Ms Eme S Ufomba

Preliminary Matters

Application to amend the allegation

1. Mr Mullen on behalf of the HCPC applied to amend the allegation as he stated that the amendments better reflected the evidence and clarified the allegation. The HCPC submitted that the proposed amendments were minor in nature and did not affect the substance of the allegation. The Registrant was notified of the proposed amendments by letter dated 22 June 2022.

2. The Panel was referred to the HCPC Practice Note on Case Management, Directions and Preliminary Hearings.

3. The Panel was aware that the HCPC’s rules are silent on amendments, but that it is within its jurisdiction to consider such applications. The principal factors the Panel must consider are whether any unfairness or prejudice arise should it permit the amendments.

4. The Registrant objected to the application to amend as she did not understand the need to change the words within the allegation. The Panel was satisfied that each of the proposed amendments were fair and could be made without any unfairness or injustice to the Registrant and that they better reflected the evidence. The Registrant has had adequate time to consider the proposed amendments and the Panel concluded that no prejudice or detriment were caused as the substance of the allegations were not affected.

Background

5. The Registrant is an Occupational Therapist who was employed as a Band 6 Occupational Therapist within the rapid response team at Virgin Care between 23 March 2020 and 4 December 2020.

6. On 29 July 2020, the Registrant attended Service User 1’s home address. Social services had requested that the Registrant undertake a functional assessment of Service User 1. Upon arrival, Service User 1 was unwell and was bleeding heavily from her lower body. The Registrant cleaned Service User 1, changed the blood-soaked bed mats and then left the property. The Registrant informed social services of Service User 1’s condition but did not contact emergency services.

7. Later that morning, carers from Austen Allen Agency arrived at Service User 1’s home. The carers found Service User 1 in a very poor condition and proceeded to call the emergency services.

8. Service User 1’s daughter made a formal complaint to Virgin Care regarding the care that was provided by the Registrant to Service User 1. As a result of the complaint, an internal investigation was conducted.

9. On 5 August 2020, Virgin Care made a fitness to practise referral to the HCPC.

10. On 19 October 2021, a panel of the HCPC’s Investigating Committee determined that there was a case to answer and that this matter should be referred to the Conduct and Competence Committee.

Evidence

11. The Panel heard live evidence from MW, AK and LH on behalf of the HCPC and considered the HCPC bundle of evidence of 200 pages. The Panel also had sight of the witness statement of the Registrant, the Registrant’s bundle consisting of 332 pages and an addendum bundle of 31 pages.

12. MW confirmed that the Registrant was employed by Virgin Care from 23 March 2020 as an Occupational Therapist in the Rapid Response Team. Due to the nature of the referrals the expectation was that an assessment would be carried out urgently. He stated that the clinical notes for 28 and 29 July 2020 were inadequate as they do not accurately record why the assessment was unable to take place, did not refer to the clinician speaking with the patient, gaining informed consent, there was no captured dialogue, and he would expect to see clinical reasoning and decision making recorded. Further, MW would expect the clinical notes to be completed immediately following the visit or within 24 hours as staff were provided with an iPad to facilitate remote working.

13. MW confirmed his actions upon receipt of the report in relation to this incident and confirmed that Service User 1 had been admitted to hospital.

14. MW was unable to confirm who had called the ambulance for Service User 1. He confirmed that the staff at Virgin Care should have had electronic access to social care records at that time, however, he was unable to confirm whether the information that Service User 1 had cancer was within the referral or the documentation which was available to the Registrant at that time. He confirmed that the rapid response team were not always provided with full or accurate information within the referral.

15. MW stated that the Registrant was taken off clinical duties while the matter was investigated. MW advised that if an occupational therapist found a patient bleeding in that way, he would expect some kind of escalation to a line manager or a call to a colleague for advice.

16. AK stated that she had been caring for Service User 1 for over a year and when she attended on 29 July 2020, she found Service User 1 to be unresponsive and clearly unwell. AK saw a number of large blood clots in the bed, she was not aware of any other similar incidents with Service User 1 and knew that things did not look normal.

17. AK spoke to her supervisor and then telephoned for an ambulance which arrived within around 15 minutes.

18. AK stated that she was aware that Service User 1 had dementia but was not aware of any other medical conditions.

19. LH advised that she worked for Kent County Council as a Case Officer and was working on the emergency desk on 29 July 2020 when she took a call from the Registrant. LH is not a qualified social worker.

20. LH stated that she made a record of the case notes after completing her conversation with the Registrant and calling the agency and the date and time were automatically added. She confirmed that the notes were not a verbatim account of what was said but reflected the conversation as much as possible. LH confirmed that there had been no agreement with the Registrant that she would call an ambulance and that had she been asked she would have done so.

21. LH described the Registrant as being in a state of severe shock and in need of an ambulance herself. LH confirmed that when she spoke with the agency they confirmed that they had called an ambulance to Service User 1.

22. LH stated that she considered it was necessary to call an ambulance as no one should be left bed bound in a vulnerable position whether life threatening or not. LH confirmed that there may have been things which she had misunderstood about the situation as the Registrant was clearly distressed when she called social services. However, her notes were written immediately following the call and reflect the situation as she understood it at that time.

23. LH confirmed that she had had no prior involvement in this case, was not aware of Service User 1’s medical condition, and did not know whether she had a social worker or when her needs were last reviewed. It was confirmed that as Service User 1 had been admitted to hospital it was the hospital’s responsibility to undertake a health care assessment.

24. LH confirmed that the telephone number which the Registrant had called was her direct dial number and that she would have got through to her. However, if she was on another call the call would be diverted through to admin and the case notes would show that. The notes reflect the fact that the Registrant gave LH her name during the call.

25. LH stated that the main focus of the call was in relation to the fact that the Registrant considered Service User 1 to be in the wrong type of accommodation to meet her needs. The Registrant was clearly distressed about the blood which was referred to by her as a ‘pool of blood’ as that is how she has recorded it on the notes.

26. The Registrant gave evidence and confirmed that she was employed as an Occupational Therapist in the Rapid Response Team of Virgin Care from 23 March 2020. She confirmed the evidence provided in her witness statement and that she was aware of what was expected of her as a qualified Occupational Therapist.

27. The Registrant stated that on 28 July 2020 she was assigned to visit Service User 1. She stated that she had the referral form which identified that Service User 1 had COVID 19 but the part about the care package was not on the referral which she received. The Registrant confirmed that she had an iPad but that there was not enough information, so it was necessary for her to go to the office to find out more.

28. The Registrant confirmed that she had visited Service User 1 on 28 July 2020 during the late morning and that Service User 1 had told her that she wanted to sleep and did not want to see her. She left and planned to return the next day. The Registrant stated that she entered her notes onto the system for that day on 29 July 2020, she did not recall adding any notes to the system on 28 July 2020. The Registrant advised that she had not received any training on the IT system but stated that she had made additional notes which were not in evidence.

29. The Registrant stated that when she attended upon Service User 1 on 29 July 2020 at around 8.45am there were some delays with being able to access the property. The Registrant stated that she spoke to the Warden who had advised her that Service User 1 had cancer and was immobile.

30. Upon finding that Service User 1 has been bleeding the Registrant cleared up the blood and returned to her car where she had left her phone. The Registrant stated that she thought about calling her manager, however her manager was not in work that day, she also considered telephoning a locum occupational therapist but she did not have a number for them. As she had received information about Service User 1 detailing a contact number for social services, she used the number to contact them about the situation.

31. The Registrant stated that she considered that she had nothing to offer Service User 1 as her needs required 24-hour care. The Registrant seemed to be aware that Service User 1 had carers attending upon her four times per day and considered that Service User 1’s nutritional needs had been attended to within the last 12 hours. The Registrant later went on to state that she believed that Service User 1 was being neglected as she did not have any water.

32. The Registrant advised that it took some time to clean up Service User 1 as she was on her own and two people were normally required to mobilise her. She stated that after cleaning her up, Service User 1 said in a firm voice ‘will you cover me up please’ and Service User 1 stated that she wanted to wait for the carers. The Registrant considered Service User 1 to be coherent and was of the opinion that the bleeding had stopped when she left. The Registrant recognised in hindsight that lots of bleeding can lead to anaemia or death.

33. In cross examination the Registrant confirmed that she was aware that Service User 1 ‘needed medical attention’ but she ‘first needed to make sure that she was comfortable’. The Registrant advised that compassion took over and her instinct was to make Service User 1 more comfortable and that as she did not have much information she did not know if this bleeding was normal. Due to the concerns she had, she rang the number she had for social care. The Registrant acknowledged that she could have asked Service User 1’s daughter for more information on any medical condition and stated that she was aware that people with ovarian cancer bleed around that area.

34. The Registrant stated that on reflection she should have called the ambulance first. The Registrant confirmed that she made a single call to social care and was confident that the lady she spoke with was called Charlotte. She stated that it was agreed that Charlotte would call an ambulance. The Registrant denied ever speaking to LH on the phone that day.

35. The Registrant stated that she was concerned that Service User 1 was there alone, immobile with no one caring for her in an inappropriate placement and this is why she rang social services as she wanted something better for her. The Registrant confirmed that she did not undertake the functional assessment as what was required for Service User 1 was way above anything that she could provide for her.

36. In cross examination the Registrant accepted that she could have called the ambulance when she went downstairs and could have returned to wait with Service User 1 for an ambulance to arrive but went on to state that the warden was there too and that she had run out of PPE equipment. The Registrant stated that she had three other visits to undertake that day and that as Service User 1 had been taken to hospital there was nothing more she could have done for her.

Decision on Facts

37. The Panel heard submissions from Mr Mullen on behalf of the HCPC in which he referred to the evidence to support the particulars of the allegation. The Panel also heard further from the Registrant.

38. The Panel was aware that the burden of proof lies with the HCPC and that the standard of proof in deciding whether the facts are proved is ‘on the balance of probabilities’. In other words, the Panel must be satisfied that the act or omission alleged is more likely than not to have occurred before it can find it proved.

39. The Panel looked at each particular of the allegation independently and in reaching its decision considered whether the facts set out in the allegation are proved, assessing the oral and written evidence, the credibility of the witnesses and attaching such weight as it saw fit to each piece of evidence.

40. It is not disputed that the Registrant attended upon Service User 1 on 28 and 29 July 2020. On 29 July 2020 Service User 1 was in bed and in blood stained bedding to the extent that the Registrant found it necessary to clean her up to make her more comfortable. The Registrant changed Service User 1’s blood-soaked bed sheets and left Service User 1’s property without making contact herself with the emergency services. When the carers arrived, they contacted 999 and Service User 1 was taken to hospital by paramedics.

41. It is accepted that the Registrant made contact with social services and informed them of Service User 1’s condition.

42. The Registrant disputes that she was provided with any, or adequate, information from her employer as to Service User 1’s medical condition and mobility and states that due to IT issues her additional notes regarding her visits were not on the system.

43. In assessing the evidence, the Panel found MW, AK and LH to be credible, reliable witnesses whose accounts were consistent and supported by the written evidence.

44. The Panel found the evidence of the Registrant to be chaotic and inconsistent and where there were conflicts in the accounts given, they preferred the evidence given on behalf of the HCPC.

Particular 1a is found proved

45. The Panel found that upon seeing that Service User 1 had been bleeding, the Registrant’s primary concern was to clean her up and make her comfortable, rather than considering whether there was a need for medical attention and / or treatment. Thereafter the evidence supports the fact that the Registrant’s focus appeared to be about the suitability of the placement.

46. The Panel considers that an experienced health care professional such as the Registrant should have acted upon the blood loss she observed by either calling immediately for an ambulance or by contacting a colleague for advice. The Registrant owed Service User 1 a duty of care and did not recognise that there was a need for medical assessment / treatment in relation to Service User 1 bleeding and failed to provide adequate care in the circumstances. The Panel found that the Registrant acted in the belief that Service User 1’s bleeding was caused by ovarian cancer. She formed this view after being told by the Warden that the service user had ‘cancer’. As a consequence of this the Registrant formed the assumption that the bleeding would have been caused by ovarian cancer. However, the Panel was presented with no evidence to support this assertion.

Particular 1b is found proved

47. The Registrant accepted in evidence that she had left Service User 1 and had gone to her car to make a phone call as this is where her phone had been left.

48. The Registrant accepted that she had not stayed with Service User 1 or returned to Service User 1 to await further assistance. The Registrant did not appear to know when the carers were due to attend upon Service User 1 and did not make that enquiry or make contact with Service User 1’s daughter to alert her to the situation.

49. The Registrant appears to have accepted the need for an ambulance to be called to Service User 1 but did not remain with Service User 1 until that assistance arrived.

Particular 1c is found proved

50. The Registrant accepts that she was not the individual who had called the emergency services requesting an ambulance for Service User 1. The Registrant did not appear to know who was responsible for calling the ambulance.

51. The Panel does not accept that the Registrant spoke to anyone called Charlotte at social services. The Panel having found LH to be a credible and reliable witness whose evidence was corroborated by the notes made up by LH immediately following the call finds that the Registrant spoke to LH. The notes do not support any discussion taking place between them regarding an ambulance being called by LH.

52. In evidence AK confirmed that she had called the ambulance.

Particular 1d is found proved

53. The Panel accepts that the Registrant made a call to social services after she left Service User 1. The Panel finds that the Registrant should have made contact with another health care professional (GP,111, nurses employed by Virgin Care) had she recognised the need for medical assessment / treatment – she did not.

54. The Panel finds that the Registrant’s primary concern in making contact with social services related to the inadequate accommodation rather than the presenting medical condition.

Particular 2 is found proved

55. The Panel finds that a qualified health care professional of the same level of experience as the Registrant should have called an ambulance immediately upon finding that Service User 1 had been bleeding. As a result of the time spent by the Registrant cleaning up Service User 1 before leaving the address and making a phone call there was a delay in Service User 1 receiving the medical treatment which she required.

56. The carers attended upon Service User 1 over an hour after the Registrant’s arrival at the address and this resulted in a delay in an ambulance being called, a delay in Service User 1 receiving the medical treatment required, and also a deterioration in her condition.

Particular 3a is found proved

57. The Panel finds that the clinical notes recorded by the Registrant were inadequate and incomplete. It would not be clear to anyone reading those notes what was happening with Service User 1. There was no risk assessment, no acknowledgement of the need for medical assessment and/or treatment for the service user and there was no detail provided in relation to the setting / lack of care, with an action plan for that service user. Critically there was no indication of any clinical reasoning.

58. The Panel finds the IT issues experienced at other times irrelevant to this issue as the Registrant has clearly had access to the system to have added the notes which she did. They are simply not detailed enough to reflect the situation.

Decision on Grounds

59. The Panel next went on to consider whether or not the facts found proved amounted to the statutory ground alleged, misconduct, which is a matter of judgment for the Panel.

60. The HCPC argue that the findings of fact establish that the Registrant acted in a way which fell far short of what would be proper in the circumstances and what the public would expect of a HCPC registered Occupational Therapist. The HCPC argue that the Registrant breached standards 3.2, 6.1, 6.2, 7.1, 7.3, 10.1 and 10.2 of the HCPC Standards of Conduct, Performance and Ethics 2016.

61. The Panel was referred to Roylance v General Medical Council (No 2) [2000] 1 A.C. 311 where the Privy Council defined “misconduct” as “a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a medical practitioner in the particular circumstances”.

62. The Panel having found all of the particulars of the allegation proved considers that these matters are serious in nature and amount to misconduct. The Registrant failed to deal with the situation presented to her and failed to undertake a risk assessment. There are numerous failings in relation to the Standards of Conduct, Performance and Ethics and the Panel can only conclude that the Registrant’s actions and omissions fell short of what would be proper in the circumstances.

Decision on Impairment

63. The Panel went on to consider impairment. It heard submissions from Mr Mullen and from the Registrant.

64. Mr Mullen argued on behalf of the HCPC that the acts / omissions found proved are capable of being remedied. However, as there has been little evidence of any remedial action in terms of training or reflection by the Registrant there was a clear ongoing risk of repetition.

65. The HCPC consider that there has been limited insight shown by the Registrant. It was stated that throughout the hearing the Registrant has failed to take responsibility for her acts / omissions, she did not acknowledge that her actions fell short of the required standards and the HCPC argued that the Registrant has sought to pass blame or responsibility onto others for what occurred in an attempt to excuse her own failings.

66. Mr Mullen considered that the Registrant has demonstrated a limited understanding of the consequences of her actions and in a situation where she had limited information, she should have taken greater care to ensure the safety of Service User 1. The HCPC argued that there is a clear risk of harm to service users. For this reason, the HCPC argued that the Registrant’s fitness to practise is currently impaired. Additionally, the HCPC argued that the conduct in the allegation is so serious that finding that the Registrant’s fitness to practise is not impaired would undermine both public confidence in the profession and in the regulatory process.

67. The Registrant made submissions that she had walked into a crisis situation on 29 July 2020 and that she did not intend any harm to be caused to Service User 1. She stated that she had reflected and would do things differently in future to ensure this would not happen again and it was a one-off situation. The Registrant confirmed that in future she would call an ambulance herself and obtain other contact numbers of people who could advise her.

68. The Registrant advised that she has undertaken safeguarding and record keeping training. She stated that if she had inadequate information about a service user in the future then she would not attend the visit. She stated that she tried to do the best she could as she is a compassionate person. She stated that whilst she accepts that she could have written more notes for Service User 1 she had not lied about the IT difficulties that she had encountered. She also reflected that if she was not well in future she would not go into work.

69. The Panel received legal advice and paid close attention to the Practice note entitled ‘Fitness to Practise Impairment’. It considered fitness to practise with reference to the public component and personal component. The Panel was aware that the test of impairment is expressed in the present tense and the Panel was tasked with determining whether the Registrant’s current fitness to practise is impaired.

70. There were no character references or testimonials for the Panel to consider.

71. In considering the personal component, the Panel was persuaded by the arguments advanced on behalf of the HCPC. The Panel had found misconduct which is remediable. However, at this time there is extremely limited evidence of insight or remediation on the part of the Registrant and there is therefore a risk of future repetition.

72. The Panel was concerned that the Registrant continued to advance a case which was not supported by the evidence and was unable to acknowledge the findings of the Panel in her representations. The Registrant continued to apportion blame in relation to the situation upon others and was unable to take responsibility for her own acts / omissions.

73. The Panel acknowledged that this was a one-off incident and was not intentional but was concerned that the Registrant’s reflections related primarily to the impact of the situation upon herself rather than to the safety of service users.

74. The Panel noted that the Registrant has undertaken some online learning in relation to first aid, safeguarding vulnerable adults and emergency resuscitation.

75. The Registrant did not demonstrate acceptance that her behaviour fell below the standards required, and she has not demonstrated that she is aware of how and why the misconduct occurred. There is no evidence that the Registrant undertook a clinical or risk assessment of Service User 1 on finding the situation such as she did on 29 July 2020. The Panel considers that the Registrant should have obtained further information about Service User 1 either prior to the visit or from the service user herself, she should have recorded clear clinical rationale for her decisions. By her omissions and her actions the Registrant failed in her duty of care to the service user. The Registrant believed what the Warden had told her about the service user’s medical condition and made an assessment of the service user’s situation without either verifying the medical condition of the service user or being clear about the service users wishes and preferences. The Panel concluded that until the Registrant is able to acknowledge and address the actions which led to the misconduct there is an increased risk of repetition.

76. The Panel concluded that the Registrant lacks insight and the risk of repetition is high. In particular, the Registrant has not acknowledged that there was a delay in Service User 1 receiving medical assessment and /or treatment, does not accept that her behaviour fell below professional standards, has shown no understanding of the potential consequences of her actions upon Service User 1 and has failed to acknowledge the impact on the wider reputation of the profession.

77. The Panel was concerned that the lack of insight shown by the Registrant means that she has failed to demonstrate an understanding that her actions may have made Service User 1’s condition worse. The Panel determined that there is a risk of harm to service users due to the reckless disregard of risk demonstrated by the Registrant on this occasion.

78. Whilst the Registrant is entitled to advance a defence, the Panel finds that the account given by the Registrant lacks credibility. The Registrant has failed to demonstrate an understanding of, or is unwilling to accept, the findings of the Panel in relation to the facts found proved within the allegation, and she continues to attempt to deflect responsibility onto others.

79. The Panel is under a duty to protect service users from harm and risk of harm and finds that, due to the lack of insight and remediation, there is a risk of the Registrant causing harm to service users in the future. The public is entitled to expect registrants to be professionally competent.

80. In considering the public component the Panel concluded that the public would be dismayed if there was no finding of impairment following a misconduct allegation of this nature being found proved. The Panel agreed with the HCPC that the public interest demands a finding of impairment. On any view, the finding of misconduct is serious and would cause concern to the public if there was no finding of impairment.

81. The regulatory process is in place to ensure professional standards are maintained and to ensure the public has confidence in the profession and its regulator. The Panel had found that the Registrant was in breach of standards 3.2, 6.1, 6.2, 7.1, 7.3, 10.1 and 10.2 of the Standards of Conduct. Performance and Ethics 2016. These are fundamental tenets of the profession, and such breaches bring the profession into disrepute.

82. The Panel therefore finds that the Registrant’s fitness to practise is currently impaired on both the personal and public components.

Decision on Sanction

83. The Panel heard submissions from Mr Mullen and the Registrant. Mr Mullen highlighted the aggravating features in this case: that there was a risk of harm to a vulnerable service user and lack of insight. The Registrant expressed a limited degree of insight and remorse for the situation which she finds herself in. She expressed a commitment to make amends to ensure this does not happen again.

84. The Panel received legal advice and referred to the Sanctions Policy. The Panel considered in detail the Sanctions Policy and was aware that they should consider the least restrictive sanction first, working up only where necessary. The Panel was aware that the final sanction should be proportionate, and the minimum required to protect the public.

85. The Panel reminded itself of the principle of proportionality, balancing the Registrant’s interests against the public interest and was mindful that the purpose of a sanction was not to punish the Registrant, but to protect the public from harm and to maintain public confidence in both the profession and in the regulator. The Panel recognised that sanctions can be punitive in character and effect.

86. The Panel referred itself to the Sanctions Policy and found the following mitigating features present:-

• The Panel considered the timing of the incident, being in the midst of a COVID 19 pandemic, as highly relevant, as this will have presented additional challenges to an already struggling health and social care system.

• The Panel noted that this was a one-off incident, and that the Registrant has no regulatory history.

• The Panel accepted that the Registrant had shown some care and compassion in dealing with Service User 1.

• The Panel acknowledged that the Registrant had engaged in the regulatory process and had attended the hearing.

87. The Panel found the following aggravating features present:-

• The Panel found the Registrant’s insight to be extremely limited and as she had failed to recognise her failings the risk of repetition remains high. Whilst there was some care and compassion shown towards Service User 1 the Panel found that this was misdirected and did not focus upon her immediate medical needs. In addition, the Registrant failed to demonstrate that she had considered Service User 1’s wishes and feelings and respond accordingly. The Registrant failed to recognise that she may have made Service User 1’s condition worse by both moving her and delaying her medical assessment and/or treatment.

• In considering remediation the Panel found that whilst the Registrant had reflected on the fact that in the future she would write more detailed notes and telephone for an ambulance, this appeared to be more to protect the Registrant from future regulatory investigation rather than out of concern for the safety of service users.

• Health care professionals have a duty of candour and a professional duty to be open and honest when things go wrong with the care, treatment and service they have provided. The Panel found that in this situation the Registrant had been less than open and honest in her account to the Panel.

• The Panel considered the issue of remediation and found this lacking on the part of the Registrant. The Registrant did not recognise the deficiencies in her conduct, and there was no evidence that she had made changes to her practice as a result of any lessons learnt or as a result of the online training which she has undertaken. The Panel is of the view that the Registrant’s attempts at remediation have been hindered by her lack of insight.

88. The Panel decided that the matters found proved are serious and involved a vulnerable service user where there was a potential for serious harm being caused. The Panel referred itself to paragraphs 59-62 of the Sanctions Policy and determined that there was both a failure to raise concern and a failure to work in partnership with health care colleagues in the circumstances of this incident. The Registrant failed to report concerns about the safety or wellbeing of Service User 1 promptly and appropriately.

89. The Panel did not feel that this matter could be concluded with either no order or a caution. They did not consider these to be appropriate sanctions due to the serious nature of the concerns raised and the requirement to protect the public from harm and to ensure that confidence in the regulatory process is maintained. The Panel concluded that some restriction on the Registrant’s practice was necessary to address the serious concerns.

90. The Panel next considered a Conditions of Practice Order. The Panel determined that whilst this was a one-off incident and the concerns found proved are capable of remediation, the matter was serious and there was a significant risk of harm being caused to Service User 1. The Panel found that the Registrant had not been able to acknowledge the failings which led to the regulatory action being brought against her. The Panel concluded that the issues are largely attitudinal in nature in relation to the lack of insight demonstrated by the Registrant.

91. The Panel reflected on paragraph 108 of the Sanctions Policy which states that ‘Conditions are also less likely to be appropriate in more serious cases, for example those involving… failure to raise concerns… failure to work in partnership’.

92. The Panel also looked at paragraph 115 of the Sanctions Policy which states ‘The panel’s primary concern should be to protect the public and public confidence in the profession. If it is not able to draft workable conditions that achieve this, it may need to consider imposing a suspension order’.

93. The Panel determined that a Conditions of Practice Order would not be appropriate, or workable and that any conditions would be tantamount to a suspension. Conditions of practice would not be sufficient to mitigate the risk of the Registrant remaining in unrestricted practice.

94. The Panel concluded that a Suspension Order is the only sanction which can be imposed in the circumstances. The order is both necessary and proportionate to protect the public from the risk of harm that the Registrant poses and to meet the public interest in maintaining confidence both in the profession and the HCPC.

95. The matters found proved are serious in nature and there is a high risk of repetition whilst the Registrant’s insight remains so limited. The Panel concluded that the Registrant requires a period of time to reflect to gain and develop a fuller insight into the failings which led to the findings against her and to mitigate any future risk of harm through reflection and remediation.

96. The Panel did carefully consider a Strike Off Order but decided that this would be disproportionate when a Suspension Order would be sufficient to protect the public and mark the public interest in this case. Strike off Orders should be reserved for the most serious cases of misconduct and the Panel had found on the facts that the Registrant’s acts and omissions were reckless rather than deliberate, and this was a one-off incident at a time when the Registrant was clearly distressed by the situation she was presented with. The Panel considered that the Registrant should be afforded the opportunity to develop the appropriate insight.

97. The Panel therefore decided to impose a Suspension Order for a period of 12 months.

98. The Panel considered that a future panel reviewing this order may be assisted by:

• Details of how the knowledge gained by the Registrant from courses; such as first aid, safeguarding vulnerable adults and emergency resuscitation has been transferred to her clinical practice.

• A reflective practice piece regarding the Panel’s findings, what went wrong in this case with regards to harm / potential harm caused to Service User 1, the impact of her acts / omissions on the profession and its regulation, and how the Registrant will change her future practices as a result.

• Evidence of understanding the requirement for and practice of keeping robust records which clearly outline the clinical rationale for any decisions made by the Registrant.

• Evidence of understanding the requirement for and practice of undertaking robust risk assessments.

• A case study of how the Registrant has effectively worked in partnership with other health professionals.

• The provision of up to date character references / testimonials about the Registrant.

Order: The Registrar is directed to suspend the registration of Ms Eme Ufomba for a period of 12 months from the date this Order comes into effect.

Interim Order

Application

1. Mr Mullen submitted that the Panel should consider covering the appeal period by imposing an 18-month Interim Suspension Order on the Registrant’s registration. He submitted that such an order is necessary to protect the public and is otherwise in the public interest and that such an order was appropriate and proportionate in the circumstances of the case.

Decision

2. The Panel heard and accepted the advice of the Legal Assessor.

3. The Panel noted that the Registrant had been informed by the Notice of Hearing dated 25 May 2023 that if this Panel found the case against her to be well founded and imposed a sanction which removes, suspends or restricts her right to practise, the HCPC may make an application to the Panel to impose an Interim Order to cover any appeal period. The Notice of Hearing clearly stated that, “An Interim Order suspends or restricts a registrant’s right to practise with immediate effect.” The Panel determined that it would also be fair and in the interests of justice to consider an Interim Order application as the Registrant was on notice that such an application may be made.

4. The Panel paid careful regard to the HCPTS Practice Note on Interim Orders, which offers guidance on Interim Orders imposed at final hearings after a sanction has been imposed. The guidance states that registrants should be made aware of the potential for an Interim Order to be imposed on their registration after the panel has made a substantive order and should be given an opportunity to make representations in respect of an Interim Order.

5. The Panel recognised that its power to impose an Interim Order is discretionary and that the imposition of such an order is not an automatic outcome of fitness to practise proceedings in which a Suspension Order has been imposed. The Panel must take into consideration the impact of such an order on the Registrant. However, the Panel was mindful of its findings in relation to the Registrant’s misconduct and the risk of repetition if the Registrant were able to practise without restriction.

6. The Panel decided to impose an Interim Suspension Order, with immediate effect, under Article 31(2) of the Health Professions Order 2001. The Panel was satisfied that an Interim Suspension Order is necessary for the protection of the public and is otherwise in the public interest to maintain confidence in this regulatory process.

7. The period of this order is for 18 months to allow for the possibility of an appeal to be made and determined.

Interim Suspension Order:

The Panel makes an Interim Suspension Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest.

This Order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

History of Hearings for Ms Eme S Ufomba