Registrant accepts that his fitness to practise is impaired but nevertheless it exercised its own professional judgement. The Panel considered that the Registrant hasn’t fully complied with the conditions of practice order. As a result of being unable to find a supervisor the Registrant has not undertaken any partial or total nail avulsions. In these circumstances the Panel concluded that the Registrant has not been able to demonstrate competence in this procedure or in any assessments prior to carrying out this procedure.

12. The Panel noted the efforts made by the Registrant to produce his PDP and the reflective documents he had produced. The Panel considered that these were not sufficient to demonstrate complete insight or remediation and were lacking in a number of key areas. In particular the Panel considered that there was no evidence of embedded learning in the Registrant’s practice. In the absence of this embedded learning together with the lack of evidence of carrying out vascular assessments the Panel considered that there remains a risk of repetition of the concerns that led to the substantive order. The Panel determined that the Registrant’s fitness to practise is currently impaired on public protection grounds.

13. The Panel also considered the public interest in upholding proper professional standards and considered that a finding of current impairment on public interest grounds was also required. The public would expect the regulator to act in circumstances where there was a risk of repetition of concerns that had the potential to cause patient harm.

14. Having determined that the Registrant’s fitness to practise remains impaired the Panel went on to consider what order was appropriate. It had regard to the need to act proportionately and to balance the public interest with the Registrant’s own interests.

15. The Panel first considered allowing the order to lapse but considered that this would be inappropriate given the risk of repetition identified. A caution order would not restrict the Registrant’s practice and the Panel therefore considered this was also not appropriate to protect the public.

16. The Panel then considered whether a further conditions of practice order was appropriate. The Panel considered that the concerns were remediable and that the Registrant had taken some steps to comply with the current conditions. The Panel noted that the Registrant had not had the benefit of professional representation until recently and had also had some personal and financial problems which had prevented full compliance with the conditions.

17. The Panel considered that the Registrant was developing insight. He had made efforts to address some of the concerns and has been practising without further concerns during the period that these conditions have been in force. The Panel noted that although the record keeping audit was not as extensive or comprehensive as required by the conditions there were no areas of concern highlighted by the supervisor. There was no evidence before the Panel that the general record keeping of the Registrant continued to be of concern and the Panel was satisfied that on a general level the Registrant had remediated this concern.

18. The Panel concluded that there were no persistent or general failures. The Panel considered that the Registrant was genuinely willing to comply with conditions and in particular had complied with the condition not to undertake partial or total nail avulsions without supervision. The Panel considered that the Registrant was committed to improving his practise and had accessed training and support albeit that this process was not yet complete. The Panel was satisfied that it could formulate conditions which protected the public.

19. The Panel considered that a suspension order was disproportionate at this stage and considered that the Registrant should be given a further opportunity to demonstrate that he can remediate the remaining concerns and return to safe practice.

20. The Panel concluded that, in all the circumstances, the appropriate and proportionate sanction to impose is a continuation of the current order of conditions for a further period of 12 months with amendments to reflect the current position.

Order

The Registrar is directed to annotate the Register to show that, for a period of one year from the date that this Order comes into effect (“the Operative Date”), you, Inderjit Singh Sagar, must comply with the conditions of practice set out below. 


1) You must not perform unsupervised partial or total nail avulsions under local anaesthetic until you have been assessed as competent, in both assessing a patient and carrying out the procedure, by a Chiropodist/Podiatrist registered with the HCPC with a minimum of five years post graduate qualification experience. You must send a copy of this completed assessment to the HCPC within 14 days of the assessment taking place.


2) You must work with a supervisor, who is a Chiropodist/Podiatrist registered with the HCPC with a minimum of five years post graduate qualification experience, who may or may not be the clinical supervisor referred to in Condition 1 above to formulate a Personal Development Plan to address the following areas:


• Completion of vascular assessments;
• Outcomes of vascular assessments and their impact on treatment and referral.


3) You must send a copy of the Personal Development Plan to the HCPC within three months of the Operative date.


4) You must meet with the supervisor referred to in condition 2 above, as required, to consider the aims as set out in your Personal Development Plan. At least 14 days before the next review of this Order, you must forward a copy of your Personal Development Plan with confirmation from your supervisor that all of the actions identified have been completed.


5) You must promptly inform the HCPC if you cease to be in self-employment or take up any other or further employment.


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


7) You must inform the following parties that your registration is subject to these conditions:


(a) any organisation or person employing or contracting with you to undertake professional work;
(b) any agency you are registered with or apply to be registered with (at the time of application); and
(c) any prospective employer (at the time of your application).


8) You will be responsible for meeting any and all costs associated with complying with these conditions.


9) Any condition requiring you to provide any information to or obtain the approval of the HCPC is to be met by you. You must send the information required to the offices of the HCPC, marked for the attention of the Director of Fitness to Practise or Head of Case Management.

Notes

The Order imposed today will apply from 27 February 2020 (the Operative Date). 

This order will be reviewed 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.

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 restricted. 

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.
 

 

 

Hearing History

History of Hearings for Mr Inderjit Singh Sagar

Date Panel Hearing type Outcomes / Status
23/01/2020 Conduct and Competence Committee Review Hearing Conditions of Practice
18/01/2019 Conduct and Competence Committee Review Hearing Conditions of Practice
29/01/2018 Conduct and Competence Committee Final Hearing Conditions of Practice
15/11/2017 Conduct and Competence Committee Final Hearing Adjourned part heard
03/07/2017 Conduct and Competence Committee Final Hearing Adjourned