Mrs Sandhya Yatham Venkataramana
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Allegation
Whilst registered as a Dietitian and during the course of your employment at Aintree University Hospital:
1. In relation to Patient 1, on 3 October 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Did not record the type of insulin being used;
c. Recorded that Patient 1 had multiple diabetes related co morbidities when there was no clinical indication of and/or diagnosis for these conditions;
d. Did not explain the role of blood glucose monitoring in assisting self-management of Patient 1’s condition;
e. Documented an agreed plan which was not appropriate for Patient 1’s individual needs and circumstances;
f. Gave inappropriate advice with regards to Carbohydrate portions;
g. Did not maintain adequate records.
2. In relation to Patient 4, on 5 December 2016, you:
a. Gave inappropriate advice with regards to Patient 4’s intake of:
i) fluid
ii) protein
b. Did not take into account Patient 4’s kidney failure when formulating a diet plan.
3. In relation to Patient 5, on 10 October 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Did not discuss Patient 5’s recent weight gain;
c. Did not discuss alternative carbohydrate sources when restricting fruit intake;
d. Did not discuss carbohydrate requirements for evening meal to help prevent pre breakfast hypoglycaemia;
e. Did not prioritise carbohydrate awareness in view of Patient 5’s recent diabetic ketoacidosis.
4. In relation to Patient 6, on 10 October 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Gave advice prior to weighing Patient 6;
c. Inappropriately advised Patient 6 that his bloods were “good” when his HbA1c was high;
d. Did not provide adequate dietetic advice in relation to:
i). prevention of hypoglacemia and/or
ii). treatment of hypogleacemia.
e. Did not provide adequate advice regarding appropriate meals.
5. In relation to Patient 7, on 10 October 2016, you;
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Did not consider the Service User’s medical plan until the conclusion of the consultation and/or consider Diabetes Mellitus medical updates until the conclusion of the consultation;
c. Did not address Patient 7’s hypoglycaemic reading of 2.8mmol/l;
d. Documented an agreed plan which was not appropriate for Patient 7’s individual needs and circumstances.
6. In relation to patient 8, on 10 October 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Did not recognise and or discuss the possibility that Patient 8’s weight loss could be due to high glucose levels;
c. Gave inappropriate advice in that you;
i). told Patient 8 not to worry about Body Mass; and
ii). told Patient 8 to focus on nutrition support.
d. Did not discuss appropriate use of Oral Nutrition Supplements to minimise hyperglycaemia;
e. Did not provide adequate and/or appropriate dietetic advice in relation to Carbohydrate intake.
7. In relation to Patient 8, on 12 December 2016, you:
a. Gave inappropriate advice in relation to:
i). insulin
ii). snacks
b. Gave incorrect advice in relation to the energy content of milk;
c. Did not communicate appropriately with Patient 8.
8. In relation to Patient 9, on 14 November 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Did not explore and /address Patient 9’s hypoglycaemic symptoms;
c. Did not explore and/or address how Patient 9 treats his hypoglycaemic incidents;
d. Gave inappropriate advice regarding a target for HbA1C levels;
e. Incorrectly documented that a nocturnal hypoglycaemic incident could be the cause of rebound pre- breakfast hypoglycaemia and/or did not suggest a dietary plant to prevent this.
9. In relation to Patient 10, on 19 September 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Did not explore and/or address the reasons for Patient 10’s weight loss of over 6 kilograms in one year;
c. Demonstrated poor clinical reasoning in that you did not associate low HbA1c with the possibility of undetected hypoglycaemic incidents;
d. Did not provide adequate and/or appropriate dietetic advice in relation to Carbohydrate intake;
e. Did not address and/ or respond appropriately to patient 10’s understanding of hypoglycaemic incidents;
f. Did not address and/ or respond appropriately to patient 10’s understanding of basal insulin.
10. In relation to patient 11, on 19 September 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Gave inappropriate and/or unclear advice in relation to Patient 11’s blood glucose levels;
c. Gave inappropriate advice in relation to Patient 11’s fruit intake;
d. Documented an agreed plan which was not appropriate for Patient 11’s individual needs and circumstances.
11. In relation to Patient 13, on the 21 November 2016, you:
a. Did not calculate Body Mass Index and/or record a Body Mass Index calculation;
b. Did not provide adequate and/or appropriate advice in relation to Patient 13’s diagnosis of:
i). diabetes
ii). pancreatitis;
c. Did not provide adequate and/or consistent advice in relation to grams of:
i). carbohydrates
ii). insulin.
12. In relation to Patient 15, on 27 September 2016, you:
a. Did not assess and/or record assessing diet until approximately half way through the consultation;
b. Did not provide adequate and/or appropriate dietetic advice;
c. Did not communicate appropriately with Patient 15;
d. Made an inappropriate comment in that you said that Patient 15 was “lucky as many diabetics do not have legs” or words to that effect.
13. The matters set out in particulars 1 – 12 amount to misconduct and/or lack of competence.
14. By reason of your misconduct and/or lack of competence, your fitness to practise is impaired.
Finding
Preliminary Matters
Proof of Service
1. The Panel was provided with a signed certificate as proof that the Notice of Hearing had been sent via email on 21 August 2020 to the address shown for the Registrant on the HCPC register.
2. The Panel had regard to the information provided in relation to the service of documentation, and received advice from the Legal Assessor, which it accepted. It also had regard to Practice Notes issued by HCPTS in respect of ‘Service of Documents’.
3. The Panel was satisfied that Notice had been properly served in accordance with Rule 3 (Proof of Service) and Rule 6 (date, time and venue) of the Health And Care Professions Council (Conduct and Competence Committee)(Procedure) Rules 2003 (“the Rules”). Further, it noted that the Registrant has been communicating with the HCPC in connection with the voluntary removal application and was aware of the hearing.
Proceeding in Absence
4. The Presenting Officer applied for the hearing to proceed in the absence of the Registrant in accordance with Rule 11 of ‘the Rules’, noting that the Registrant had consented to voluntary removal from the register, and had not sought an adjournment or to be represented at the hearing.
5. The Panel was advised by the Legal Assessor and accepted that advice. The Panel also took into account the guidance issued by the HCPTS in the Practice Note entitled ‘Proceeding in the Absence of the Registrant’.
6. The Panel determined that it was fair and reasonable to proceed with the hearing in the absence of the Registrant. The Registrant was aware of the hearing (as evidenced by her email communications with the HCPC and her declining of the virtual hearing invitation) and was seeking voluntary removal from the register. In support of the application, she has executed the Voluntary Removal Agreement provided to her and reiterated on a number of occasions in correspondence that she wished to be removed from the register. The Panel noted that the purpose of the hearing is to consider the signed agreement, which is treated as a joint application made on behalf of both parties. In these circumstances, the Panel concluded that it would be reasonable to infer that the Registrant’s expectation is that the hearing will proceed in her absence.
7. The Registrant has not made an application to adjourn the proceedings and there is no indication that even if the case were to be adjourned that she would be willing or able to attend on any future date. She had also not indicated that she wished to be represented in the proceedings. The Panel was satisfied that the Registrant would not be disadvantaged by the matter proceeding in her absence given her clearly expressed wish to be removed from the register. It concluded that it was in the public interest, and in the Registrant’s own interest, that the hearing proceed expeditiously.
Proceeding in Private
8. The HCPC applied for the parts of the hearing that referenced the Registrant’s health to proceed in private pursuant to the Rules, stating this provided that “proceedings shall be held in public unless the Committee is satisfied that, in the interests of justice or for the protection of the private life of the health professional … the public should be excluded from all or part of the hearing”.
9. The Panel received advice from the Legal Assessor and had regard to the HCPTS practice note entitled ‘Conducting Hearings in Private’. The Panel noted that there is reference to the health of the Registrant in the supplied documentation and determined that it was appropriate for the parts of the hearing that related to the health of the Registrant to proceed in private so as not to compromise the Registrant’s right to a private life.
Background
10. The Registrant is a registered Dietitian who was employed by Aintree University Hospital NHS Foundation Trust (“the Trust”) between November 2015 and February 2017 as a Band 6 Dietitian. She was dismissed from her employment by the Trust on 13 February 2017 on the grounds of unsatisfactory and poor performance following informal support and then a formal capability process.
11. On 17 March 2017, the Trust referred the following concerns about the Registrant to the HCPC:
a. Documentation:
i. Pattern of incorrect information and documentation in patients’ case notes;
ii. Clinically relevant information missing or incorrect (i.e. dates and blood results);
iii. Spelling and grammatical errors making documentation difficult to read/ follow;
iv. Disorganised management of patient records which made it more difficult for other health professional to understand what had occurred in the Registrant’s sessions.
b. Communication:
i. Incorrect clinical results discussed with patients;
ii. Ongoing use of closed and suggestive questioning;
iii. Consultations lacking in structure;
iv. Not always listening or acknowledging what patients said and making assumptions about the information disclosed to her.
c. Clinical Skills:
i. Appropriate clinical information not always provided at every patient consultation;
ii. Providing advice regarding insulin which is outside of professional scope of practice;
iii. Giving dietary advice which was incorrect or unclear for the patient to understand;
iv. Inadequate clinical assessment of the patients.
d. Personal Development
i. Lack of reflective practice and not able to readily identify areas for self-improvement;
ii. CPD portfolio incomplete (i.e. CV was out of date, no copy of job description and no evidence of recent professional development that has been undertaken);
iii. Band 6 competencies set not complete.
12. The HCPC obtained the opinion of a Registrant Assessor, Dr B, on 21 January 2019. Her opinion was that the Registrant’s practice showed serious errors and did not appear to improve during the 3-month period of close supervision, guidance and education provided by her employer. Dr B stated that the Registrant’s “practice is of poor standard, her documentation of a low quality, and her advice could have on occasion caused serious harm to the patient.”
13. On 6 June 2019 a panel of the Investigating Committee determined that there was a case to answer in respect of the Allegation against the Registrant. Solicitors were instructed to finalise investigations and prepare the matter for a final hearing, which included obtaining witness statements.
14. In view of the Registrant’s consistent position that she would not be returning to practise, the HCPC determined that the matter could be suitable for disposal by way of a voluntary removal agreement and sought an update from the Registrant on 25 June 2019 as to her health and intention to practise in the future. She provided a response to the Allegation, confirmed she had no intention of returning to her profession and provided information as to her health.
15. On 11 March 2020 the HCPC provided further information to the Registrant in relation to voluntary removal by agreement, including sending her the practice note entitled ‘Disposal of Cases by way of Consent’. Further correspondence was sent to the Registrant on 24 April 2020 and 6 May 2020 and by an email dated 4 August 2020, the Registrant confirmed she was content to be removed from the register and not return to practice.
16. A Voluntary Removal Agreement was provided to the Registrant by the HCPC on 11 September 2020, which she signed and returned, thereby accepting that her current fitness to practise is impaired and confirming that she has no intention of returning to practise.
Submissions
17. The Presenting Officer submitted that the Voluntary Removal Agreement is an appropriate means of resolving the case against the Registrant. She submitted that voluntary removal is equivalent to a Striking Off Order and would therefore ensure public protection and maintain public confidence in the profession. She further submitted that voluntary removal would not be detrimental to the wider public interest. In addition, she drew to the Panel’s attention the relevant documents within the hearing bundle which highlighted the Registrant’s desire to be removed from the register, and confirmed that the HCPC was satisfied that the agreement for removal entered into between it and the Registrant was legally binding and in the public interest.
18. Although there were no formal written submissions from the Registrant, the Panel had sight of the communications between the HCPC and the Registrant in respect of the proposal for voluntary removal. It had also been provided with a letter from the Registrant dated 10 September 2020 in which she admitted the Allegation against her and confirmed she was not aware of any other matters which could give rise to any further allegations against her. She acknowledged that the HCPC would withdraw the Allegation to enable her to make a request for voluntary removal, and signed the voluntary removal agreement.
Decision
19. The Panel carefully considered all of the information provided to it in relation to the application for voluntary removal from the register, particularly the letter from the Registrant dated 10 September 2020 and the Voluntary Removal Agreement signed by both the HCPC and the Registrant. It also noted that the Registrant had not worked as a registered professional since her dismissal by the Trust in February 2017.
20. The Panel received advice from the Legal Assessor and noted that the Registrant is prevented from seeking to resign from the Register whilst subject to an Allegation, a Conditions of Practice Order or a Suspension Order. The Panel also took into account the guidance contained within the HCPTS Practice Note entitled ‘Disposal of Cases By Consent’ which, in respect of Voluntary Removal Agreement states:
“In cases where the HCPC is satisfied that it would be adequately protecting the public if the Registrant was permitted to resign from the Register it may enter into a Voluntary Removal Agreement allowing the registrant to do so, but on similar terms to those which would apply if the registrant had been struck off.”
21. The Panel noted that a panel of the Investigating Committee determined that there was a ‘case to answer’ and that the Registrant had fully admitted the Allegation and that her practise is currently impaired. The Panel also noted that as the Voluntary Removal Agreement mirrors the terms of a Striking Off Order, it would prevent the Registrant from practising as a Dietitian or using any title associated with that profession and would prevent her from making an application to be re-admitted to the register within 5 years.
22. The Panel had regard to the fact that, if this matter proceeded to a substantive hearing and the Allegation was determined to amount to the statutory ground of lack of competence, as opposed to misconduct, the maximum sanction would be a Suspension Order. It was satisfied that the circumstances of this case met the underlying purpose of removal by consent, which is to avoid unnecessary proceedings when the public interest can be met by a consensual disposal.
23. The Panel then went on to consider whether approving the voluntary removal of the Registrant from the register would provide adequate public protection or be detrimental to the wider public interest. It was conscious that if it concluded the removal would not adequately protect the public interest, the proposed voluntary agreement would have to be rejected, which would mean that the Allegation would continue to a substantive hearing before a differently constituted panel of the Conduct and Competence Committee. The Panel also considered the Registrant’s own interests in being voluntarily removed from the register.
24. Given the documentary evidence and the full admissions made by the Registrant, the Panel was satisfied that the Particulars of the Allegation were capable of being found proved on the balance of probabilities. The Panel took into account the extent of the support offered to the Registrant by the Trust over a three month period, and the wide-ranging deficiencies in the Registrant’s practice as a Dietitian which had the potential to put patients at risk of harm. It was however satisfied that the Allegation did not relate to reprehensible conduct incompatible with continued registration, and there was no indication that any patients were actually harmed as a result of the Registrant’s conduct.
25. The Panel determined that a panel conducting a substantive hearing would be likely to find that the Registrant’s fitness to practice is impaired. In addition, the Panel noted that the Registrant has made it clear that she has no expectation that she would ever seek to return to the profession and is fully aware of the consequences of voluntary removal, evidenced by the agreement entered into with the HCPC in respect of her voluntary removal from the register.
26. In considering whether removal of the Registrant’s name from the Register was proportionate the Panel noted that her conduct had the potential to damage the reputation of the profession and was likely to undermine public trust and confidence in the profession.
27. In all the circumstances, the Panel concluded that approval of the proposed agreement for voluntary removal is both proportionate and appropriate. The Panel also determined that there is a legitimate public interest in dealing with this matter efficiently and expeditiously by avoiding a substantive hearing given the full admissions made as to the facts and grounds of the allegation and the Registrant’s desire to be removed from the register and not return to the profession.
28. The Panel supported the disposal of this matter by consent and was satisfied that the professional disciplinary proceedings should be withdrawn.
Order
The Registrar is directed to remove the name of Ms Sandhya Yatham Venkataraman from the Register with immediate effect.
Notes
No notes available
Hearing History
History of Hearings for Mrs Sandhya Yatham Venkataramana
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 08/10/2020 | Conduct and Competence Committee | Voluntary Removal Agreement | Voluntary Removal agreed |