Charles Edmonds

Preliminary matters

1. The case for the Health and Care Professions Council (HCPC) was presented by Mr Sam Smart of Kingsley Napley Solicitors. The Registrant was not present nor represented at the hearing. His representatives, Thompsons Solicitors, submitted written representations in which the Registrant denied the allegation. His representatives also confirmed that the Registrant had health issues, was now retired and that neither they nor the Registrant would be attending the hearing.

2. Mr Smart made an application under Rule 10(1)(a) of the HCPC (Conduct & Competence) (Procedure) Rules 2003 (“the Rules”) for any references to the Registrant’s health to be considered in private. The Panel accepted the advice of the Legal Assessor and considered the Practice Note on Conducting Hearings in Private. The Panel concluded that the right of the Registrant to protection of his private life and confidentiality of his health issues outweighed the general presumption of hearings being conducted wholly in public and agreed to consider any evidence in relation to the Registrant’s health in private.

3. The Panel was satisfied that notice had been properly served on the Registrant in accordance with Rules 3 and 6, having had sight of an email sent to the Registrant’s registered email address on 16 June 2022. The Panel also had sight of correspondence between the HCPC and the Registrant’s representatives from which it is clear that the Registrant is aware of these proceedings

4. Mr Smart, on behalf of the HCPC, made an application for the hearing to proceed in the Registrant’s absence in terms of Rule 11. He made reference to the correspondence between the HCPC and the Registrant’s representatives from which it was clear that the Registrant was aware of the hearing and had stated that he would not be attending as a result of a long-term illness which was unlikely to resolve itself, although no independent verification or medical evidence had been submitted. He advised the Panel that there were four witnesses in this case and that the Registrant had taken legal advice and decided not to attend. He stated that any disadvantage to the Registrant was a just consequence of this decision and that the Panel had the ability to make any points on the Registrant’s behalf.

5. In reaching its decision, the Panel has had at the forefront of its consideration that the discretion to proceed in the absence of the Registrant is one that must be exercised with the utmost care and caution. The Panel also accepted the advice of the Legal Assessor and had regard to the guidance as set out in the HCPTS Practice Note “Proceeding in Absence”.

6. The Panel determined that it was reasonable and in the public interest to proceed with the hearing for the following reasons:

i. The Panel noted that the Registrant’s representatives sent an email to HCPC, dated 22 July 2022, in which they referred to the Registrant’s ill-health and stated, “We will not be looking for an adjournment as this is a long-term illness that is not likely to resolve itself. This matter has been ongoing for some 10 years and the registrant is keen to not have it hanging over him any more as this too is contributing to his ill-health”;

ii. The Panel also considered the written submissions to the Panel in which the Registrant’s representatives stated, “We wish to make it clear that he is fully aware that this hearing will proceed in his absence. It is submitted to the panel that postponing these proceedings will not result in the attendance of the Registrant as he has general on-going ill health and owing to his age, he no longer feels confident or strong enough to attend and give evidence on this matter”;

iii. There has been no application to adjourn or indication from the Registrant that he would be willing or able to attend on an alternative date and therefore re-listing this hearing would serve no useful purpose. The Registrant’s representatives have confirmed that the Registrant’s health condition is a long-term condition and that he does not wish the matter to be adjourned to enable him to attend;

iv. The HCPC has made arrangements for four witnesses to give evidence during the hearing. In the absence of any reason to re-schedule the hearing, the Panel was satisfied that the witnesses should not be inconvenienced by an unnecessary delay and given the age of the allegations, the Panel is of the view that there should be no further delay in this matter;

v. The Panel recognised that there may be some disadvantage to the Registrant in not being able to give evidence or make oral submissions. However, the Panel noted that he has provided written submissions with the assistance of his legal representatives, and responses in the internal investigations which are included within the HCPC bundle of documents and which may go some way to mitigate any potential disadvantage to the Registrant; and

vi. As this is a substantive hearing there is a strong public interest in ensuring that it is considered expeditiously. It is also in the Registrant’s own interest that the allegation is heard as soon as possible.

7. In the course of its deliberations, the Panel identified two minor typographical errors in the allegation as follows: particular 5a) the word "patients" required an apostrophe and particular 16a) the word "lumar" should read "lumbar". The Panel raised these matters with Mr Smart on resuming in public session and Mr Smart thereafter made an application to amend these particulars to correct the typographical errors.

8. The Panel considered the application together with the advice of the Legal Assessor. The Panel agreed to grant the application as it was satisfied that it corrected typographical errors and did not cause any injustice to the Registrant.

Background

9. The Registrant is a Physiotherapist who was employed as a Band 7 Physiotherapist within the Argyll and Bute & Social Care Partnership NHS Highland in the Learning Disability Team. The Registrant’s role was split: four days a week he provided specialist physiotherapy services to adults with learning disabilities and one day a week he worked in musculoskeletal (‘MSK’) outpatients.

10. In August 2015, concerns were raised about the Registrant’s practice. The Registrant was suspended pending an investigation. DL was asked to investigate these concerns and he subsequently completed his report in January 2017. A referral was made to the HCPC by his employer.

11. A meeting was held to facilitate the Registrant’s return from suspension on 23 March 2017, where a process was discussed to assist with a supported improvement plan and develop a timetable for implementation. The Registrant did not comply with the agreed actions and this culminated in a further suspension from duty on 21 September 2017 and a further investigation. PC was subsequently requested to conduct this further investigation, which commenced in November 2017.

12. At its meeting on 10 September 2019, a Panel of the HCPC’s Investigating Committee determined that there was a case to answer in relation to an allegation of impairment of the Registrant’s fitness to practise. The Panel therefore confirmed the allegation against the Registrant as set out above.

Decision on Facts

13. The Panel heard oral evidence from four witnesses on behalf of the HCPC: DL, Professional Lead Physiotherapist; PC, Team Community Physiotherapist; NG, Team Community Physiotherapist and GB, an Advanced Practitioner Physiotherapist, all of whom were employed by the National Health Service (NHS) Highland in the Argyll and Bute Areas Trust (“the Trust”) at the time of the allegations. The Panel also considered the Registrant’s written submissions (in which he made specific references to particulars 1, 2, 3, and 4) and his responses in the course of the investigatory processes which were included within the bundle.

Particulars 1a)i) and 1a)ii)

14. The Panel heard evidence from DL in support of this particular. The Panel also had sight of Patient A’s case notes from the assessment undertaken on 18 June 2015 and the Consultant Surgeon’s referral for physiotherapy which was received on 19 May 2015. DL gave evidence that he was asked to investigate a number of allegations about the Registrant’s practice and behaviour in 2015, during which he reviewed patient notes that the Registrant had completed in relation to his MSK caseload. He stated that in Patient A’s notes, the Registrant documented that he conducted an initial assessment on 18 June 2015 in the course of which he tested Patient A’s hip flexion at 110 degrees and internal (medial) rotation of the hips between 25 and 30 degrees. He gave evidence that, in doing so, there was a risk that the Patient's hip could have dislocated due to the reduced integrity of the hip joints in patients with Perthes. He told the Panel that high degrees of flexion and internal rotation are both movements which increase the risk of hip dislocation and that the referring Consultant Surgeon had requested that the physiotherapist avoid flexion over 90 degrees of his leg and lateral rotation of the hip.

15. In his written submissions to the Panel, the Registrant has stated that from what he recollected, Patient A was young, fit and had no issues with the level of care he provided. He also stated that the patient regularly swam and ran, and so to rotate his hips in the manner done would not have caused any harm. His written submissions also stated that “Patients A and B are from the first investigation and this matter was resolved. The Registrant was thereafter invited back to work”.

16. DL is an experienced Professional Lead Physiotherapist who gave clear and consistent evidence, whose evidence is supported by the patient case notes and his investigation report. The Panel accepts his evidence that the Registrant tested Patient A’s flexion at 110 degrees and internal (medial) rotation of the hips to between 25 and 30 degrees, as supported by the case notes. The Panel also accepts DL’s evidence that in doing so, there was a risk of dislocation. With regard to the Registrant’s assertion that Patient A was a young and fit man who undertook exercise, the Panel concluded that this would not justify the Registrant acting contrary to the instructions of the Consultant Surgeon. The Panel therefore finds the facts of particulars 1a)i) proved on the balance of probabilities.

17. The Panel had regard to the terms of the Consultant Surgeon’s referral which states “Please avoid flexion >90 degrees and lat rotation of the hips”. There is no instruction in relation from the Consultant Surgeon in respect of internal (medial) rotation. The Panel therefore finds the facts of particular 1a)ii) proved on the balance of probabilities only in respect of testing Patient A’s hip flexion at 110 degrees.

Particular 1b)i) and ii)

18. DL gave evidence that following this assessment, the Registrant gave Patient A a Home Exercise Programme (HEP) sheet with diagrams highlighting the exercises to be completed and it was documented that the hip exercises were demonstrated and the patient was instructed to do them 1-2 times daily. He stated that exercise 2 showed an exercise in lying whereby the patient is asked to pull one knee at a time to their chest and that this exercise would require flexion of the hip to over 90 degrees. He told the Panel that exercise 3 showed an exercise in lying where the patient was asked to bend and drop their knees together to their left and right alternatively. He further stated that this exercise required lateral rotation of the hip and that elements of the HEP directly contravened the instructions in the Consultant Surgeon’s referral.

19. DL also gave evidence that the HEP had a patient identification sticker on the sheet and the notes reference a home exercise programme. He stated that the HEP programme itself was not dated and that it would be normal practice to provide a copy to the patient and keep a copy with the physiotherapy notes. He told the Panel that the copy with the physiotherapy notes appeared to be a photocopy which would suggest that there was an original version somewhere and that there were a number of handwritten comments on the sheet but none of them related to limiting flexion.

20. The Panel also had sight of the Consultant Surgeon’s referral received on 19 May 2019 and Patient A’s case notes which contained the Home Exercise Programme.

21. In the course of the Trust’s internal investigation, it is documented that when asked about the above concerns, the Registrant stated that he could not be sure that he had given the HEP to Patient A. He further stated that he may have instructed Patient A to limit flexion to 90 degrees when the sheet was provided.

22. The Panel accepts the evidence of DL that exercises 2 and 3 of the HEP devised by the Registrant contravened the instructions from the referring Consultant Surgeon. In reaching this conclusion, the Panel has had regard to the patient case notes and the Consultant Surgeon’s referral letter which support DL’s evidence. The Panel therefore finds the facts of particulars 1b)i) and 1b)ii) proved on the balance of probabilities.

Particulars 2a) and b)

23. The Panel heard evidence from DL in support of this. DL gave evidence that Patient B self-referred requesting physiotherapy input for lower back pain on 6 July 2015 and was assessed by the Registrant on 20 July 2015. Having reviewed Patient B's notes, he stated that he was concerned that during that assessment the Registrant had highlighted a number of positive answers to red flag questions. He explained to the Panel that red flags are features from a patient's subjective and objective assessment which can indicate a higher risk of serious pathology and may warrant referral for further diagnostic testing or caution during treatment.

24. DL told the Panel that Patient B had four red flags: lower limb weakness, pain at night, pain on coughing and sneezing and gait disturbance, and that these presentations could have indicated malignancy. He stated that once red flags like these are identified, the physiotherapist should become suspicious of underlying neurological issues or malignancy. He further stated that there was no record of the Registrant referring Patient B to anyone or discussing his findings with a colleague and that there was nothing documented in the notes to explain why these red flag features were apparently ignored.

25. The Panel also had sight of Patient B’s notes from the assessment on 20 July 2015 from which it can be seen that there were four red flags identified and there was no further/onward referral or record of having taken these into account in the assessment. In addition, the Panel had sight of a copy of the Highland Lumbar Spine Pathways, a standardised tool which helps identify risks to patients presenting with back pain and which includes a pathway on the management of red flags. The pathway in the document states “discuss with a senior colleague with a view to onward referral to A&E for immediate consult”. From this, it is clear that the Registrant should have discussed this with a senior colleague or recorded the clinical justification in his notes as to why he did not do so.

26. In the course of the Trust’s internal investigation, the Registrant was unable to state during interview whether he had made an onward referral and he was also unclear on whether he would have taken further action, based on the information provided.

27. The Panel accepts the evidence of DL which was supported by the patient notes and by the NHS Highland Lumbar Spine Pathways and finds that the Registrant did not refer Patient B to their GP or to A&E for further investigation and did not make any record in the patient notes and therefore finds the facts of particular 2a) proved on the balance of probabilities.

28. In the absence of any clinical reasoning within the patient notes, the Panel also finds that the Registrant had not taken into account the red flag results into account or recorded that he had done so when devising a treatment plan for Patient B. The Panel therefore finds the facts of particular 2b) proved on the balance of probabilities.

Particulars 3a)i) and ii)

29. The Panel heard evidence from DL in support of this particular and had sight of Patient C’s case notes. DL told the Panel that Patient C had a history of osteopenia and breast cancer and had self-referred to physiotherapy with back problems associated with an old spinal injury. He gave evidence that the Registrant’s treatment on the initial assessment on 13 July 2015 involved self-directed exercise, as shown on the exercise sheet included within the patient notes.

30. He stated that exercise 1 shows an exercise taking the patient into full range of lumbar extension and that this exercise required her to undertake a full range of back extension which could have caused an increase in pain for her as a result of issues associated with an old spinal injury.

31. He also gave evidence that exercise 3 takes the patient into a lumbar rotation in both directions and that this rotation exercise was also inappropriate because Patient C had told the Registrant that any rotation caused her pain. In addition, the Registrant has noted “twist” as an aggravating factor in his assessment.

32. DL told the Panel that the Registrant should not have undertaken any treatment of Patient C until metastatic disease had been ruled out and that it was reckless to give her any exercises that were likely to cause further damage, if that had been the diagnosis, particularly where the patient had self-referred and the Registrant had no information from a doctor.

33. The Panel accepts the evidence of DL that the exercise programme was inappropriate. In accepting this evidence, the Panel is aware that DL is not a Specialist MSK Practitioner and that he is not an expert witness. However, the Panel is satisfied that his view of the appropriateness of this exercise programme in light of the patient’s medical history would be well within his competence, given his role as an experienced Professional Lead Physiotherapist. The Panel therefore finds that the exercise programme was inappropriate both in light of Patient C’s medical history and the findings of the assessment, and finds the facts of particulars 3a)i) and ii) proved on the balance of probabilities.

Particulars 4a)i)-iv)

34. The Panel heard evidence from DL in support of this particular and had sight of Patient C’s case notes in respect of the review conducted on 17 August 2017.

35. DL gave evidence that in relation to the review on 17 August 2017 Patient C said that the exercises the Registrant had given her before were causing more pain and making her symptoms worse, as recorded in Patient C’s notes. He told the Panel that at this point the Registrant had started manual treatment for Patient C and that the Registrant applied a significant amount of pressure to the bone, which he described as grade 4 rotation force (orthopaedic medicine course grading). He stated that the force of this rotation could have caused further damage to Patient C's already damaged lumbar vertebrae and increased pressure on her spinal cord. He further stated that if there was metastatic bone spread, this manipulation could have caused a fracture to that bone and that this type of manipulation was usually used for a muscle in spasm whereby you hold the rotation until the muscles fatigue and it releases the muscle tension. He told the Panel that it was not a gentle treatment and was not appropriate for someone with a spinal injury.

36. The Panel has also had regard to the Case Notes for Patient C which indicate that the patient had vertebral collapse at the L5 level, a diagnosis of osteopenia and a previous history of cancer.

37. In his submissions to the Panel, the Registrant included a letter from Patient C dated 18 September 2016 in which she states “It seems some of the ongoing concern is over the statement I gave regarding his treatment of me during physiotherapy sessions at the local hospital. I apparently used the word ‘manipulated’ in this statement without necessarily considering what this could mean to professionals. I used this word wholly in a lay person’s way, inasmuch I visited a physiotherapist and had a session which did involve a practical demonstration of exercises I should engage in to help me overcome the issues I was having. Mr Edmonds did lay hands on me to demonstrate the full range these exercises should be completed to and I have then used the term ‘manipulated’. At no time did I feel the exercises were forcing my back in any way and at no time did I feel they were beyond my capacity and at no time did I feel they were at any risk of causing a deterioration in my condition. Had I felt any such issues I can assure you I would have been the first to raise my concerns and more so not only would I have raised them immediately with Mr Edmonds, I would have then taken them up with his line manager”.

38. The Registrant has also submitted that at the time of this review, Patient C was not being investigated for metastatic bone cancer as the patient had been cleared through the MRI scan in May. The Panel accepts that there is evidence that on 17 August 2015, the Registrant was aware of the result of the MRI scan which did not indicate metastatic bone cancer. However, the Panel notes that the sub-particular relates to a contraindication of a previous history of cancer.

39. In the course of the internal investigation within the Trust, the Registrant denied that he had conducted any manual therapy on Patient C. In his written submissions to this Panel, he has stated that “this was an active lumbar spine mobilisation as opposed to a manipulation”.

40. The Panel accepts the evidence of DL, which is supported by the patient notes that the Registrant manipulated the lumbar spine using Grade 4 rotation force on the left and right side of the patient, despite the contraindications set out in sub-particulars i) to iv). In reaching this decision, the Panel is using the term “manipulated” in the general sense of positioning or handling. The Panel therefore finds the facts of particulars 4a)i) to iv) proved on the balance of probabilities.

Particular 4b)

41. The Panel heard evidence from DL in support of this particular and had sight of Patient C’s case notes in respect of the review conducted on 17 August 2015. DL gave evidence that the Registrant appears to have ignored the red flag of Patient C’s cancer history during the review conducted on 17 August 2015. DL also produced a list of contraindications for manipulations of the lumbar spine which, he stated, the Registrant would have learned as part of the orthopaedic medicine course he completed prior to this patient contact.

42. The Panel accepts the evidence of DL, which is supported by the patient notes in that there is no record within Patient C’s notes that the Registrant had taken account of the contraindications. The Panel finds that, in the absence of any record that he had taken account of the contraindications, the Registrant did not take these into account. The Panel therefore finds the facts of particular 4b) proved on the balance of probabilities.

Particular 4c)

43. The Panel heard evidence from DL in support of this particular and had sight of Patient C’s case notes in respect of the review conducted on 17 August 2015. DL gave evidence that the manipulation was completely inappropriate in light of the red flag of Patient C’s cancer history and that there were no notes as to why the Registrant had done this.

44. The Panel accepts the evidence of DL, which is supported by the patient notes in that there is no record within Patient C’s notes of any clinical justification for undertaking a manipulation of the lumbar spine. The Panel therefore finds that the Registrant did not record the clinical justification for this treatment and finds the facts of particular 4c) proved on the balance of probabilities.

Particular 5a)

45. The Panel heard evidence from GB in support of these particulars and had sight of Patient D’s case notes. The Registrant did not make specific submissions in respect of Patients D to L, other than a denial of the allegation as a whole.

46. GB gave evidence that she was asked by DL to review some of the Registrant’s case notes from an MSK perspective as this was her speciality and that she went through the case notes for Patients D to L.

47. GB gave evidence that Patient D had self-referred to the physiotherapy service because he had pains in his leg due to back pain, especially when he was at work and that the Registrant saw Patient D on 24 August 2015. She told the Panel that the Registrant did not assess or record the 24-hour nature of the patient’s condition. She explained to the Panel that this should be completed by the physiotherapist to record the patient's pain and how long it lasts for throughout the day and that this helps add to the physiotherapist's diagnosis hypothesis and subsequent treatment plan.

48. The Panel found GB to be clear and consistent in her evidence. The Panel also noted that GB was an advanced physiotherapy practitioner and was clearly knowledgeable and experienced in MSK and, with minor exceptions, accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording of the 24-hour nature of Patient D’s condition, the Registrant did not assess this. The Panel therefore finds the facts of particular 5a) proved on the balance of probabilities.

Particular 5 b)i)

49. The Panel heard evidence from GB in support of this particular and had sight of Patient D’s case notes. GB gave evidence that the Registrant had left the section in the patient notes headed 'Patient Beliefs I Fear-avoidance I Expectations' blank. She explained that these questions are present to ensure a conversation is entered into with the patient so they can express their concerns and expectations from the physiotherapy process and any worries they may have about their presentation and that if no information is recorded, it has to be assumed that the questions were not asked and this information has therefore not been taken into account.

50. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording that he had asked the questions of Patient D, the Registrant did not ask the questions. The Panel therefore finds the facts of particular 5b)i) proved on the balance of probabilities.

Particulars 5c)i) to iv)

51. The Panel heard evidence from GB in support of these particulars and had sight of Patient D’s case notes. GB gave evidence that the Registrant had not recorded an assessment of hips or pelvis, which could be involved in this pain presentation and that he had not carried out muscle testing or sensation testing.

52. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording that the Registrant had assessed these areas, the Registrant did not assess these areas. The Panel therefore finds the facts of particulars 5c)i) to iv) proved on the balance of probabilities.

Particular 5d)

53. The Panel heard evidence from GB in support of this particular and had sight of Patient D’s case notes. She gave evidence that the Registrant had not demonstrated a full assessment of Patient D and that without doing this, there was not enough evidence to formulate a proper diagnosis and subsequent treatment plan. She told the Panel that in the problem section there are boxes for 'Active date, No., Problem, Plan, and Inactive Date' and that the Registrant had recorded a general statement only and had not identified specific factors causing the pain nor any limitations or deficits which would make the basis for his treatment plan.

54. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording of an adequate treatment plan for Patient D, that the Registrant did not produce an adequate plan for Patient D. The Panel therefore finds the facts of particular 5d) proved on the balance of probabilities.

Particulars 5e)i) and ii)

55. The Panel heard evidence from GB in support of these particulars and had sight of Patient D’s case notes. GB gave evidence that in respect of exercise 2, which was a rotational movement on the Home Exercise Programme, the Registrant had not documented in the objective section of the notes any limitation in respect of lumbar spine rotation, and so there was no clinical reasoning for prescribing this exercise. With regards to exercise 3, the Registrant had not assessed Patient D's hip joint, so there was no clinical reasoning for prescribing this exercise.

56. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particulars 5e)i) and ii) proved on the balance of probabilities.

Particular 6a)i)

57. The Panel heard evidence from GB in support of these particulars and had sight of Patient E’s case notes. GB gave evidence that in the course of an assessment of Patient E conducted on 21 April 2015, the Registrant had not completed the section for the subjective assessment of Patient E and either did not ask Patient E to describe his pain (sharp shooting / dull ache etc.) or did not record it. She told the Panel that this is information required to guide further questioning and give guidance towards diagnosis.

58. Having considered the patient notes, the Panel has found that there is a reference to a “dull ache” and an “x” marking the sight of the pain within the notes of the assessment conducted on 21 April 2015. In addition, there is a pain score recorded. The Panel therefore finds that the Registrant did question and record that he had questioned the patient about the nature, type and spread of pain. The Panel therefore finds the facts of this particular are not proved.

Particular 6a)ii)

59. The Panel heard evidence from GB in support of this particular and had sight of Patient E’s case notes. GB gave evidence that there were sections left blank including beliefs and expectations / mood. She told the Panel that the problem list only contains what the GP diagnosed and not what was found on examination. She stated that no specific timed goals had been documented and that there was no plan for treatment, only the treatment given on first assessment.

60. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording that the Registrant asked Patient E about belief, mood or expectation, the Registrant did not ask the questions of Patient E. The Panel therefore finds the facts of particular 6a)ii) proved on the balance of probabilities.

Particulars 6b)i)-iii)

61. The Panel heard evidence from GB in support of these particulars and had sight of Patient E’s case notes. GB gave evidence that the Registrant did not assess Patient E's shoulder girdle and that these muscles can cause shoulder pain. She told the Panel that without assessing Patient E's shoulder girdle, the Registrant could not have known for certain what was causing the pain and potentially could have been treating the wrong structure.

62. GB also gave evidence that the Registrant did not record an assessment of Patient E's muscle strength and that it was standard practice to test muscle power around the shoulder joint to determine a rotator cuff strain / rupture / tendinopathy etc. In addition, she stated that the Registrant had not undertaken any tests on Patient E to see if there was any impingement causing his pain and that there were several tests that the Registrant could have done to check into this.

63. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particulars 6b)i) to iii) proved on the balance of probabilities.

Particular 6c)

64. The Panel heard evidence from GB in support of these particulars and had sight of Patient E’s case notes. GB gave evidence that the Registrant did not produce any impression, which is a working theory of a diagnosis. She stated that once the narrative/subjective assessment had been undertaken, and followed up with the objective assessment, the physiotherapist should start to form a hypothesis as to what the diagnosis may be. She stated that the Registrant had not recorded anything in the diagnosis box at all.

65. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording by the Registrant of a potential diagnosis, the Registrant did not identify a potential diagnosis and therefore finds the facts of particular 6c) proved on the balance of probabilities.

Particular 6d)

66. The Panel heard evidence from GB in support of these particulars and had sight of Patient E’s case notes. GB gave evidence that the Registrant had recorded that he commenced DTF (Deep Transverse Friction) without recording a diagnosis and showing no evidence of clinical reasoning or justification. She explained that DTF massage is used to break down collagen fibres, scar tissue and restart the healing process in chronic conditions and that this treatment could be painful for the patient and cause bruising and redness. She also stated that it was potentially problematic for Patient E if it was not clinically indicated and that as there was so little recorded by the Registrant in Patient E's records, it cannot be assumed that this treatment was correct.

67. The Panel accepts her evidence which is supported by the patient notes. The Panel therefore finds the facts of particular 6d) proved on the balance of probabilities.

Particular 7a)i) to iii)

68. The Panel heard evidence from GB in support of these particulars and had sight of Patient F’s case notes in respect of the assessment conducted on 2 March 2015. GB gave evidence that in the patient notes, the Registrant had recorded “a long Hx of quads weakness” but had not questioned this further to find the reason why. She stated that sudden onset weakness is recorded but no further detail which should have been generated from direct questioning, such as: what was the patient doing at the time/what had he been doing etc. She told the Panel that there were many further questions that should have been asked here to give the clinician a better idea of the mode of injury and help towards a plan for helping this patient recover and prevent a similar episode in the future.

69. She also told the Panel that no information had been recorded in the section 'Patient Beliefs I Fear Avoidance I Expectations' and that even though Patient F was referred by a neurosurgeon, the Registrant should have undertaken a subjective assessment of Patient F in order to come to his own conclusions, whilst taking the neurosurgeon's views into account as well. She stated that if the Registrant was referencing the neurosurgeon's view, this should have been clearly recorded.

70. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of a diagnosis, an adequate subjective assessment or adequate planning, the Registrant did not make a diagnosis, an adequate subjective assessment or adequate plan. The Panel therefore finds the facts of particulars 7a)i) to iii) proved on the balance of probabilities.

Particulars 7b)i) and ii)

71. The Panel heard evidence from GB in support of these particulars and had sight of Patient F’s case notes in respect of the assessment conducted on 2 March 2015. GB gave evidence that she would have expected the Registrant to have undertaken a comprehensive objective assessment including reflexes, sensation testing and muscle power and that an assessment of Patient F's gait should have been carried out. She told the Panel that if muscle weakness is an issue then it is not unreasonable to assume there may be an alteration to gait, and it may even be unsteady or unsafe. She stated that there is no record of the Registrant doing a gait assessment in Patient F's notes, so she had to conclude that he did not do one.

72. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording that the Registrant assessed Patient F’s muscle or gait, that he did not do so and therefore finds the facts of particulars 7b)i) and ii) proved on the balance of probabilities.

Particular 7c)

73. The Panel heard evidence from GB in support of this particular and had sight of Patient F’s case notes in respect of the assessment conducted on 2 March 2015. GB gave evidence that the Registrant did not test Patient F's weakness, despite it being the reason for referral and that he had not addressed this within his treatment plan. She stated that the Consultant Surgeon flagged it as an issue, so this should have been reviewed by the Registrant and that if he did not give Patient F a programme of strengthening exercises then the leg may not get any stronger.

74. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particular 7c) proved on the balance of probabilities.

Particulars 8a) to c)

75. The Panel heard evidence from GB in support of these particulars and had sight of Patient F’s case notes in respect of the assessments conducted on 16 March 2015, 13 April 2015 and 11 May 2015. GB gave evidence that the Registrant did not record that he had obtained Patient F's consent for assessment or treatment in the patient notes on 16 March 2015, 13 April 2015 and 11 May 2015. She stated that the Registrant had not recorded that he obtained Patient F's consent to be assessed and treated again. She explained that obtaining a patient's consent at the beginning of every treatment and recording how this consent was obtained is fundamental to physiotherapy practice.

76. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particulars 8a) to c) proved on the balance of probabilities

Particular 9

77. The Panel heard evidence from GB in support of these particulars and had sight of Patient F’s case notes. GB gave evidence that when a patient is referred by a GP or another doctor, it is best practice to write back to them upon discharge of the patient confirming the outcome of the treatment has been achieved or documenting reasons or concerns if not achieved. She explained that this is done so the referrer can carry out further investigations / review the patient so the best outcome can be reached. She stated that the Registrant has recorded that he discharged Patient F on 11 May 2015 and that there was no record of a discharge letter to the neurosurgeon. In addition, the Panel can see that there is no discharge summary within the patient notes.

78. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particular 9 proved on the balance of probabilities.

Particulars 10a)i) to vi)

79. The Panel heard evidence from GB in support of these particulars and had sight of Patient G’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that she would have expected the Registrant to have undertaken a comprehensive objective assessment including gait pattern, reflexes, sensation testing and muscle power. She stated that there was no record of the Registrant doing these assessments in Patient G's notes, so she had to conclude that he did not do them. She said that all of the findings would aid diagnosis and give a base line objective measure for reassessment / progress to be observed. In addition, she stated that the Registrant did not undertake an assessment of Patient G's hip or pelvis and that the joints around the area of the patient's pain should be assessed in order to get a full picture of what is going on.

80. The Panel accepts her evidence which is supported by the patient notes in respect of particulars 10a)i) to v). The Panel finds that, in the absence of any recording that the Registrant had assessed Patient G’s muscle power, hips, gait, pelvis or sensation, the Registrant did not carry out any such assessments. The Panel therefore finds the facts of particular 10a)i) to v) proved on the balance of probabilities.

81. The Panel has considered the entry in Patient G’s notes which states “reflexes NAD” and is therefore satisfied that the Registrant did assess and record Patient G’s reflexes and therefore finds the facts of particular 10a)vi) not proved.

Particular 10b)

82. The Panel heard evidence from GB in support of this particular and had sight of Patient G’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that the Registrant did not record his analysis of Patient G's assessment and had not reached a conclusion about his investigation. She explained that because of this any future treating clinician would not be able to understand the clinical reasoning behind the physiotherapist treatment.

83. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of any recording of an analysis of Patient G’s assessment, the Registrant did not produce such an analysis. The Panel therefore finds the facts of particular 10b) proved on the balance of probabilities.

Particulars 10c)i) and ii)

84. The Panel heard evidence from GB in support of these particulars and had sight of Patient G’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that the Registrant had not recorded a diagnosis in the diagnosis box. She stated that a diagnosis should always be recorded so anyone picking up these notes will be able to work out immediately what is wrong with the patient. She explained that the hypothesis of a physiotherapist’s diagnosis is sometimes called an impression and that the Registrant had not recorded this anywhere on Patient G's notes.

85. She also gave evidence that the Registrant had not completed the action plan of what needed to be done and by when. She explained that each part of Patient G's complaint should be recorded under 'problem' and then the plan of how this is going to be treated should be recorded under 'plan' and then the date that it is hoped that this problem will become inactive, with each of these points being numbered in a list.

86. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording of a diagnosis and impression and plan for Patient G, the Registrant did not make a diagnosis and impression or plan for Patient G. The Panel therefore finds the facts of particulars 10c)i) and ii) proved on the balance of probabilities.

Particular 10d)

87. The Panel heard evidence from GB in support of this particular and had sight of Patient G’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that the Registrant had written "RW 4W" and she believed this shorthand meant that he intended to review Patient G in four weeks' time. However, when she reviewed Patient G's notes, there were no follow-up notes, or anything recorded to indicate why the Registrant did not see Patient G again, for example Patient G not wanting to return or having improved and not requiring further intervention or the patient having missed an appointment.

88. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that the Registrant did not undertake a review appointment in respect of Patient G and did not record why a follow up did not take place. The Panel therefore finds the facts of particular 10d) proved on the balance of probabilities.

Particular 10e)

89. The Panel heard evidence from GB in support of this particular and had sight of Patient G’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that there was no record of a discharge summary within the patient notes completed by the Registrant. She explained that this should be sent back to the referrer to confirm what the physiotherapist found out (diagnosis, treatment plan, and whether the patient had made an improvement or not) and that without a discharge summary, the referrer would not know what was going on. In addition, she said that this also meant that Patient G was not discharged formally from the service.

90. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particular 10e) proved on the balance of probabilities.

Particular 10f)

91. The Panel heard evidence from GB in support of this particular and had sight of Patient G’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that the Registrant did not record that he had undertaken any subjective assessment of Patient G at all and that a full and detailed subjective history should be taken to determine activity prior to and during the pain onset.

92. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of any recording of an adequate subjective assessment, the Registrant did not make an adequate subjective assessment. The Panel therefore finds the facts of particular 10f) proved on the balance of probabilities.

Particular 10g)

93. The Panel heard evidence from GB in support of this particular and had sight of Patient G’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that she was concerned that there was no tailoring of the exercise programme that the Registrant gave to Patient G. She explained that as he did not come to any hypothesis of diagnosis for Patient G's condition, she did not understand then how he could have recommended these exercises. She gave evidence that he had not recorded his clinical reasoning as to why he has recommended the exercises and that the exercise sheet is the same one that he photocopied and used for a large number of his patients with the same handwritten annotations appearing on a lot of the exercise programmes, showing that he was not tailoring them specifically to the patient's condition. She told the Panel that a physiotherapist should come to a diagnosis, then tailor the exercise programme and record why they have recommended that exercise in their clinical reasoning.

94. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particular 10g) proved on the balance of probabilities.

Particular 11a)

95. The Panel heard evidence from GB in support of this particular and had sight of Patient H’s case notes in respect of the assessment conducted on 29 June 2015. She gave evidence that the Registrant had recorded very little information in the subjective section of Patient H's notes. She stated that she would expect to see some narrative from Patient H about his condition which, given he was going to require a knee replacement, had most likely been on-going for some time. She also stated that she would have expected the Registrant to record where Patient H was experiencing pain, whether there was any swelling, and if there was any muscle weakness.

96. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any recording of an adequate subjective assessment, the Registrant did not make an adequate subjective assessment and therefore finds the facts of particular 11a) proved on the balance of probabilities.

Particular 11b)i) to vi)

97. The Panel heard evidence from GB in support of this particular and had sight of Patient H’s case notes in respect of the assessment conducted on 29 June 2015. She gave evidence that the Registrant did not record that he had assessed Patient H's muscle power and that if a patient has painful joints, she would have expected an assessment of muscle power. In addition, she told the Panel that she would have expected the Registrant to assess the patient’s pelvis and hip as issues with muscle length / power or biomechanical alignment as these joints may affect the knee. She also told the Panel that the Registrant did not assess Patient H's alignment and posture. She told the Panel that she would have expected him to do this because Patient H had knee pain, which was most likely to have affected the way he stood.

98. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of any recording of an assessment of Patient H’s muscle, pelvis, hip or alignment/posture as part of his objective assessment, the Registrant did not assess these areas. The Panel therefore finds the facts of particular 11b)i) to iv) proved on the balance of probabilities.

Particular 11c)

99. The Panel heard evidence from GB in support of this particular and had sight of Patient H’s case notes in respect of the assessment conducted on 29 June 2015. She gave evidence that the Registrant recorded in Patient H’s notes that he applied MCL DFT (a deep transverse massage of the collagen fibres in the ligament) for two minutes. She also stated that there was no clinical reasoning or justification in the notes to explain why he did this.

100. The Panel accepts her evidence which is supported by the patient notes and therefore finds the facts of particular 11c) proved on the balance of probabilities.

Particulars 12a) and b)

101. The Panel heard evidence from GB in support of this particular and had sight of Patient H’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that due to the lack of subjective assessment, it appears that the Registrant simply accepted the diagnosis from the referral letter and did not undertake a full assessment himself. She told the Panel that whilst it is acceptable for the view of the referrer to inform a physiotherapist's decision, this should be done in conjunction with their own assessment. She also referred to the lack of recording in Patient H’s notes.

102. GB also gave evidence that the Registrant had not recorded much information about Patient H's condition at all and that he had not recorded whether Patient H experienced any improvement or worsening in his condition.

103. The Panel accepts her evidence which is supported by the patient notes and finds that the Registrant did not undertake or record an adequate assessment and did not record whether Patient H had experienced any improvement or worsening of their condition. The Panel therefore finds the facts of particulars 12a) and b) proved on the balance of probabilities.

Particular 13

104. The Panel heard evidence from GB in support of this particular and had sight of Patient H’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that within these notes, the Registrant wrote to recap on the home exercise programme, and to review it in four weeks' time. She stated that there is nothing recorded in Patient H's records after this. She told the Panel that if Patient H was not reviewed, there would be no reassessment or advice to the patient and no conclusion or discharge letter and as such Patient H would have remained open to the service.

105. The Panel accepts her evidence which is supported by the patient notes and therefore finds that the Registrant did not undertake any follow up with respect to Patient H and did not record why this did not take place. The Panel therefore finds the facts of Particular 13 proved on the balance of probabilities.

Particular 14a)

106. The Panel heard evidence from GB in support of this particular and had sight of Patient I’s case notes in respect of the assessment conducted on 30 March 2015. She gave evidence that the Registrant had not completed the subjective assessment. She told the Panel that the self-referral is unclear whether the fall came before the neck and back pain or afterwards and that there should have been a lot of questioning about the sequence of events as this would impact significantly on the assessment and conclusions drawn/pathway for assessment and treatment.

107. She also told the Panel that the Registrant had not recorded asking Patient I any questions about his pain, how bad it was, whether it came or went, or was permanent, whether it got better as the day went on or whether it was worse first thing, and that the Registrant jumped straight to the 'lumbar' questions. In addition, she stated that he had not recorded any information about Patient I's fall or about her neck pain. She explained that the subjective part of the assessment is particularly important when the patient self-refers, as the physiotherapist does not have any other information to go on to form part of the assessment and diagnosis.

108. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of any record of an adequate subjective assessment, the Registrant did not make one. The Panel therefore finds the facts of Particular 14a) proved on the balance of probabilities.

Particulars 14b)i) to vi)

109. The Panel heard evidence from GB in support of this particular and had sight of Patient I’s case notes in respect of the assessment conducted on 30 March 2015. She gave evidence that there is no record of testing Patient I's muscle power. She stated that the Registrant had not done this for either of the patient’s lower or upper limbs and that the Registrant should have tested her muscle power because the results give an indication of nerve involvement or pain inhibition.

110. She also gave evidence that he had not completed a gait analysis and that she would have expected him to assess how Patient I was standing and walking and how she looked when doing this.

111. She told the Panel that he had not completed an assessment of Patient I's pelvis and that she would have expected this to be done because Patient I was complaining of lower back pain.

112. She said she also would have expected him to explore and assess both Patient I's complaints: her neck pain and her lower back pain and that he had only recorded information about her lower back/lumbar spine. She explained that there was nothing in the notes to suggest that the neck pain had gone away and so the Registrant should have explored this and either included it in his assessment or recorded that it was no longer an issue.

113. In addition, she told the Panel that he did not undertake an assessment of Patient I's hip as she would have expected given her reported pain pattern and that this would have assisted him with his diagnostics of what was causing Patient I's pain.

114. She also explained that he had not recorded that he assessed Patient I's sacrum, but had carried out a mobilisation technique for the sacrum and that he should not have treated something that he had not assessed.

115. She told the Panel that the Registrant had recorded that he had assessed Patient I's range of movement, and reflexes as well as palpation and that what he had recorded was not clearly written and so she was unable to understand exactly what he had done in relation to the back assessment. She said that he had recorded that Patient I had tenderness over the soft tissue on the right-hand-side of her back, but there was no in-depth assessment recorded. She gave evidence that an increase ache is recorded on the body chart (subjective assessment) but he had not explored this further with targeted questions about her back pain as she would have expected.

116. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of any record of assessing Patient I’s muscle power, pelvis, back and neck, gait analysis, hip or sacrum, the Registrant had not assessed these areas. The Panel therefore finds the facts of Particulars 14b)i) to vi) proved on the balance of probabilities.

Particular 14c)

117. The Panel heard evidence from GB in support of this particular and had sight of Patient I’s case notes in respect of the assessment conducted on 30 March 2015. She gave evidence that Patient I was given a home exercise programme which was the same generic one that the Registrant gave many other patients. She told the Panel that there was no clinical justification contained with Patient I's notes and no analysis of her pain, so she was unable to understand whether the exercises would have helped her or not. She stated that this was the problem with not recording everything in the patient’s notes, as a new clinician reviewing them could not understand the Registrant’s thinking, reasoning or decision making.

118. The Panel accepts her evidence which is supported by the patient notes. In the absence of any record of a clinical justification for the home exercise plan, the Panel finds that the Registrant devised a home exercise programme for Patient I without clinical justification. The Panel therefore finds the facts of Particulars 14c) proved on the balance of probabilities.

Particular 15a)

119. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 22 June 2015. She gave evidence that Patient J was referred by her GP for bilateral shoulder pain, left worse than right with a painful arc. She told the Panel that the Registrant had not recorded the timelines for Patient J's condition and pain and that he had not recorded what Patient J thought brought the pain on, for example an accident. She stated that the Registrant had also not recorded whether and what type of movement affected Patient J's pain. She explained that he had drawn a line on the body chart with "burning sensation from neck to mid-anterior arm" recorded and that if Patient J was reporting this sort of pain, the Registrant should have questioned her about her neck, to investigate whether this may be involved in her pain presentation.

120. She told the Panel that the Registrant had completed the 'Cervical Special Questions' and noted that Patient J had headaches and nausea and that this was significant information in combination with the burning sensation she reported in her neck. She said that the Registrant had recorded that Patient J had an MRI scan two years ago, but does not record what this was for. In addition, she said that he had also put "query left hip replacement" – and that she did not believe that a patient would not recall whether she had a hip replacement or not and that in the subjective assessment, she would have expected the Registrant to have recorded when she had the hip replacement and any subsequent issues with it.

121. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any record of an adequate subjective assessment, the Registrant did not make an adequate subjective assessment. The Panel therefore finds the facts of Particular 15a) proved on the balance of probabilities.

Particulars 15b)i) to iii)

122. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 22 June 2015. She gave evidence that the Registrant had recorded that he palpated Patient J's neck and found tender areas in her neck and thoracic spine. She stated that he should have completed a full assessment of the neck / thoracic spine including muscle power test on Patient J's upper limbs and neurological tests such as sensation/reflexes to determine whether there were any neurological issues.

123. She explained to the Panel that the objective assessment is a process of elimination and that the Registrant should have methodically followed all these parts of the assessment to drill down on what he thought could have caused Patient J's condition and pain. She said that he had highlighted pain on palpation of her cervical spine but did not given any further information as she would have expected. She stated that he then moved on to Patient J's shoulder, but not assessed the shoulder girdle, including the acromioclavicular and sternoclavicular joints, and had only looked at joint movement in the shoulder. Given the GP indicated that Patient J indicated a painful arc, she said that she would have expected him to have also tested these joints, muscle power and resistance testing.

124. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any record of assessing muscle function, sensation and shoulder girdle, the Registrant did not do so. The Panel therefore finds the facts of Particulars 15b)i) to iii) proved on the balance of probabilities.

Particular 15c)

125. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 22 June 2015. She gave evidence that the Registrant did not record what his hypothesis of diagnosis was in the diagnosis box and that the problem list that he recorded is generic and follows what the GP has written. She also stated that there is no plan related to any of the problems and no numbering.

126. The Panel accepts her evidence which is supported by the patient notes. In the absence of any record of a diagnosis or impression, the Panel finds that the Registrant did not identify a diagnosis or impression. The Panel therefore finds the facts of Particular 15c) proved on the balance of probabilities.

Particular 15d)

127. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 22 June 2015. She gave evidence that the Registrant had not recorded what his hypothesis of diagnosis is in the diagnosis box. She also stated that the problem list that he recorded is generic and follows what the GP has written and that there is no plan related to any of the problems and no numbering.

128. The Panel accepts her evidence which is supported by the patient notes. In the absence of any record of an adequate plan, the Panel finds that the Registrant did not formulate an adequate plan. The Panel therefore finds the facts of Particular 15d) proved on the balance of probabilities.

Particular 15e)

129. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 22 June 2015. She gave evidence that the Registrant had Patient J lie on her back and he provided some traction/pulling from her head to separate the joint spaces in the cervical spine and that there is no clinical reasoning recorded as to why he undertook this treatment for her. She told the Panel that she could not say if this was the correct treatment, because he did not record the diagnosis or his clinical reasoning for doing this.

130. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of any record of clinical reasoning and/or justification in respect of the treatment the Registrant provided, the Panel finds the facts of Particular 15e) proved on the balance of probabilities.

Particular 15f)

131. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 22 June 2015. She gave evidence that the Registrant ticked the consent box, but did not record how this consent was given and whether it was for the assessment or for any treatment.

132. The Panel accepts her evidence which is supported by the patient notes and finds that the Registrant did not record if consent was obtained for assessment or treatment. The Panel therefore finds the facts of Particular 15f) proved on the balance of probabilities.

Particular 16a)

133. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 17 August 2015. She gave evidence that at no point in that assessment did the Registrant record an assessment of the lumbar spine.

134. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of any recording in the patient notes that the Registrant assessed Patient J’s lumbar spine on 17 August 2015, the Registrant did not do so. The Panel therefore finds the facts of Particular 16a) proved on the balance of probabilities.

Particular 16b)

135. The Panel heard evidence from GB in support of this particular and had sight of Patient J’s case notes in respect of the assessment conducted on 17 August 2015. She gave evidence that the Registrant did make reference to Patient J's hamstrings on this visit, but there is no record of assessment for this and that it appears to be a side note about her hamstrings being tight, and he added in some exercises for her to do in the home exercise programme. She stated that this is the same generic exercise sheet that has been used for others with back exercises and that at no point in the assessment did the Registrant record an assessment of the lumbar spine. She also gave evidence that the home exercise programme is generic and has not been tailored to Patient J and that the Registrant had also not provided any clinical justification as to why he recommended these exercises.

136. The Panel accepts her evidence which is supported by the patient notes and finds that in the absence of any recording of a clinical justification in the patient notes, the Registrant devised the home exercise programme without clinical justification. The Panel therefore finds the facts of Particular 16b) proved on the balance of probabilities.

Particular 17a)

137. The Panel heard evidence from GB in support of this particular and had sight of Patient K’s case notes in respect of the assessment conducted on 6 July 2015. She gave evidence that Patient K self-referred with severe pain in her shoulder and down her right arm and that the Registrant saw Patient K on 6 July 2015. She stated that the Registrant had not undertaken any in-depth narrative questioning of Patient K; that he had not recorded that he asked Patient K about the onset of the pain and whether she had sustained an injury/ repetitive movements/mode of onset and that he had not recorded if he had asked Patient K about whether the pain had gotten better or worse, how it happened, the nature of the pain, or how long she had it for. She told the Panel that he had written three weeks, but not said what this relates to. She said that without a clear narrative from the patient explaining the pain, and the onset of it, the Registrant would not know how to go about the objective part of the assessment and which way to direct his questions, and specific assessments.

138. The Panel accepts her evidence which is supported by the patient notes and finds that in the absence of any recording of an adequate subjective assessment, the Registrant did not conduct an adequate subjective assessment in respect of Patient K on 6 July 2015. The Panel therefore finds the facts of Particular 17a) proved on the balance of probabilities.

Particulars 17b)i) and ii)

139. The Panel heard evidence from GB in support of this particular and had sight of Patient K’s case notes in respect of the assessment conducted on 6 July 2015. She gave evidence that the Registrant had not recorded that he undertook any neurological checks on Patient K's neck, such as reflexes / sensation testing and that if he had done this, it may have highlighted the cause of the symptoms that she had to allow him to form his diagnosis. She told the Panel that he also should have checked this to rule out any other serious pathology that might have been causing her pain. She also gave evidence that the Registrant did a general muscle check and graded it as grade 5 but did not record that he checked all myotomes (a group of muscles innervate by the ventral root of a single spinal nerve) for power.

140. The Panel accepts her evidence which is supported by the patient notes. In the absence of any record of the Registrant assessing Patient L’s neurological checks for the neck or muscle power for the neck, the Panel finds that he did not assess these areas. The Panel therefore finds the facts of Particular 17b) proved on the balance of probabilities.

Particulars 18a) and b)

141. The Panel heard evidence from GB in support of these particulars and had sight of Patient K’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that the Registrant recorded that he treated Patient K with DTF to supraspinatus muscle belly and that he had not recorded any testing of supraspinatus to indicate why he would carry out this treatment and there is no clinical reasoning to justify this treatment. She also stated that he had not recorded in the notes that Patient K consented to this treatment and that this should always be recorded for each appointment. In addition, she told the Panel that there is no clinical reasoning to justify this treatment.

142. The Panel accepts her evidence which is supported by the patient notes and finds that in the absence of any recording of clinical reasoning, the Registrant treated Patient K with DTF to the supraspinatus muscle without clinical justification and/or recording clinical reasoning on 20 July 2015. The Panel also finds that in the absence of any record of consent for DTF Treatment, the Registrant did not obtain consent for this treatment. The Panel therefore finds the facts of Particulars 18a) and b) proved on the balance of probabilities.

Particular 18c)

143. The Panel heard evidence from GB in support of these particulars and had sight of Patient K’s case notes in respect of the assessment conducted on 20 July 2015. She gave evidence that on 20 July 2015, the Registrant recorded in Patient K's notes that he would recap on posture and review in four weeks and that there is no discharge summary or follow up appointment after 20 July 2015. She stated that he did not record a reason why Patient K did not return for a follow up appointment.

144. The Panel accepts her evidence which is supported by the patient notes and finds that the Registrant did not undertake a review of Patient K following the appointment 20 July 2015 and did not discharge Patient K following the appointment 20 July 2015. The Panel therefore finds the facts of Particular 18c) proved on the balance of probabilities.

Particular 19a)

145. The Panel heard evidence from GB in support of this particular and had sight of Patient L’s case notes in respect of the assessment conducted on 18 June 2015. She gave evidence that Patient L self-referred for physiotherapy because he had pain in his left shoulder and neck brought about by attempting to lift a heavy weight from ground level (according to what Patient L has written), and that the Registrant saw this patient on 18 June 2015. She also gave evidence that the Registrant had not recorded any detailed questions about the nature of Patient L's pain over the last year, for example whether it got better or worse, or whether doing any specific movements made the pain better or worse.

146. The Panel accepts her evidence which is supported by the patient notes. In the absence of any recording of a detailed patient history, the Panel finds that the Registrant did not take one. The Panel therefore finds that the facts of particular 19a) proved on the balance of probabilities.

Particulars 19b(i) to vii)

147. The Panel heard evidence from GB in support of this particular and had sight of Patient L’s case notes in respect of the assessment conducted on 18 June 2015. She gave evidence that there is no record of the Registrant assessing Patient L’s shoulder girdle or shoulder joint power which she would have expected given Patient L’s pain symptoms. She also stated that he had not recorded that he tested Patient L’s reflexes and that he should have done this to test for any neurological reasoning for his pain and should have used this information to assist with informing his diagnosis.

148. She also gave evidence that he had not recorded that he assessed Patient L’s sensation which would have been useful for informing his diagnosis of Patient L. She explained that sensation tests can show/rule out neurological causes of pain.

149. She further stated that he had not recorded that he assessed Patient L’s cervical spine rotation. She told the Panel that the neck has specific movements that it is capable of, like looking over your shoulder and that the Registrant should have checked the range of movement for Patient L’s neck as any reduced movement of the neck could indicate facet joint problems or nerve impingement. She also stated that this would have assisted with informing the Registrant’s diagnosis of Patient L.

150. She told the Panel that the Registrant had not recorded that he assessed Patient L’s muscle function for his shoulder, but he had for his neck. She explained that the reason she would also have assessed Patient L’s muscle function in his shoulder is because if there had been weakness it could have indicated an issue with the muscle, and not the nerve. She explained that the physiotherapist needs to test the full range of the muscle and power throughout the assessment to assist with informing the diagnosis and that the Registrant should have tested the whole shoulder, rotator cuff, biceps and triceps of Patient L to inform his diagnosis properly.

151. She also told the Panel that the Registrant had not assessed Patient L’s posture and that she would have expected him to do this and record if there was any issue.

152. The Panel accepts her evidence which is supported by the patient notes and finds that in the absence of any record of assessing the areas outlined in particulars 19b)i) to vii), the Registrant did not assess these areas in the course of the assessment on 20 July 2015. The Panel therefore finds the facts of Particular 19b)i) to vii) proved on the balance of probabilities.

Particular 19c)

153. The Panel heard evidence from GB in support of this particular and had sight of Patient L’s case notes in respect of the assessment conducted on 18 June 2015. She gave evidence that the Registrant had undertaken DTF treatment of Patient L supraspinatus muscle belly without recording any clinical reasoning or justification for this treatment. She explained that supraspinatus shoulder should have been power-tested for pain, length tested for pain and impingent tests carried out to determine if supraspinatus was actually the cause of the pain. She stated that he had recorded that he palpated this area and found that the supraspinatus muscle belly is painful for Patient L, but he had not tested anything to explain this or justify his treatment.

154. The Panel accepts her evidence which is supported by the patient notes and finds that in the absence of any recording of a clinical reasoning in the patient notes, the Registrant treated Patient L with DTF without clinical justification. The Panel therefore finds the facts of Particular 19c) proved on the balance of probabilities.

Particular 19d)

155. The Panel heard evidence from GB in support of this particular and had sight of Patient L’s case notes in respect of the assessment conducted on 18 June 2015. She gave evidence that the Registrant had not recorded his diagnosis or impression in Patient L’s notes. She told the Panel that the box where this should be recorded is empty and that she did not understand how the Registrant could be treating Patient L without having any sort of hypothesis of diagnosis/impression of what he is treating. She also stated that Patient L’s problems were not clear from the plan boxes either.

156. The Panel accepts her evidence which is supported by the patient notes and finds that in the absence of any record of a diagnosis or impression in the patient notes, the Registrant did not make a diagnosis or impression in respect of Patient L in the course of the assessment on 18 June 2015. The Panel therefore finds the facts of Particular 19d) proved on the balance of probabilities.

Particulars 20a)i) - vii)

157. The Panel heard evidence from NG in support of these particulars and had sight of the case notes for Patients M, N, O, P, R, T and V. The Panel found NG to be clear, precise and consistent in her evidence, and noted that she had significant experience within the Learning Disability Physiotherapy Service. She gave evidence that in May 2017 she reviewed the Registrant’s Learning Disability caseload as he was suspended from work due to an investigation relating to his MSK caseload. She produced a copy of the Learning Disability Network (Argyll and Bute) Referral and Caseload Management Policy and directed the Panel to the heading “Formal Client Review” which states: “A minimum of a six-monthly formal review of your involvement with the Client should be undertaken on any Client if they remain on your active caseload over six months from the date of your active involvement.” She gave evidence that reviews were not undertaken at a minimum of six-monthly intervals in respect of Patients M, N, O, P, R, T or V. The Panel accepts her evidence which is supported by the patient notes for Patients M, N, O, P, R, T and V and finds the facts of particulars 20a)i) to vii) proved on the balance of probabilities.

Particulars 20b)i) -vii)

158. The Panel heard evidence from NG in support of these particulars and had sight of the case notes for Patients M, N, P, Q, R, T and V. She gave evidence that patient consent is required for taking photographs of patients. She explained that physiotherapists take photographs of patients to assist the patient with learning and understanding the exercise programme they are given by the physiotherapist and that the NHS Highland Protocol required written consent from patients for photographs to be taken. She also referred the Panel to the Chartered Society of Physiotherapists Quality Assurance Standards for Physiotherapy Service Delivery (a copy of which she produced) Section 5.2.1 which states that : “A policy is in place detailing those physiotherapy procedures where written consent is to be obtained.” and Section 5.2.2 which states: “Where written consent is gained, a copy is retained in the service user's records and a copy is given to the service user.”

159. She told the Panel that as the majority of the patients that were allocated to the Registrant had a learning disability, consent may not have been possible to obtain from the patient, in which case the guardian or carer's consent should have been sought. She told the Panel that all of this information relating to consent should be recorded in the patient's records and that this would have included how the consent was obtained, and whether it was verbally given and by whom. She stated that there was a standard form that was used to record the written consent of the patient for photographs. She told the Panel that that some of the patient files of cases allocated to the Registrant which she reviewed did contain the requisite consent form and/or a written record of the patient providing consent for photographs. However, she stated that there were no records of signed written consent forms for Patients M, N, P, Q, R, T or V.

160. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any record that the Registrant had obtained consent for photographs for patients M, N, P, Q, R, T or V, he had not done so. The Panel therefore finds the facts of particulars 20b)i) to vii) proved on the balance of probabilities.

Particulars 20c)i) – x)

161. The Panel heard evidence from NG in support of these particulars and had sight of the case notes for Patients M, N, O, P, Q, R, S, T, U and V. She gave evidence that patient consent is required for all treatment the physiotherapist provides and that this includes any treatment that the patient undertakes with the physiotherapist during an appointment for advice, assessment, examination, intervention, treatment or procedure. She stated that a patient's consent for treatment should be documented by the treating physiotherapist at each stage of the assessment and that it should be documented how that consent is obtained - either in writing or verbally/non-verbally. She explained that a lot of learning disability patients are unable to give express verbal consent to treatment, but they can give it implicitly through their actions and that this should be clearly documented in the patient's record.

162. She also referred the Panel to Section 5.1.1 of the CSP Quality Assurance Standards for Physiotherapy Service Delivery which states: “The service user's consent is obtained and documented before giving advice or beginning an assessment, examination, intervention, treatment or procedure.” She also referred to Section 5.1.2 of the CSP Quality Assurance Standards for Physiotherapy Service Delivery which explains the consent process and states that if consent is not obtained, this should be recorded in the patient's record, including the patient's rationale for this (5.1.2.f). In addition, she referred to Section 5.2.2 of the CSP Quality Assurance Standards for Physiotherapy Service Delivery which states: “Where written consent is gained, a copy is retained in the service user's records and a copy is given to the service user.” She gave evidence that there was no recorded consent to treatments for Patients M, N, O, P, Q, R, S, T, U or V.

163. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that, in the absence of any record that the Registrant had obtained consent to treatments for patients M, N, O, P, Q, R, S, T, U or V, he has not done so. The Panel therefore finds the facts of particulars 20c)i) to x) proved on the balance of probabilities.

Particulars 20d)i)-x)

164. The Panel heard evidence from NG in support of these particulars and had sight of the case notes for Patients M, N, O, P, Q, R, S, T, U and V. She gave evidence of what she would expect to see recorded in a patient's record to evidence that the assessment had been undertaken. She explained that this is important because it is recorded in Section 8.3 of the CSP Quality Assurance Standards for Physiotherapy Service Delivery and stipulates what appropriate information relating to the service user and the presenting problem should be collected during the assessment as follows:

'Criteria

8.3.1 Where appropriate, standardised datasets are in use that facilitate benchmarking of data and respond to national good practice initiatives and requirements

8.3.2 There is evidence that information is collected to inform the physiotherapeutic process which, where appropriate, includes:

a. the service user's demographic details

b. presenting condition/problems

c. history of the presenting condition including management of the problem to date

d. the service user's perception of their needs

e. the service user's expectations of intervention

f. past medical history

g. current medication/treatment

h. contra-indications/precautions/allergies/red flags

i. social and family history/lifestyle

j. documentation and evaluation of relevant clinical investigations/results to assist the diagnosis and management process

8.3.3 There is written evidence of a physical examination carried out including measurable data which includes:

a. observation

b. use of specific assessment tools/techniques/handling/palpation'

165. She also gave evidence that when an assessment is undertaken after a referral, the physiotherapist analyses the findings of the assessment which can lead to a diagnosis which can then lead on to treatment or referral to another healthcare professional. She explained that the analysis which is recorded in the patient's file justifies why the physiotherapist has chosen that specific treatment plan. She also explained that assessment of patients needs to be completed and documented fully and then analysed and documented to evidence clinical reasoning and justification of any treatment plan and interventions. She stated that each time treatment is reviewed it should be analysed again to justify continuing or changing the treatment plan and that the need to analyse a patient's assessment and record it in the patient's record is documented in Section 6 and 8.4 of the CSP Quality Assurance Standards for Physiotherapy Service Delivery.

166. In respect of Patient M, she gave evidence that upon review of the case notes, she found that the Registrant had not provided any written analysis of his assessment and that there was no record of the Registrant fully documenting any assessment that he undertook, just some rough handwritten notes dated 6 March 2013.

167. In respect of Patient N, she gave evidence that upon review of the case notes, she found that there was only evidence of the Registrant completing a partial assessment from notes.

168. In respect of Patient O, she gave evidence that upon review of the case notes, she found that there was no record of the Registrant completing a full assessment and/or documenting this fully. She stated that the assessment had only been partially completed by the Registrant.

169. In respect of Patient P, she gave evidence that upon review of the case notes, she found that there was no record of the Registrant completing an assessment and/or documenting it fully. She stated that the assessment had only been partially completed by the Registrant.

170. In respect of Patient Q, she gave evidence that upon review of the case notes, she found that there was no record of the Registrant completing an assessment or recording that he had completed an assessment of Patient Q after the referrals in 2010 or 2015.

171. In respect of Patient R, she gave evidence that upon review of the case notes, she found that the Registrant had not completed the necessary assessments in 2010 or 2014 and that there was no record of the Registrant fully documenting any assessment that he undertaken, just some rough handwritten notes.

172. In respect of Patient S, she gave evidence that upon review of the case notes, she found that the Registrant had not documented any assessment of Patient S after the 2014 referral.

173. In respect of Patient T, she gave evidence that upon review of the case notes, she noted that Patient T's review by the Registrant was required to check the effectiveness of the treatment plan and review objective measures as to Patient T's progress or lack thereof and there was no record of the assessment in the first place.

174. In respect of Patient U, she gave evidence that upon review of the case notes, she noted that the Registrant saw Patient U on 24 July 2013 and there is no record of the Registrant fully documenting any assessment that he undertook, and he had just made some rough handwritten notes.

175. In respect of Patient V, she gave evidence that upon review of the case notes, she noted that it is recorded in the Progress Notes that the Registrant saw Patient V at home on 16 April 2015 and there is no record of a full assessment being conducted.

176. The Panel accepts her evidence which is supported by the patient notes. The Panel finds that in the absence of a record of an adequate assessment or analysis of Patients M to V, the Registrant did not conduct an adequate assessment or analysis of these patients and finds the facts of particulars 20d)i) to x) proved on the balance of probabilities.

Particulars 20e)i) – x)

177. The Panel heard evidence from NG in support of these particulars and had sight of the case notes for Patients’ M, N, O, P, Q, R, S, T, U and V. She gave evidence that she reviewed 32 sets of patient notes that the Registrant had completed in relation to his MSK caseload and that overall, she found little documented analysis of the clinical findings and the information jumped from their assessment findings straight to the intervention without establishing clear clinical reasoning pathways.

178. In respect of Patient M, she gave evidence that upon review of the case notes, she found that the Registrant had not provided any written analysis of his assessment and there was no record of the Registrant fully documenting any assessment that he undertook, just some rough handwritten notes dated 6 March 2013. She gave evidence that upon review of the case notes, she found that there was no documented analysis to evidence his clinical reasoning and justification for the treatment plan and interventions for Patient M.

179. In respect of Patient N, she gave evidence that upon review of the case notes, there was not a full assessment recorded and therefore there was no documented analysis to evidence his clinical reasoning and justification for the treatment plan and interventions the Registrant had recommended for Patient N.

180. In respect of Patient O, she gave evidence that upon review of the case notes, she found that as there was not a full assessment recorded, there was no documented analysis to evidence the Registrant’s clinical reasoning and no justification for the treatment plan and interventions for Patient O.

181. In respect of Patient P, she gave evidence that upon review of the case notes she found that as there was no full assessment recorded, there was no documented analysis to evidence his clinical reasoning and justification for the treatment plan and interventions for Patient P.

182. In respect of Patient Q, she gave evidence that upon review of the case notes she found that as there was no assessment recorded after the referrals in 2010 and 2015, there was no documented analysis to evidence his clinical reasoning and justification for the treatment plan and interventions for Patient Q. She stated that the Registrant had not provided any clinical justification for the treatment method for Patient Q.

183. In respect of Patient R, she gave evidence that upon review of the case notes she found that the Registrant had not provided any clinical justification for the treatment method for Patient R. She stated that this meant the possible cause of Patient R’s symptoms were not documented and it is possible that the most appropriate treatment plan was not chosen.

184. In respect of Patient S, she gave evidence that upon review of the case notes she found that the Registrant had not documented any assessment of Patient S after the 2014 referral and that as there was no record of any such assessment it follows that there was no documented analysis to evidence his clinical reasoning and justification for the treatment plan and interventions for Patient S.

185. In respect of Patient T, she gave evidence that upon review of the case notes she found that the Registrant recorded in the progress notes that he visited Patient T on 2 July 2014 and that there was no record of the clinical reasoning or justification for the treatment or intervention or any other treatment or intervention from that date.

186. In respect of Patient U, she gave evidence that upon review of the case notes she found that the Registrant saw Patient U on 24 July 2013 and that the exercises issued to Patient U by the Registrant were provided with no evidence of clinical reasoning or justification.

187. In respect of Patient V, she gave evidence that upon review of the case notes she found that the exercise programme that the Registrant devised for Patient V in April 2015 was issued without a full assessment being undertaken and with no evidence of clinical reasoning or justification.

188. The Panel accepts her evidence which is supported by the patient notes and finds that, in respect of Patients M, N, O, P, Q, R, S, T, U, and V, the Registrant did not record his clinical reasoning or justification for treatment or interventions. The Panel therefore finds the facts of particulars 20e)i) to x) proved on the balance of probabilities.

Decision on Grounds

189. The Panel next considered whether the Registrant’s actions found proved in particulars 1 to 20 (excluding particulars 6a)i) and10a)vi)) amount to misconduct and/or lack of competence. The Panel is aware that this is a matter for its professional judgement. In reaching its decision, the Panel has considered the submissions of Mr Smart and the Registrant’s written submissions and has had regard to the HCPTS Practice Note on Fitness to Practise Impairment. The Panel has also accepted the advice of the Legal Assessor.

190. The Panel is aware that the Registrant is an experienced Band 7 physiotherapist. The Panel has also heard evidence from NG that in the course of her audit of the Registrant’s Learning Disability caseload, there were a number of cases where he demonstrated that he had the necessary knowledge and skills, although he did not use them consistently. The Panel has also had sight of case records in which the Registrant has appropriately obtained consent. The Panel has therefore concluded that the Registrant had the necessary knowledge, skills and experience and his actions therefore do not amount to a lack of competence.

191. The Panel has found that the Registrant has failed to conduct assessments and reviews appropriately; failed to provide clinical justification for treatments and interventions; failed to obtain consent for photographs and treatment; failed to keep accurate records; failed to produce discharge summaries and has acted contrary to the instructions of the referring Consultant Surgeon. These were fundamental and serious failings and, in all but the last case, were repeated over a prolonged period of time.

192. The Panel has concluded that the Registrant’s conduct found proved breached the following standards:

The HCPC’s Standards of Conduct, Performance and Ethics (2003):

• Standard 9 – You must get informed consent to give treatment (except in an emergency).

• Standard 10 – You must keep accurate patient, client and user records.

The HCPC’s Standards of Conduct, Performance and Ethics (2012):

• Standard 1 -You must act in the best interests of service users.

• Standard 9 - You must get informed consent to provide care or services (so far as possible).

• Standard 10 - You must keep accurate records.

193. In addition, the Panel finds that the Registrant’s conduct found proved fell well below the standards expected of a Band 7 physiotherapist. The Panel heard evidence from GB that his performance would fall short of the standards expected of a Band 5 newly qualified physiotherapist. Given the nature of his numerous serious failings in fundamental aspects of physiotherapy over a lengthy period of time, the Panel has concluded that his actions and omissions would be considered to be deplorable by fellow practitioners and as such amount to misconduct.

Decision on Impairment

194. The Panel next considered whether the Registrant’s current fitness to practise is currently impaired by that misconduct. In reaching this decision, the Panel has considered both the personal and the public components. In addition, the Panel has considered the submissions of Mr Smart on behalf of the HCPC, together with the submissions of the Registrant and his representatives. The Panel has also had regard to the HCPC Practice Note on Fitness to Practise Impairment and has accepted the advice of the Legal Assessor.

195. In terms of the personal component, the Panel has first considered whether the Registrant’s actions are remediable. While the Panel is of the view that the failings found proved could be remediated, it has found no evidence of remediation in his written submissions or in the course of the Trust investigation. In their written submissions to the Panel, the Registrant’s representatives state that “The Registrant submits that, at all times during his practice, he has adhered to HCPC Standards”. In addition, the Panel has found no evidence of insight or remorse in respect of his failings. In light of this absence of insight, the Panel is of the view that the Registrant cannot begin the process of remediation when he does accept any of his failings. The Panel therefore finds that there is a high risk of repetition, particularly so where there have been repeated failings in fundamental aspects of physiotherapy practice over a prolonged period of time and a lack of any insight, remorse or remediation.

196. The Panel has also considered the critically important public component which includes the collective need to maintain public confidence in the profession and in the regulatory process, the protection of service users and the declaring and upholding of proper standards of behaviour. The Panel is of the view that the Registrant’s misconduct would very seriously impact on public confidence in the profession, where an experienced physiotherapist working at a senior level has been found to have repeatedly breached fundamental tenets of the profession over a prolonged period of time and has failed to demonstrate any insight, remorse or remediation. The Panel has concluded that there is a risk of an adverse impact on public confidence in the profession and in the regulatory process if a finding of impairment were not made in these circumstances.

197. The Panel has therefore concluded that the Registrant’s current fitness to practise is impaired by his misconduct on both the public and personal components.

Decision on Sanction

198. The Panel has heard submissions from Mr Smart on the issue of sanction. The Panel has considered the sanctions available to it in ascending order of severity and has had regard to the HCPC Sanctions Policy. The Panel also accepted the advice of the Legal Assessor.

199. The Panel is aware that the function of fitness to practise panels is not punitive and that the primary function of any sanction is to address public safety from the perspective of the risk the Registrant may pose to those using or needing their services in the future. In reaching its decision, the Panel must also give appropriate weight to the wider public interest considerations, which include the deterrent effect on other registrants, the reputation of the profession and public confidence in the regulatory process.

200. The Panel has considered the mitigating and aggravating factors in this case. The aggravating factors are:

• The Registrant’s actions were serious as his failures in recordkeeping and failures to provide clinical justification amount to a failure to work in partnership. In these cases the Registrant has failed to share essential information about the care and treatment provided to service users with other professionals who may have to access the patient notes.

• The Registrant is an experienced Band 7 physiotherapist and there were a number of cases where he demonstrated that he had the necessary knowledge and skills but chose not to use them consistently;

• There was a pattern of unacceptable conduct repeated over an extended period of time;

• There has been no evidence of remediation;

• There has been no remorse demonstrated;

• There has been no evidence of insight;

• There is a high risk of repetition;

• There was potential for harm to service users;

• The Learning Disability service users were particularly vulnerable.

201. The Panel also had regard to the following mitigating factors:

• There appeared to be a lack of supervision, training and auditing of the Registrant’s case notes within the Trust;

• The Registrant has stated through his representatives’ written submissions that he has general ongoing ill-health and owing to his age, he no longer feels confident or strong enough to attend the hearing.

202. The Panel first considered whether to take no further action and was of the view that this would not be sufficient to mark the seriousness of the conduct found proved.

203. The Panel considered that mediation would not be appropriate in the circumstances of this case.

204. The Panel next considered a Caution Order. In terms of the Sanctions Policy, a caution may be appropriate where the lapse is isolated, limited or relatively minor in nature, there is a low risk of recurrence and the Registrant has shown good insight and has undertaken remedial action. In this case, the Panel has not found that the Registrant’s failings were isolated or minor. In addition, he has not demonstrated insight or undertaken remedial action. The Panel has concluded that a Caution Order would not be an appropriate or proportionate sanction and would not address the public interest considerations.

205. The Panel next considered a Conditions of Practice Order. The HCPC Sanctions Policy states that conditions are likely to be appropriate where the registrant has insight; the failure or deficiency is capable of being remedied; there are no persistent or general failures which would prevent the registrant from remediating; appropriate, proportionate, realistic and verifiable conditions can be formulated; the panel is confident the registrant will comply with the conditions; a reviewing panel will be able to determine whether or not those conditions have been or are being met; and the registrant does not pose a risk of harm by being in restricted practice. The Policy also states that conditions will only be effective where the registrant is genuinely committed to resolving the concerns raised and the panel is confident they will do so.

206. While the Panel has found that the Registrant’s failings are capable of remediation, the Panel has also found a lack of insight. In addition, the Panel heard evidence that on his return to practice following his initial period of suspension by the Trust, which started in 2015, a process was discussed to assist with a supported improvement plan and timescale for implementation. The Registrant did not comply with the agreed actions and this culminated in a further suspension from duty. The Panel has found persistent failures over a prolonged period of time and is not confident that the Registrant would be willing to comply with conditions or that, given the nature and repetition of the conduct found proved, conditions would be sufficient to address the public interest considerations. The Panel has therefore concluded that a Conditions of Practice Order would not be an appropriate or proportionate sanction and would not address the public interest considerations.

207. The Panel next considered a Suspension Order. In terms of the HCPC Sanctions Policy, a Suspension Order may be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register, the registrant has insight, the issues are unlikely to be repeated and there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings. The Panel has found that the Registrant’s conduct cannot be addressed by conditions. The Panel has also identified a high risk of repetition, as the Registrant has not demonstrated insight or remediation. There is no evidence before the Panel to suggest that the Registrant is willing to remedy his failings. There is evidence that the Registrant did not comply with his supported improvement plan when he returned to practice following the period of suspension starting in 2015. The Panel has therefore concluded that a Suspension Order would not be an appropriate sanction and while it would protect the public for the duration of the order, it would not be sufficient to address the public interest considerations.

208. The Panel next considered a Striking Off Order. In terms of the HCPC Sanctions Policy, a Striking Off Order may be appropriate where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the profession, and public confidence in the regulatory process, particularly where the Registrant lacks insight, continues to repeat the misconduct or is unwilling to resolve matters. The Panel has concluded that given the repeated serious failings over a prolonged period by an experienced Band 7 physiotherapist, the lack of insight, remorse or remediation and the high risk of repetition identified, a Striking Off Order is the only appropriate sanction and in all the circumstances is proportionate.

ORDER: That the Registrar is directed to strike the name of Charles Edmonds from the Register on the date this order comes into effect.

Interim Suspension Order

209. Mr Smart made an application to the Panel for an Interim Suspension Order for a period of 18 months in terms of Article 31 of the Health Professions Order 2001 on the grounds that it was necessary for the protection of the public and was in the public interest. The Panel considered Mr Smart’s application and had regard to the advice of the Legal Assessor. The Panel agreed to grant the application as it was satisfied that it was both necessary for the protection of the public and in the public interest given the decisions above.

History of Hearings for Charles Edmonds

Date	Panel	Hearing type	Outcomes / Status
01/08/2022	Conduct and Competence Committee	Final Hearing	Struck off