Mrs Diana Zuramskiene

Preliminary Matters

1. The Panel has been convened to undertake a review of a substantive order of suspension imposed in respect of the HCPC registration of the Registrant, Ms Diana Zuramskiene, a Radiographer.

Service
2. The Panel was provided with unredacted service documentation. It demonstrated that on 8 June 2022 the HCPC sent a notice of this hearing by email to the Registrant. The notice contained the required particulars, including the date and time of the hearing and that the hearing was to take place as a virtual hearing by video. The Panel was satisfied that this email constituted good service of the notice of hearing.

Proceeding in the absence of the Registrant
3. After the Panel announced its decision that there had been good service of the notice of hearing, the Presenting Officer applied for a direction that the hearing should proceed in the absence of the Registrant.

4. The Panel heeded the advice that a decision to proceed with a hearing in the absence of the Registrant is one not to be taken lightly, and the Panel had regard to the factors outlined in the relevant HCPTS Practice Note. After careful consideration the Panel concluded that the direction sought by the HCPC should be made and that the hearing should continue in the absence of the Registrant. The reasons for this decision were as follows:

• The information available to the Panel indicated that the Registrant has disengaged from these fitness to practise proceedings:

o The Registrant did not participate in the substantive hearing, and the Panel conducting that hearing was informed that there had not been any engagement on the part of the Registrant since February 2020, approximately seventeen months before that hearing took place.

o The notice of hearing email requested the Registrant to confirm receipt of it. The HCPC received a delivery receipt of its email, but the Registrant did not confirm receipt as requested.

o On 15 June 2022, the Presenting Officer sent an email to the Registrant in which she introduced herself and asked the Registrant if she intended to attend the hearing and provide any documentation. A delivery receipt of this email was obtained, but the Registrant did not respond to it.

o The Registrant has not communicated with the HCPC for well over two years.

• It follows that the Panel concluded that the Registrant had voluntarily absented herself from this hearing.

• Even if (which for the reasons set out below, is not likely) the hearing could be re-scheduled to another date, there were no grounds on which the Panel could conclude that the Registrant would be likely to participate in it.

• The current period of suspension is due to expire on 11 August 2022. If the review is not undertaken before it expires, jurisdiction to undertake a review will be lost. The service requirements for reviews of this nature demand that 28 days’ notice is given. Accordingly, it is unlikely that valid notice could be given for a hearing before the expiry of the present order. It is clearly in the public interest that jurisdiction to undertake a mandatory review is not lost.

• All of these factors require that the present hearing should proceed.

Background
5. The Registrant graduated with a degree in Radiography in Lithuania, and subsequently applied for registration with the HCPC as a Radiographer.

6. After she was admitted to the HCPC Register, the Registrant was employed as a Band 5 Radiographer by the Swansea Bay University Health Board (“the Board”) at Singleton Hospital (“the Hospital). That employment commenced on 13 August 2108. On her first day of work, concerns were raised by colleagues with the Registrant’s Line Manager, VW, who advised that the Registrant should not be left on her own, and that the Superintendent of General Radiography, Colleague A, should monitor the Registrant’s practice.

7. The Registrant was provided with an induction programme, but did not pass it as it was decided that she did not have the necessary knowledge. As a result, a training programme was devised for the Registrant, which was similar to provided to student radiographers. During the period of this training programme, the concerns remained.

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

9. Further assessments were undertaken and the Registrant showed a slight improvement as she had learnt from the Radiographers around her, but issues with her practice remained.

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

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

The findings made at the substantive hearing held in July 2021
12. Four witnesses appeared to give evidence before the substantive hearing Panel. They were:

• VW, the Site Superintendent at the Hospital;

• Colleague A, a Superintendent Radiographer at the Hospital who had particular responsibility for supervising and teaching Radiographers and student radiographers. It was colleague A who was appointed on 14 August 2018 to ascertain the Registrant’s knowledge and skills;

• Colleague C, an Advanced Practice Radiographer at the Hospital, who was involved in the training and assessing of radiology students;

• Colleague D, a Senior Diagnostic Radiographer at the Hospital, who amongst other activities, assisted with training junior staff and students on their placements from university.

13. In summary, the decisions made by the substantive hearing Panel in relation to the specific factual particulars were as follows:

• Particular 1(a). The evidence relating to the foot image the HCPC conceded was entirely hearsay and weak, and the Panel did not find that it was sufficient upon which a finding could be made against the Registrant. However, in relation to the elbow, the Panel accepted the evidence of Colleague A that the Registrant placed the cassette in the wrong position, missing the elbow completely. Colleague A stated that it was like teaching a first year student.

• Particular 1(b). Colleague C described that not only did the Registrant x-ray the wrong shoulder, but much of the anatomy of the shoulder had been omitted from the image.

• Particular 1(c). Because of the risk that radiation could cause to an unborn foetus, steps were required to be taken to investigate whether any woman of childbearing age requiring an x-ray of an area between the diaphragm and the knees might be pregnant. This check involved checking the last menstrual period. Colleague D discovered that the Registrant had performed an abdominal x-ray without the check having been made.

• Particular 1(d)(i). A Consultant had requested a lateral x-ray of a 13 year-old patient’s lumbar spine. When Colleague A checked the image taken by the Registrant she discovered that it was not a true lateral image because it had been centred too high and there was a lot of the patient’s upper spine on the x-ray.

• Particular 1(d)(ii). The patient required a left wrist and elbow x-ray. To reduce the patient’s exposure to radiation, it would have been possible and desirable for both the wrist and elbow to be included in a single x-ray, but to do so the machine had to be re-focused from fine to broad. The evidence of Colleague A was that the Registrant appeared not to know how to re-focus the machine.

• Particular 1(d)(iii). It was the evidence of Colleague A that when the Registrant was performing an x-ray of a knee, and could not understand why her lateral knee image was not correct, she did not know that she needed to adjust the two directions of the tube, as well as rotating it around its axis in order to obtain the required image.

• Particular 1(e). A protocol requirement in relation to lumbar spine images was that it the patient was under the age of 55 years, then only a lateral projection x-ray would be taken. It was discovered that the Registrant had taken an AP image, in circumstances where she been requested to, but not understood, that only a lateral projection image should be taken. She was also unaware of the protocol referred to.

14. When the substantive hearing panel addressed the issue of whether the statutory ground of lack of competence had been made out, in addition to applying its findings on the specific factual particulars to the consideration, there were two other pieces of evidence it considered, namely:

• What the Registrant herself said in an email sent to the HCPC on 23 January 2020, which included this sentence, “It was clear it was a lack of competence as soon as I started work.”

• The evidence of both VW and Colleague A who described the Registrant’s level of achievement as being comparable to that of a first year radiography student.

• The feedback from the clinical supervisor at Cardiff University who assessed the Registrant who stated, “I would assess [the Registrant] to be at a practical level 4/5 (1st/2nd year undergraduate) but with the theoretical knowledge of a lower level 4 student (1st year undergraduate) ….”

15. So far as impairment of fitness to practise was concerned, the substantive hearing panel determined that there was current impairment of fitness to practise in relation to both the personal and public components.

16. In relation to sanction, the substantive hearing panel determined that the only sanction that sufficiently addressed the findings it made was one of a suspension order. It made that order for a period of 12 months, and it is that order that is being reviewed today.
The submissions made to the present Panel

17. The Presenting Officer outlined the background to the case and took the Panel to the determination of the substantive hearing panel. She also outlined the powers available to the Panel today, and suggested the proper approach to the decision to be made. She submitted that by failing to submit any information to the HCPC since the substantive decision was reached, the Registrant had not discharged the persuasive burden resting upon her to demonstrate that she has addressed the shortcomings identified. That being so, it was submitted, there would be a likelihood of repetition resulting in the Registrant’s fitness to practise remaining impaired in respect of both components to be considered. The Presenting Officer submitted that the appropriate outcome of the review would be the making of a further suspension order for a period of 12 months.

18. There were no submissions made by or on behalf of the Registrant.
Decision

19. The issue to be decided by the Panel is whether, upon the expiry of the present period of suspension, a further sanction is be imposed, and, if it is, what that sanction should be. In reaching this decision, the Panel has approached the matter as follows:

• The findings made by the substantive hearing panel as to the factual particulars are to be taken as settled, as is the finding of that panel that those facts demonstrated a lack of competence.

• It is part of the background to the case that the substantive hearing panel determined that the lack of competence was impairing the Registrant’s fitness to practise in July 2021, but it is for the present Panel to decide if the Registrant’s fitness to practise is still impaired. In reaching this decision, the Panel is to apply the usual considerations applicable to a decision on current impairment of fitness to practise, is to have regard to the HCPTS Practice Note entitled, “Fitness to Practise Impairment” dated February 2022. In particular, it is important for the Panel to address both the personal and public components of impairment.

• If the conclusion is that there is no continuing impairment of fitness to practise, then no further sanction will be imposed upon the expiry of the present period of suspension.

• If, however, the finding is that there is continuing impairment of fitness to practise then the available sanctions must be considered. The HCPC’s Sanctions Guidance is to be considered in that regard. The present Panel has available to it all the sanction powers that were available to the substantive hearing panel, but as the finding in July 2021 was one of lack of competence, the available sanctions do not extend beyond the making of a suspension order.

20. The Panel confirms that it has applied the approach set out above. The Panel also accepted that that, as knowledge of any remedial measures taken will be within the knowledge of a registrant, and not to the HCPC, when a decision is to be made as to whether remedial steps have been taken to address identified shortcomings, there is a persuasive burden on the registrant to provide evidence of any steps taken.

21. In the present case the absence of any engagement by the Registrant has the consequence that there are no grounds on which the present Panel could find that any of the failings identified at the substantive hearing have been addressed. That being so, it is to be assumed that the Registrant is not capable of practising autonomously as a Radiographer, and there would be a very significant risk of repeated errors with serious implications for patient safety were she to be permitted to return to practise without restriction. This finding has the consequence that her fitness to practise remains impaired upon consideration of the personal component. It also means that the public component is engaged because fair minded and informed members of the public would be alarmed by the prospect of such a practitioner being permitted to return to practise.

22. It follows from this finding that the Panel concluded that a further sanction is required upon the expiry of the present period of suspension. The Panel considered the available sanctions in an ascending order of seriousness, but concluded that no sanction short of suspension would afford a proper degree of public protection.

23. Accordingly, the Panel determined that upon the expiry of the present period of suspension on 11 August 2022, a further period of suspension is to be imposed. In the judgement of the Panel the appropriate duration of that further period of suspension is 12 months.

24. Finally, the Panel would wish the Registrant to be aware that although at present the power to make a striking off order is not available to the Panel, if she remains suspended (or subject to conditions of practice) for a continuous period of 2 years, that power will become available to a reviewing panel.

ORDER: With effect from the expiry of the present period of suspension, namely from 11 August 2022, the Registrar is directed to suspend the Registration of Diana Zuramskiene for a further period of 12 months.

This Order will be reviewed again before its expiry on 11 August 2023.

History of Hearings for Mrs Diana Zuramskiene