Mrs Diana Zuramskiene

Profession: Radiographer

Registration Number: RA78060

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 12/07/2021 End: 17:00 15/07/2021

Location: Virtual hearing via video conference

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation


Allegation (with amendments annotated)

Whilst As a registered as a Radiographer (RA78060) your fitness to practise is impaired by reason of your lack of competence. In that:

1. You did not demonstrate adequate the basic and/or appropriate skill and/or knowledge in respect of the correct use of equipment and/or examination of patients on:

a) 14 August 2018, during a foot radiograph and/or an elbow radiograph
b) 30 August 2018, in that you examined the wrong shoulder and omitted with a necessary large portion of the image missing
c) 31 August 2018, in that you performed an abdominal image on a woman of child bearing age without asking about her Last Menstrual Period
d) 10 September 2018, you:

i. did not carry out the appropriate projections on a patient which resulted in the image for the lateral lumbar spine being centred too high.
ii. you were unable to independently shown how to perform an examination on a patient with pains down the whole of the forearm to include the areas of concerns
iii. had used the wrong you were unable to use the equipment for an examination of a patient’s knee
e) 25 September 2018, you did not perform a lumber lumbar spine examination on a patient in accordance with the local protocol.

2. The matters set out in paragraph 1 a) to e) amounts to lack of competence.

3. By reason of your lack of competence your fitness to practise is impaired.

Finding

Preliminary Matters

Service

1. The Hearings Officer provided an unredacted copy of the service documentation to the Panel, which included a copy of the notice, an unredacted certificate of registration which contained the Registrant’s postal and email registered addresses. On 3 March 2021, the HCPC sent the notice of this hearing by email to the registered email address recorded for the Registrant. The notice contained the required particulars, including the date, time and venue, which was by video conference due to the pandemic.

2. The Panel was satisfied on the documentary evidence provided, that the Registrant had been given proper notice of this hearing in accordance with Rules 3 and 6 of the HCPC (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules).

Proceeding in absence of the Registrant

3. Mr Ferson, on behalf of the HCPC, applied for the hearing to proceed in the Registrant’s absence. He informed the Panel that the Registrant had sent an email to the HCPC, dated 23 January 2020, which was a response to the ICP investigation, in which she did not contest the matters. He also informed the Panel that the Registrant had submitted a proforma response to the allegations, dated 21 February 2020, in which she had stated that she did not intend to attend a final hearing or to be represented. Mr Ferson explained that there had been no communication from the Registrant since February 2020.

4. Mr Ferson submitted that the nature and circumstances of the Registrant’s absence amounted to a waiver of her right to attend and in the absence of cogent material to the contrary, the Panel should conclude that her absence was voluntary. She had not sought an adjournment and there was nothing to suggest that an adjournment would secure her attendance. The proforma stated that the Registrant did not intend to attend or be represented and there was nothing to indicate that her position had changed. In terms of the extent of the disadvantage to her in proceeding in absence, Mr Ferson submitted that the Panel had all the papers and could ask questions of the witnesses to mitigate against any potential unfairness. He submitted that it was in the public interest to proceed, as the matters dated back to 2018 and there would be a potential effect on the witnesses and their memory.

5. The Panel heard and accepted the advice of the Legal Assessor, who cited the cases of Haywood, Jones and Purvis [2001] EWCA Crim 168, R v Jones [2002] UKHL 5, and GMC v Adeogba; GMC v Visvardis [2016] EWCA Civ 162. She advised that the discretion to proceed in a Registrant's absence must be exercised with the utmost care and caution. It also had regard to the HCPTS Practice Note on proceeding in the absence of a Registrant.

6. The Panel was satisfied that the HCPC had fulfilled its obligations and taken all reasonable steps to serve the notice on the Registrant in accordance with Rule 11. In light of her responses in the proforma, dated 21 February 2020 and subsequent absence of communication with the HCPC, the Panel concluded that the Registrant had voluntarily absented herself, thereby waiving her right to attend. It did not consider that an adjournment would be likely to secure her attendance, and noted that in February 2020 she confirmed that she did not intend to be represented at any hearing. The Panel did not identify any prejudice in proceeding in her absence, and noted that four witnesses had been warned to give evidence. In all the circumstances, the Panel was satisfied that it was in the public interest to proceed with the case, in the Registrant’s absence, in order to resolve matters which dated back to 2018.

Application to amend the Allegation

7. Mr Ferson applied to amend the allegation. He explained that it was proposed to remove the statutory grounds from the stem, and allege a lack of competence at particular 2. He submitted that the other proposed amendments were to clarify the allegations and to set out the objective standard of having adequate knowledge and skill. He informed the Panel that notice of the HCPC intention to apply for amendments had been notified to the Registrant by letter, dated 14 February 2020, and the Registrant had not objected to the proposed amendments in her correspondence of 21 February 2020.

8. Mr Ferson submitted that there would be no prejudice to the Registrant as the proposed amendments did not change the substance of the allegation, but would better reflect the evidence.

9. The Panel, having heard and accepted the advice of the Legal Assessor, decided to allow the application to amend in its entirety. It was satisfied that they provided greater accuracy and clarity as to what was alleged against the Registrant and would better reflect the anticipated evidence. They would not materially change the substance of the allegations. Consequently, the Panel did not identify any prejudice to the Registrant in allowing the application.

Background

10. The Registrant obtained a four year Radiography degree in Lithuania and subsequently applied for registration on the HCPC Register as a Radiographer. She was admitted to the HCPC Register.

11. She commenced employment with the Swansea Bay University Health Board (the Board) within the Radiology Department at Singleton Hospital (the Hospital) on 13 August 2018 as a Band 5 Radiographer. On her first day of work, concerns were raised by colleagues with her Line Manager, VW, who instructed that the Registrant should not be left on her own and for the Superintendent of General Radiography, Colleague A, to monitor the Registrant’s practice. The Registrant was provided with an induction programme, but she did not pass it as she allegedly did not have the necessary knowledge.

12. As a result, a training programme was devised for the Registrant, which was similar to those implemented for student radiographers. During this period the concerns remained.

13. On 25 September 2018, the Registrant had an official assessment where the level of her alleged lack of knowledge was ascertained. Following this assessment, the Registrant’s Line Manager met with the Registrant on 26 September 2018 to discuss the outcome of the assessment and the Registrant was given a further four weeks to complete the general stage of the induction programme during which she would continue to receive additional support. During this time, the Registrant was not to work alone and was required to only attend to adults with a qualified Radiographer with her at all times. Shortly after the meeting of 26 September 2018, input was sought from the Human Resources Department, and the Capability Process was initiated.

14. On 24 October 2018, and 13 October 2018, further assessments were undertaken and the Registrant showed a slight improvement as she had learnt from the Radiographers around her but there were still issues with her practice.

15. Although the Registrant was pro-active and engaged fully with the support put in place, she remained unable to work unsupervised. After the Stage 1 Capability Hearing held on 12 December 2018, the Registrant looked for redeployment within the Histology Department, but this did not happen, through no fault of the Registrant.

16. With the support of VW, the Registrant then enrolled on an Assistant Practitioner Course run by Cardiff University, which on completion she would have reached the level of an Assistant Radiographer, and the Hospital would have looked to employ her at a Band 4 role in the Radiography Department. While undertaking the course, the Capability Process was not proceeded with and the Registrant continued as a Band 2 Assistant Practitioner in the Radiography Department. However, the Registrant did not successfully complete all of the components of the Assistant Practitioner course and subsequently resigned from her post.

Decision on Facts

17. On behalf of the HCPC, the Panel heard evidence from four witnesses:

• VW was employed as the Site Superintendent by the Board at the Hospital and managed the Radiology Service of the Hospital. She was also the Registrant’s Line Manager.
• Colleague A was a Superintendent Radiographer at the Hospital whose responsibilities included managing the radiographic team and supervising and teaching radiographers and student radiographers. She was appointed by VW on 14 August 2018 to ascertain the extent of the Registrant’s knowledge and capabilities with regards to examining patients and to determine the level of support the Registrant required in order for her to settle into the Department.
• Colleague C was an Advanced Practice Radiographer at the Hospital, whose role included being involved in the training and assessing of radiology students, ensuring that their technique, image quality and radiation safety was understood and maintained to the required standard.
• Colleague D was a Senior Diagnostic Radiographer at the Hospital, whose day-to-day role included: the general coordination of the imaging rooms, dealing with queries from general practitioners and other departments, working in accordance with radiation regulations, quality assurance, and assisting with training junior staff and students on their placement from university.

18. The Panel also received documentary evidence, including:

• VW’s referral to the HCPC, dated 7 September 2018;
• Relevant correspondence between the Registrant and the Hospital;
• A copy of the diary of events maintained by Colleague A regarding the Registrant, for the period from 13 August 2018 to 26 September 2018;
• A copy of the Induction Programme for Radiographers at the Hospital;
• A copy of the Registrant’s Lumbar Spine Assessment;
• Job descriptions for Band 5 and Band 4 radiography posts at the Hospital;
• A copy of the feedback from the academic supervisor at Cardiff University regarding the Registrant’s Clinical Assessment;
• A copy of the Registrant’s Clinical Assessment;
• A copy of the Board’s Capability Policy.

19. The Panel heard and accepted the advice of the Legal Assessor. It understood that the burden of proving each alleged fact rests on the HCPC. It further understood that the HCPC will only be able to prove an alleged fact if it satisfies the required standard of proof, namely the civil standard, whereby it is more likely than not that the alleged incident occurred.

20. At the outset of its deliberations, the Panel conducted an assessment of each of the witnesses who had given evidence. In respect of each of the witnesses, the Panel had considered they were highly qualified and professional Radiographers, all of whom had been clear, objective and detailed in their evidence, and their oral evidence had been consistent with the contemporaneous documentation and their written witness statements. Each had spent a considerable amount of time with the Registrant and had described a good working relationship with the Registrant who was hard working and eager to learn. The Panel was satisfied that the evidence of each witness was credible and could, therefore be relied upon.

Particular 1

You did not demonstrate adequate skill and/or knowledge in respect of the use of equipment and/or examination of patients on:

(a) 14 August 2018, during a foot radiograph and/or an elbow radiograph

21. The Panel finds particular 1(a) proved in respect of the elbow.

22. Mr Ferson, in his closing submissions, conceded that Particular 1(a), in respect of the foot was based on a reported concern of another member of staff who had not given evidence, was not capable of proof and so he did not pursue that aspect of the allegation.

23. The Panel noted that the reported concern was hearsay evidence. Whilst it was potentially admissible as hearsay, it was so inherently weak on its own, that the Panel gave little weight to it. It noted that the reported concern was what led Colleague A to invite the Registrant to undertake a radiograph of a patient’s elbow, which she observed. She relied on her contemporaneous diary entry and consequent witness statement regarding her observations of the Registrant taking the elbow radiograph.

24. Colleague A stated that the Registrant attended to an adult, GP patient who had walked-in with pain in their elbow, which she considered was one of the easier types of x-ray to perform, requiring two images, an anterior posterior (AP) view and a lateral view. Colleague A described that a cassette must first be placed under the area being x-rayed, but the Registrant failed to put the cassette under the patient’s elbow which meant that it was missing the elbow completely. Colleague A described that the cassette is what the image comes out on, and at that point, she moved the cassette under the patient’s arm and took over performing the x-ray. Colleague A described the situation as like teaching a first year student because the Registrant did not know the position that the elbow needed to be in or the centring point for the elbow, or how to perform the x-ray. Colleague A said that she had to position the cassette, show the Registrant how to position the elbow, position the tube and choose the correct exposure for the image. It was Colleague A who actually took the image in this case.

25. In light of the evidence of Colleague A, the Panel was satisfied to the required standard that the Registrant had not demonstrated either the adequate skill or knowledge in both using the equipment itself, or in the examination of the patient.

Particular 1

You did not demonstrate adequate skill and/or knowledge in respect of the use of equipment and/or examination of patients on:

(b) 30 August 2018, in that you examined the wrong shoulder and omitted a necessary portion of the image

26. The Panel finds Particular 1(b) proved.

27. The Panel had regard to the evidence of Colleague C, who told the Panel that on 30 August 2018, the Registrant approached him to ask if she could x-ray an adult female patient for a left shoulder and thoracic and lumbar spine. Having vetted the request form, Colleague C was satisfied that there was sufficient information to require an x-ray. He explained that he conducted the thoracic and lumbar spine x-ray himself, talking the Registrant through the process. When it came to the patient’s shoulder x-ray, as the Registrant had previously performed such x-rays she was happy to proceed with this unassisted. Colleague C explained that student radiographers are also permitted to perform shoulder x-rays and as the Registrant was in the role of a Band 5 Radiographer, he considered that it was an x-ray she should have been capable of performing.

28. Colleague C explained that the Registrant called him to check the images that she had taken. Upon checking them, he identified that firstly the wrong shoulder had been x-rayed, and secondly, much of the anatomy required for a shoulder x-ray had been omitted from the image. He said that there were ‘regions of interest’ which needed to be included for each type of x-ray so that an accurate diagnosis could be made. In respect of a shoulder x-ray, colleague C said that the clavicle needed to be included so that a doctor could rule out any fracture of the bone, but in the Registrant’s x-ray, at least half of the clavicle was not included so the doctor would not be able to rule out whether there was arthritis in the area or any other potential injury. Colleague C said that he did not think that the Registrant realised that she had made these mistakes until they were pointed out to her.

29. In light of the evidence of Colleague C, the Panel was satisfied to the required standard that the Registrant had not demonstrated either the adequate skill or knowledge in both using the equipment itself, or in the examination of the patient.

Particular 1

You did not demonstrate adequate skill and/or knowledge in respect of the use of equipment and/or examination of patients on:
(c) 31 August 2018, in that you performed an abdominal image on a woman of child bearing age without asking about her Last Menstrual Period
30. The Panel finds Particular 1(c) proved.

31. The Panel had regard to the evidence of Colleague D. She stated that for every female patient between the ages of 12 and 55, a Radiographer should always check when the last menstrual period (LMP) occurred if imaging an area between the diaphragm and the knees. The reason for the LMP check is to ensure that females of a childbearing age are not pregnant as radiation can cause damage to unborn foetuses. She said that on every Radiology Request Form there was a disclaimer for the Radiographer to fill in when x-raying a patient of childbearing age. The Radiographer should ask the patient to fill in a form stating whether or not she is pregnant and the date of the LMP. The Radiographer would then countersign the form to confirm that they were authorising the exposure of radiation, whether the patient was pregnant or not, and, depending on the importance of the x-ray required, whether the risks and benefits of the radiation dose had been explained to the patient (even if they were pregnant).

32. Colleague D said that on 31 August 2018, the Registrant was attending to an adult female of childbearing age, and took the abdominal x-ray. Colleague D then discovered that the LMP check had not been undertaken before the x-ray had been performed. She said that once she noticed that the LMP check had not been done she asked the Registrant if she had checked the LMP and the Registrant told her that she had not checked it. They then both went to the patient to ask her to confirm her LMP and that she was not pregnant, which the patient did. After the x-ray colleague D asked the patient to sign the disclaimer and Colleague D countersigned it to ensure completeness.

33. In light of the evidence of Colleague D, and the Registrant’s admission to Colleague D, the Panel was satisfied to the required standard that the Registrant had not demonstrated the adequate skill or knowledge in the examination of the patient.

Particular 1

You did not demonstrate adequate skill and/or knowledge in respect of the use of equipment and/or examination of patients on:

(d) 10 September 2018, you:

i. did not carry out the appropriate projections on a patient which resulted in the image for the lateral lumbar spine being centred too high.

34. The Panel finds Particular 1(d)(i) proved.

35. The Panel had regard to the evidence of Colleague A. She told the Panel that on 10 September 2018, the Registrant performed an x-ray on a 13 year old out-patient, for whom the Consultant had requested a lateral x-ray. Colleague A described that the Registrant took the x-ray and asked Colleague A to check the image. Upon checking the image, Colleague A discovered that it was not a true lateral image as it had been centred too high and there was a lot of upper spine on the x-ray but the clinician would have been looking at the patient’s lower spine.

36. In light of the evidence of Colleague A, the Panel was satisfied to the required standard that the Registrant had not demonstrated the adequate skill or knowledge in the examination of the patient.

ii. you were unable to independently perform an examination on a patient to include the areas of concerns
37. The Panel finds Particular 1(d)(ii) proved.

38. The Panel had regard to the evidence of Colleague A, that the next patient seen by the Registrant was an adult with pains down the whole of her forearm, requiring a left wrist and elbow x-ray. Colleague A said that she thought that the Registrant was going to take separate x-rays of the wrist and elbow, which would necessitate four images, and consequently four doses of radiation. She instructed the Registrant to take a forearm view, which would give a view of the whole wrist and arm and require only two images and therefore two doses of radiation.

39. Colleague A said that in order to undertake an x-ray of the forearm, a Radiographer would need to adjust the focus on the machine from fine to broad, but the Registrant did not know about the focus button or why Colleague A had altered it from fine to broad. This caused Colleague A to have concerns about the Registrant’s knowledge of the equipment or knowing how and why to adjust the focus. Colleague A said that the Registrant asked her how to conduct the x-ray and so Colleague A explained to her how to do it, after which the Registrant was able to take the x-rays.

40. The Panel bore in mind that Colleague A had to explain to the Registrant the need to alter the focus from fine to broad and to show her how to do it, as well as to explain how to take the x-rays. Therefore, the Panel was satisfied that the Registrant was unable to independently perform the examination to include the areas of concern and required instruction in order to do so. Consequently, the Panel was satisfied to the required standard that the Registrant had not demonstrated either the adequate skill or knowledge in both using the equipment itself, or in the examination of the patient.

iii. you were unable to use the equipment for an examination of a patient’s knee

41. The Panel finds Particular 1(d)(iii) proved.

42. The Panel had regard to the evidence of Colleague A, that the next patient seen by the Registrant was for a knee x-ray. She described that the Registrant was very good at performing knee x-rays as she had been taught by the Radiographers in the Hospital how to do so. However, on this occasion, the Registrant was not successful in undertaking a lateral image. Colleague A explained that the Registrant attempted to angle the static tube head but did not realise that it did not make a difference and the Registrant could not understand why her lateral knee image was not correct. Colleague A said that the Registrant did not know that she needed to adjust the two directions of the tube as well as rotating it around its axis in order to obtain a lateral image. Colleague A explained that the image obtained by the Registrant was not passable and had to be repeated, meaning that the patient was exposed to more radiation than needed as a result.

43. In light of the evidence of Colleague A, the Panel was satisfied to the required standard that the Registrant had not demonstrated either the adequate skill or knowledge in both using the equipment itself, or in the examination of the patient.

Particular 1

You did not demonstrate adequate skill and/or knowledge in respect of the use of equipment and/or examination of patients on:

(e) 25 September 2018, you did not perform a lumbar spine examination on a patient in accordance with the local protocol.

44. The Panel finds Particular 1(e) proved.

45. The Panel had regard to the evidence of Colleague A, who had recorded in her contemporaneous diary of events, that on 25 September 2018, the Registrant had asked Colleague G if she could perform a lumbar spine examination on an adult patient, who was under the age of 55. Colleague A explained that under the Board’s protocol, if a patient was under the age of 55, then only a lateral projection (x-ray) should be undertaken.

46. Colleague A explained that Colleague G had attended on the Registrant and the patient, and had seen an AP view on the monitor which she explained to the Registrant was an image that was not needed. Colleague A stated that the Registrant had taken the image. Although Colleague A was not present when the x-ray was taken, she spoke to the Registrant about it afterwards and the Registrant told her that she had not heard Colleague G tell her that the image was not needed.

47. The Panel was satisfied that it could place weight on the hearsay evidence of Colleague G, because it was contemporaneously recorded by Colleague A in her diary, and was supported by the fact that Colleague A had spoken to the Registrant about it. In that conversation it became apparent to Colleague A that the Registrant was not aware of the protocol requirements.

48. In light of the evidence of Colleague A, the Panel was satisfied to the required standard that the Registrant had not demonstrated the adequate skill or knowledge in the examination of the patient.

Decision on Grounds

49. The Panel next considered whether the matters found proved, amounted to a lack of competence on the Registrant’s part, and if so, whether by reason thereof, her fitness to practise is currently impaired.

50. The Panel considered the submissions made by Mr Ferson on behalf of the HCPC. He submitted that the particulars represented a fair sample of the Registrant’s work. He submitted that the standard of the Registrant’s work was unacceptably low and this was underpinned by the four Radiographers, all of whom had worked with the Registrant and had all given evidence and concluded that she was not up to the standards of a Band 5 Radiographer. He submitted that the Registrant had not achieved a large number of the HCPC Standards of Proficiency for Radiographers.

51. The Panel bore in mind that the Registrant had accepted the following in her email to the HCPC, dated 23 January 2020.
I started to work as a radiographer in Singleton hospital in August, 2018.

“It was clear it was a lack of competence as soon as I started to work. As a result my manager and I we had meetings, in order to decide which option would be the best for me. In January, 2019 I became a health support worker, band 2. I was not radiographer anymore. Also I started to do Assistant Practitioner course at Cardiff University in January, 2019. When I pass my exams I will become a band 4 Assistant Practitioner at Singleton Hospital.”

52. The Panel heard and accepted the advice of the legal assessor. In her advice she cited the cases of: Calhaem [2007] EWHC 2606 (Admin) and Holton v GMC [2006] EWHC 2960. The Panel was aware that any finding of a lack of competence was a matter for the independent judgement of the Panel.

53. The Panel approached the question of whether the facts found proved amounted to a lack of competence by asking itself firstly whether it had a fair sample of the Registrant’s work by which to assess her level of competence, and secondly whether the standards attained by the Registrant were unacceptably low when measured against the standards of a reasonably competent Radiographer.

54. In relation to whether the evidence represented a fair sample of the Registrant’s work, the Panel noted that the particulars related to seven patients and occurred within the period from 14 August 2018 to 25 September 2019. Whilst on one view this was a relatively short time frame and a relatively small number of x-rays, the Panel considered them within the context of the Registrant’s practice. It noted that the Registrant was a newly qualified Radiographer, and the post at Singleton Hospital was her first employment as a Radiographer since her registration with the HCPC. The time frame was the entirety of her practice as a Band 5 Radiographer and she had been consistently monitored throughout the whole of that time due to the serious concerns about her lack of knowledge and practical training. The seven x-rays were representative of a range of patients, including females of childbearing age and children, as well as being of different body parts. The Panel was satisfied that in the context of the Registrant’s practice, the particulars represented a fair sample of her work.

55. In relation to whether the standard of the Registrant’s work was unacceptably low, the Panel had regard to the evidence of each of the four Radiographers who had given evidence. Each of them had identified that there was an extensive deficit in the Registrant’s knowledge and training following her degree course in Lithuania compared to that which would be provided by a UK university degree. Concerns had been identified from the Registrant’s first day and the significant support and training given by fellow Radiographers at the Hospital, in particular Colleague A, did not compensate for that extensive deficit.

56. Following the first incident on 14 August 2018, Colleague A concluded that a qualified member of staff was required to check all projections (x-rays) performed by the Registrant and, where necessary, should intervene. Colleague A ensured that a member of staff checked whether an image performed by the Registrant should pass as the Registrant had no knowledge of what an acceptable or passable image for diagnostic purposes, should look like. Consequently, each x-ray produced by the Registrant, had to be checked by a qualified member of staff before it could be passed to a Radiologist for reporting.

57. Both VW, the Registrant’s Line Manager, and Colleague A described the level that the Registrant achieved as being comparable to that of a first year radiography student, and not to a Band 5 Radiographer. In September 2018, Colleague A arranged for the Registrant to be assessed by a clinical supervisor at Cardiff University. His feedback was as follows:
I observed [the Registrant] over the period of about 2 hours whilst working with the student AP and a 2nd year student – unfortunately they both demonstrated more confidence and competence during that time.

[The Registrant] was supervised when examining patients, and whilst she seems to have some basic skills, she could not adapt her technique or approach to deal with any patient limitations. I was unable to directly engage with her, and felt it inappropriate to do so; however I don’t think she would be safe working alone.

In comparative terms, she was below the clinical reasoning and adaptive skill level of the second year student (level 5), so a good way off the standard of a graduate from our programme; the trainee Assistant Practitioner (equivalent level 4) had better clinical reasoning skills, however she is an exceptional candidate.

I would assess [the Registrant] to be at practical level 4/5 (1st/2nd year undergraduate) but with a theoretical knowledge of a lower level 4 student (1st year undergraduate) – though I am aware she has been found to have even more limited radiation protection and anatomical understanding.

58. In light of all the evidence, the Panel had regard to the HCPC Standards of Proficiency for a reasonably competent Radiographer and considered that the Registrant had not achieved the following Standards:

• 1 - be able to practise safely and effectively within their scope of practice
• 2.5 - know about current legislation applicable to the work of their profession
• 4 - be able to practise as an autonomous professional, exercising their own professional judgement
• 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.

59. In all the circumstances, the Panel concluded that the Registrant had not achieved the Standards expected of a reasonably competent Radiographer, as judged against a fair sample of her work. As such, in the Panel’s judgement, the facts found proved amount to a lack of competence on the Registrant’s part. The Panel concluded that the Registrant’s lack of competence is sufficiently serious to lead the Panel to a consideration of whether or not her fitness to practise is currently impaired by reason of that lack of competence.

Decision on Impairment

60. Having determined that the Registrant's actions amounted to lack of competence in respect of the facts found proved, the Panel went on to consider whether her fitness to practise was currently impaired as a consequence of that lack of competence.

61. The Panel heard and accepted the advice of the Legal Assessor. It had regard to the HCPC's Practice Note on impairment, and in particular the two aspects of impairment, namely the ‘personal component’ and the ‘public component’, based on the case of Cohen v GMC [2008] EWHC 581 (Admin). The Panel was aware that consideration of impairment only arises in the event that the Panel judges that the facts found proved do amount to a lack of competence and that what has to be determined is current impairment, that is looking forward from today.

62. In relation to remediation, the Panel firstly considered whether the Registrant’s lack of competence was capable of remediation. Given that the lack of competence related to clinical practice, and the Registrant had been engaged and hard working in Singleton Hospital’s efforts to assist her gain competency, the Panel considered that the lack of competence was capable of remediation. However, the Panel also bore in mind that there was an extensive deficit in the Registrant’s knowledge; she had received significant support and training in the role; and she had subsequently not passed the Assistant Practitioner course at Cardiff University to achieve a Band 4 Assistant Practitioner qualification. In these circumstances, the Panel was of the view that it may be unlikely that the Registrant would be capable of remediating her lack of competence.

63. The Panel next considered whether the Registrant had taken remedial action to address her lack of competence. It noted that she had started to take such steps by enrolling on the Assistant Practitioner course at Cardiff University, and in July 2019 had been described as doing well in her studies and it was hoped she would complete the course in January 2020 to achieve a Band 4 Assistant Practitioner post. However, VW had told the Panel that the Registrant had successfully completed three out of four of the components of the course, but had not passed the final component and had resigned from her post and gone back to Lithuania. The Panel was mindful that it had no information regarding the Registrant’s current position, in particular whether she was still in the field of radiography and was taking steps to address the significant deficit in knowledge and practical training. In the absence of any engagement and therefore information from the Registrant since February 2020, the Panel concluded that it did not have evidence to demonstrate that the Registrant had remediated her lack of competence.

64. In relation to insight, the Panel was of the view that the Registrant had some insight in that she recognised and accepted that she was below the required standards. She had understood that her university course undertaken in Lithuania had not equipped her with sufficient knowledge or practical experience to practise competently as a registered Radiographer. Colleague A had described that the Registrant would apologise to staff for not being at the required level and needing so much support. However, the Panel considered that from the evidence, it did not appear that she fully understood the potential risk to patients, resulting from her lack of competence. In addition, Colleague A and VW had explained that the Registrant ‘did not know what she did not know’, and this indicated to the Panel that she did not fully appreciate the extent of the deficit in her knowledge, or the level of remedial action required in order to meet the required level of competency.

65. In the absence of fully developed insight and remediation, the Panel concluded that there remained a high risk of repetition, which in turn exposed patients to a risk of harm. Those risks included unnecessary doses of radiation if x-rays needed to be repeated due to not being diagnostic, or because projections were not appropriately taken to sufficiently cover the areas of concern. They also included exposing foetuses to radiation, if the required checks had not been made of women of childbearing age.

66. The Panel acknowledged that the Registrant had not set out to cause harm, and it was not a question of recklessness or negligence on her part. Each of the witnesses had been clear that she had been a hard working member of the Department who was eager to learn, and picked up some aspects of the role quickly. The issue was that the university degree that the Registrant had obtained in Lithuania had not equipped her for the level of a Band 5 Radiographer registered with the HCPC. The Panel concluded that the deficit in respect of both her knowledge and practical experience, was so great that the Registrant was not able to achieve the required level, even with the extensive support and commitment of the Radiographers throughout her employment.

67. In all the circumstances, the Panel concluded that the Registrant’s fitness to practise is currently impaired in respect of the personal component.

68. In relation to the public component, the Panel was of the view that members of the public need to have confidence that Radiographers are able to act independently and autonomously, without every aspect of their work having to be checked. The Panel concluded that public confidence in the profession would be undermined if no finding of current impairment were made in the particular circumstances of this case.

69. Accordingly, the Panel concluded that the Registrant’s fitness to practise is currently impaired in respect of the public component.

Decision on Sanction

70. Having determined that the Registrant’s fitness to practise is currently impaired by reason of her lack of competence, the Panel next went on to consider whether it was impaired to a degree which required action to be taken on her registration. The Panel took account of the submissions of Mr Ferson on behalf of the HCPC. It also had regard to all the evidence it had heard, and all of the material previously before it.

71. The Panel heard and accepted the advice of the Legal Assessor and it exercised its independent judgement. It bore in mind the Sanctions Policy (the Policy) and considered the sanctions in ascending order of severity. The Panel was aware that the purpose of a sanction is not to punish but to protect members of the public and to safeguard the public interest, which includes upholding professional standards within the profession, together with maintaining public confidence in the profession. It therefore understood that it must impose the least restrictive sanction to address those risks which it had identified. It further understood that as this was a case of lack of competence, the most severe sanction available to it today was a Suspension Order.

72. In light of the Panel’s conclusions that the risk of repetition was high, which in turn posed a potential risk of harm to patients, the Panel did not consider that the options of taking no further action or mediation were appropriate to protect the public or to safeguard the wider public interest. The Panel bore in mind that neither option would restrict the Registrant’s practice, and so neither option was sufficient to protect against the high risk of repetition identified or to maintain public confidence in the profession.

73. The Panel next considered a Caution Order, and bore in mind that such an Order would not restrict the Registrant’s practice and so would not protect the public or the wider public interest. In addition, the Panel had regard to paragraph 101 of the Sanctions Policy and did not consider that any of the factors which might indicate that a Caution Order was appropriate were applicable in this case. In particular, the Panel considered that the lack of competence was serious and wide-ranging with a consequent risk of harm to patients; there was a high risk of repetition; the Registrant had not shown a ‘good level of insight’; and she had not provided evidence of appropriate remediation.

74. The Panel next considered whether the imposition of a Conditions of Practice Order was the appropriate and proportionate response in this case. The Panel noted its earlier observations that whilst the lack of competence related to clinical practice and so was potentially remediable, it had concluded that the Registrant may not be capable of achieving remediation. Further, given the absence of information about the Registrant’s present circumstances, the Panel did not consider that it was able to accurately assess the current level of her insight or competence to determine whether conditions would be sufficient to protect the public or safeguard the wider public interest. The Registrant had not engaged with the regulatory process since February 2020. The Panel did not, therefore, consider that it was possible to formulate workable, measurable and verifiable conditions which would both protect the public and the wider public interest. In addition, in the absence of engagement, the Panel was not confident that the Registrant would be either willing or able to comply with conditions.

75. The Panel next considered whether a Suspension Order was the appropriate and proportionate response. Given that it had concluded that a Conditions of Practice Order was not sufficient to protect the public against the risks which it had identified, or to maintain public confidence in the profession, the Panel concluded that a Suspension Order was the only sufficient sanction in the circumstances of the Registrant’s lack of competence. It also noted that the Sanctions Policy identified that a Suspension Order was likely to be appropriate where there were serious concerns which could not reasonably be addressed by a Conditions of Practice Order.

76. The Panel determined to impose a Suspension Order for a period of 12 months. Given the wide ranging and serious concerns, the extent of the deficit in the Registrant’s knowledge and practical experience, the high risk of repetition, and the lack of engagement from the Registrant, the Panel considered that this length, the maximum, was required in order to protect the public and to safeguard the wider public interest.

Order

The Registrar is directed to suspend the registration of Ms Diana Zuramskiene for a period of 12 months from the date that this Order comes into effect.

Notes

Interim Order:

1. Mr Ferson applied for an Interim Suspension Order to cover the appeal period before the substantive Suspension Order comes into effect, or if the Registrant appeals, until such time as the appeal is withdrawn or otherwise finally disposed of. He explained that as the Panel had determined that there was a high risk of repetition, an Interim Suspension Order was necessary to protect the public, and was otherwise in the public interest. He confirmed that the original notice of hearing put the Registrant on notice that an Interim Order may be applied for if the allegation was well founded and a restrictive sanction was imposed.

2. Having heard and accepted the advice of the Legal Assessor, the Panel was satisfied that an Interim Order was necessary to protect the public for the same reasons as set out in the substantive decision, in particular having found that the Registrant has not remediated her lack of competence, so there was a high risk of repetition, leading to a consequent potential risk of harm to patients. The Panel was satisfied that an Interim Order was also required in the wider public interest to maintain public confidence in the profession and uphold standards for the same reasons as set out in the substantive decision.

3. Having concluded that an Interim Order is necessary, the Panel considered what type of Interim Order to impose. For the same reasons as set out in the substantive decision, the Panel was satisfied that an Interim Suspension Order was the only appropriate and sufficient response, in order to protect the public and the wider public interest.

4. In all the circumstances the Panel decided to make an Interim Suspension Order for a period of 18 months. In deciding this length, it took account of the fact that any appeal may take a considerable period of time.

Hearing History

History of Hearings for Mrs Diana Zuramskiene

Date Panel Hearing type Outcomes / Status
13/07/2022 Conduct and Competence Committee Review Hearing Suspended
12/07/2021 Conduct and Competence Committee Final Hearing Suspended
16/12/2020 Conduct and Competence Committee Voluntary Removal Agreement Adjourned
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