Maria Efthymiou

Preliminary Matters

Amendments to the Allegation

1. At the commencement of the hearing Mr Ross, on behalf of the HCPC made an application to amend the original Allegation as indicated above. He submitted that: The proposed amendment to particular 1b) would clarify the language used. The proposed amendment to particular 1d) would also clarify the particular, by specifying the relevant time period. The proposed amendment to particular 2 was to delete that particular and there were some further minor amendments. The Registrant was given notice of the proposed amendments in July 2022 and did not oppose the amendment application.

2. The Legal Assessor advised the Panel that there is a general discretion to permit amendments at any stage, subject to the fairness of the application and the extent to which it clarifies the HCPC case.

3. The Panel granted the HCPC’s amendment applications, on the basis that particular 2 was being correctly withdrawn to reflect the HCPC’s evidence, with no element of under prosecution. The remaining amendments were minor and assisted the Registrant and the Panel by clarifying the HCPC case.

Background

4. Miss Maria Efthymiou (‘the Registrant’) was employed by Manx Care, for the Isle of Man Government as a Band 7 Advanced Wheelchair Occupational Therapist from January 2015 until 15 August 2018. Prior to this, she worked for the same employer as a Band 6 Occupational Therapist from 9 August 2006 until 23 January 2015. On 13 April 2017, the Registrant was suspended from work pending an investigation into concerns raised. On 4 September 2017, the HCPC received a self-referral from the Registrant. On 20 October 2017, the HCPC received documentation from the Registrant’s employer Manx Care. In January 2017, concerns regarding the Registrant’s practice had come to light after it was reported that one of her patients, Patient A, had developed a pressure ulcer from his wheelchair. In April 2017 a second unrelated complaint had also come to light relating to an assessment of a child, Patient B. The employer confirmed that the concerns being investigated were as follows:

a) Poor clinical record keeping;
b) Outstanding assessments/actions;
c) Poor communication between the Registrant and the contractor;
d) Inadequate assessment of patients;
e) Inadequate monitoring of a patient;
f) No routine monitoring of wheelchairs or pressure cushions;
g) Inability to draw on appropriate knowledge and skills to inform practice.

HCPC’s submissions

5. Whether any proved facts amount to the statutory ground of misconduct is a matter of judgement for the Panel. The HCPC submits that if the conduct alleged in particulars 1-2 is found proved, this establishes that the Registrant acted in a way which fell far below what would be expected in the circumstances and what the public would expect of a HCPC registered Occupational Therapist. It is alleged the Registrant breached standards 1, 2, 3, 4 and 10 of the HCPC Standards of Conduct, Performance and Ethics (January 2016) and standard 8 of the HCPC Standards of Proficiency for Occupational Therapists (March 2013).

6. Whether any misconduct found gives rise to impairment of fitness to practise is also a matter of judgement for the Panel. The HCPC submits that if the proved facts are determined to constitute misconduct, there is an on-going risk to patients given the seriousness of the alleged misconduct and the lack of self-reflection by the Registrant. There is a risk of repetition and the alleged misconduct is so serious that a finding that the Registrant’s fitness to practise is not impaired, would undermine public confidence in the profession and the regulatory process.

7. In view of the fact that the Registrant is unrepresented in these proceedings, the HCPC invited the Panel at the outset of the hearing to determine first whether any of the factual particulars were proved and if so, whether the ground of misconduct was well founded. The Registrant did not object to this proposal.

8. The Panel therefore made decisions on the facts and ground at the first stage of this hearing. The Registrant indicated that she admits factual particulars 1a) i-iv inclusive, 1b) and 2. She denies particulars 1a) v 1c) and 1d.

HCPC’s Evidence

9. The Panel heard evidence from HCPC witnesses AS (formerly AP), JB, SG, MB and FB. They each adopted their witness statements and produced exhibits, and this comprised their evidence in chief.

10. AS has been employed by Manx Care as a Care, Quality and Safety Coordinator for Community Health Services on the Isle of Man since July 2017. She was appointed as the investigating officer initially to consider the Registrant’s conduct with regard to Patient A.

11. JB has been the Clinical Team Lead in Community Adult Therapy for the Isle of Man Government since July 2017. As Patient Safety and Governance Coordinator, she completed a Root Cause Analysis (RCA) concerning the Registrant’s treatment of Patient A. The RCA raised concerns regarding the Registrant’s assessment and care of Patient A.

12. Patient A was a paraplegic long-term wheelchair user who was known to have suffered from an acute brain injury and behavioural insurgence which left him vulnerable. On 26 October 2016, the Registrant had an appointment with Patient A and measurements were taken for a new wheelchair. During the appointment the Registrant failed to check Patient A’s cushion or pressure areas, despite him being a high-risk client. There was no evidence to suggest the Registrant carried out a thorough assessment of the patient during this appointment. It was agreed that a new wheelchair would be sourced for Patient A. The Registrant did not book an appointment for a review of Patient A whilst he was waiting for his new wheelchair to arrive. In December 2016, Patient A was referred to the District Nursing team with a Grade 4 pressure ulcer on his buttock. An examination of Patient A’s wheelchair revealed significant damage to the cells of his pressure cushion.

13. JB stated that the Registrant should have performed a full range of assessments of Patient A. It is expected that a full initial and functional assessment will be carried out to identify what needs the patient has and patients who rarely attend appointments should be treated as new patients. This would apply to Patient A as he had not been reviewed in the wheelchair clinic for 2 years. By failing to assess Patient A thoroughly during his appointment on 26 October 2016, the Registrant missed an opportunity to intervene and reduce harm. A full functional assessment would have revealed the presence of a pressure sore or would have highlighted the increased risk of Patient A developing one. This was compounded by failing to arrange a follow up appointment with Patient A whilst he was waiting for his new wheelchair.

14. JB stated that any newly qualified Occupational Therapist would have the skills to undertake the assessments that the Registrant should have carried out on Patient A. The Registrant had been provided with training and support and therefore should have carried out an adequate assessment of Patient A. The assessment that she was expected to complete was basic and taught to any Occupational Therapist as standard. Notes on Patient A had been written by the Registrant retrospectively, after she became aware of the RCA. There were no pictures of the patient, documentation of what he needed or management plan.

15. The Registrant had tried to place the blame for everything onto managers, systems or Ability Matters (a company providing contracted in services to the Wheelchair Service, also referred to as Opcare). Her attitude to the RCA was very defensive and she did not demonstrate any insight or remorse during her interview. The Registrant did not reflect on anything that was fed back to her. She was asked about patient records and whether her understanding that Ability Matters were going to order the wheelchair would be recorded. She responded "of course", or words to this effect and when presented with records showing no corresponding entry, did not seem concerned. When asked who had responsibility to arrange reviews, the Registrant responded that it would be her or her Line Manager. The Registrant did not know that the records show Patient A had the same cushion for 11 years because the Registrant had not read the notes. Her reply was that this did not mean he had not had another cushion in the meantime. There were concerns regarding her professionalism, poor clinical recording and communicating within the team, between the Registrant and the contracted service. When she was shown her training record of 6 courses in 2 years, she stated it was not enough and that she did not consider that she had sufficient skill to carry out the necessary assessments.

16. JB stated in her evidence in response to cross-examination, that it was the Registrant’s responsibility to conduct a full assessment of Patient A and record the outcome. The training records show the Registrant had received more training than was usual. The clinical assessment should be performed by the therapist not the contractor who was not a registered healthcare professional. JB stated the Registrant was keen to participate in the RCA but was very defensive and felt it was somebody else’s fault; (e.g. due to her lack of training). The RCA concluded there were many causes and factors for the harm to Patient A. One factor was the professional ability of the Registrant. In reply to Panel questions, JB stated it was difficult to get a clear picture of who was responsible for placing wheelchair equipment orders and following up these orders and there was no procedure to follow up Patient A, until the ulcer was revealed.

17. SG was an Ability Matters Senior Occupational Therapist who expressed concerns regarding the Registrant’s conduct which she observed during a visit on 7 March 2017, in relation to Patient B. SG raised concerns that the Registrant had not carried out a postural management assessment of Patient B. He was a child who was still growing and required an adjustment to his wheelchair following a growth spurt and the fact that he had a cast to his leg following a fracture. He was a high-risk patient due to his young age and therefore more care needed to be taken in terms of looking after his posture. SG challenged the Registrant’s clinical reasoning for requesting that BV (an engineer) carry out the postural assessment. The Registrant stated BV was far more qualified to carry out the assessment than she was. SG stated that the Registrant did have the ability to carry out the assessment, was suitably qualified and carrying out this assessment was part of her role.

18. A postural management assessment is carried out to look if there is symmetry, identify any pressure areas and determine what equipment is available and provide the client with a suitable wheelchair. This assessment is carried out on a patient if they have not been seen recently, or there is a change in circumstances. The Occupational Therapist will look at the client from head to toe whilst they are on a plinth both whilst they are lying down and whilst they are sitting. When the Registrant asked BV to carry out the postural assessment SG challenged her clinical reasoning, as BV is a rehab engineer and although he had some skill around postural management, he is not a qualified Occupational Therapist. SG did not believe that BV should be carrying out the postural management assessment alone. His skills may allow him to offer what equipment is available as a solution to an identified issue, but looking at the patient's anatomy and conducting the physical assessment should always fall to the qualified Occupational Therapist.

19. SG stated that on 7 March 2017 the Registrant was very agitated and shouted with a lot of aggression in her tone of voice and body language when SG challenged her. The Registrant appeared defensive about the fact that SG had challenged her and the Registrant left the assessment room. SG carried out the assessment and was able to identify that Patient B’s pressure cushion was not supportive, could cause a pressure area (referred to as "bottoming out") and was an emergency. He had fractured a bone in one of his legs and was in a cast. The clinical decision was to request an elevated foot rest that could be adjusted to give support and a new cushion. This was how the assessment should be carried out by an Occupational Therapist and a rehab engineer.

20. The day after the appointment with Patient B, the Registrant called SG and BV into her office and said that they had not been working as a team. The Registrant stated that she had been patient and diplomatic about SG and BV being there, but was annoyed that BV appeared grumpy. This rang alarm bells for SG as the Registrant had chosen to focus on the group dynamic, rather than the questioning of her Occupational Therapy clinical reasoning and assessments. SG subsequently raised her concerns about the postural management assessment of Patient B, in an email to her manager.

21. SG stated in her evidence in response to cross-examination, that it was not correct that postural assessment could be done without training, as it was a complex assessment. The Registrant was qualified to assess Patient B and she was employed to carry out that type of assessment. A new postural assessment by an Occupational Therapist (not an engineer) was required. The Registrant had the skills to do so, based on her training. SG had attended a similar course delivered by the same provider albeit 3 years later, and it gave the necessary skills and training.

22. MB is Project Lead for Intermediate Care for the Isle of Man Government. At the relevant time she was employed as the Head of Therapies and Podiatry. She stated the Registrant was employed as a Band 6 Occupational Therapist at the Department of Health and Social Care (which became Manx Care) from 9 August 2006 until 23 January 2015. In January 2015, the Registrant was interviewed and redeployed in the Band 7 Advanced Wheelchair Therapist role until 15 August 2018. Her role was to provide expert assessment and advanced solution-based intervention for persons referred to the Isle of Man Wheelchair Service; and provide wheelchairs in line with national guidance and local policy.

23. MB was the Registrant’s operational manager in 2015 for 2 years and held management supervision with her once per month. Clinical supervision of the Registrant was to be undertaken by the Occupational Therapy Lead.

24. The Registrant came to the wheelchair service as a transfer from another occupational therapy job and needed additional help with the more specialist aspects of the Wheelchair Service, such as postural management and product information. She received training in postural assessments, products and manual and powered wheelchair assessments. MB anticipated that it would take between 18 months and 2 years for the Registrant to have obtained the relevant additional help and training, to allow her to adequately fulfil her role. The Registrant attended specialised training courses, including a postural management group conference between 18 July and 20 July 2016 and a specialist course for the assessment and treatment of postural management and seating issues in adults and children, from 6 December to 9 December 2016.

25. In addition, a contract was agreed with Ability Matters to support the Registrant in her learning and development as a wheelchair specialist. The Wheelchair Provider Service gave support and training to her, whilst she was increasing her knowledge and skills. The contract supported the Service technically and for specialist seating. Ability Matters would send a seating assessor to the Isle of Man every 2–3 weeks. Anybody who wanted support could speak to the seating assessor or request a dual appointment, to learn and discuss queries.

26. MB stated in her evidence in response to cross-examination, that the Registrant was responsible for her actions as a professional. The Registrant had asserted that the service was understaffed but had not presented MB with any statistics or objective evidence to substantiate that claim.

27. In re-examination MB stated the Registrant should have been fully able to practise in her role after 12 to 18 months of bedding in at the Wheelchair Service. The oral evidence of MB where she stated the time frame of 12-18 months bedding in a wheelchair service was different to her statement which gave the timeframe as 18-24 months. It was the Registrant’s responsibility as the clinician to assess patients’ needs in relation to the prescription of wheelchairs. An engineer would provide solutions once the problems were diagnosed. As a qualified Occupational Therapist, the Registrant should be able to decide if a wheelchair is suitable for a patient. It was not correct that the Registrant was unable to assess patients due to staffing levels in 2016-2017. In response to Panel questions MB stated that the clinical assessment by the Registrant of Patient A in October 2016 should have included: functional and cognitive ability, skin checks, ability to transfer, pressure care requirements and the pressure cushion, behaviour and engagement with services, a review of records, ordering and delivery of equipment and a follow up appointment. MB further explained that at no point was the Registrant asked to deliver care outside her skills.

28. FB (Interim Head of Therapies at Manx Care) confirmed she has produced all the documents which were available in relation to the Registrant’s request.

The Registrant’s Evidence

29. The Registrant gave evidence and went through each particular in turn.

30. In relation to Patient A, and her admitted lack of assessment or record of his functional, cognitive and physical abilities (particular 1 a(i)), The Registrant said that she was not the assessor. It was the role of ‘Ability Matters’ to assess the patient. The patients who came into the clinic to be assessed were those patients whom she did not have the knowledge or skills to assess. This patient was paraplegic with an acquired brain injury. The Registrant was not equipped to assess patients with complex neurological impairments. Her role as service lead was to receive referrals, triage them, and decide who was to assess each patient. It had been agreed with MB that complex patients would remain patients of Ability Matters. Patient A’s wheelchair was not functioning properly, so the Registrant carried out her role by getting him an assessment in the next available clinic. She was present in the clinic and took the notes. Those notes made clear that she was not the assessor. Both Patient A’s diagnosis, and the type of wheelchair he used were things she had no experience of. Further, the goal for Patient A was a new wheelchair. The assessment was targeted to that goal. These assessments were not relevant for that goal to be achieved.

31. Particular 1a(ii) was that the Registrant did not complete or record a skin check. She had admitted this. She stated that in her time in the wheelchair service, she had never seen any visiting assessors undertake a skin check. When the Registrant moved to the service, she learnt by observing. She suggested that there was no need to perform a skin check every time a patient was seen. Patient A did not mention issues with pressure areas. This allegation was the first time she had heard of the need for skin checks in the wheelchair service. The Registrant disputed the assertion of MB that that skin checks are done for every patient.

32. Particular 1a(iii) was that the Registrant did not assess Patient A’s ability to transfer. She had admitted she did not do so. She stated that this assessment was not always done in clinic. She would do this if a patient had said their arms had become weaker, or given information that indicated transfers were a problem, for example a patient was struggling to transfer to bed at night. Patient A was in his early 30s and his upper body was physically fit. Transfer assessments were not done every time a patient was seen, it depended on why the patient was being seen.

33. Particular 1a(iv) was admitted. The Registrant did not assess or record pressure care requirements or examine the pressure on Patient A’s pressure relieving cushion. She accepted that she could have done this, and although she was not the assessor, not having intervened to undertake this assessment was her biggest regret. However, Patient A did not mention anything about a new cushion, and neither she, nor the assessor picked up on the potential need for this assessment. The Registrant said that she had done some pressure care training early on in her role as a wheelchair therapist, and that her biggest goal was to try to prevent pressure sores. She had been to a conference and was taught about the grades of pressure sores, but it was not a wheelchair specific conference. This (the pressure sore) was the part she felt most responsible for. The assessor needs to take part of the responsibility, but this was her hearing. The Registrant explained that they did not review cushions in every clinic. Patient A did not say the cushion was an issue. The assessor said Patient A's posture looked ok. Her guess was that the assessor’s judgement was that the cushion was ok. Checking it did not cross her mind. The Registrant was aware witness JB had said the cushion was 10 years old, but she did not think it was so old, however she had been unable to obtain the ward notes.

34. Particular 1a(v) was that the Registrant did not assess Patient A’s behaviour and/or engagement with services. This was denied. The Registrant stated that when a patient comes into clinic, these things are assessed throughout via observation. There was nothing untoward about Patient A’s behaviour. Technically, she did an assessment, in that she listened to him. There was no non-engagement with the service. The Registrant stated that she was aware that in the past there had been issues with Patient A not accessing the service and not undergoing monitoring. She had read that he had stopped phoning and would just come in. Under cross examination, it was put that the Registrant made no reference in her note to Patient A’s engagement or behaviour. She stated that her notes relate to a particular episode in time. Patient A was presenting normally, so nothing was recorded. In terms of compliance or engagement, he had come to the clinic. That was compliance. He had agreed to the assessment, and there had been nothing to indicate that he did not want to be assessed.

35. The Registrant had admitted particular 1b, that she did not review Patient A’s notes before or during the appointment on 26 October 2016. She accepted she did not go back very far, and it had been suggested by witness JB that she should have reviewed all the notes. However, clients would not get a full assessment for everything. When the Registrant took 
on the role she shadowed for 4-6 weeks. The person she shadowed would run through the notes, but they would not look at all the notes together. The way the Registrant wrote her notes was very much the way she had seen notes written by others. She did pick up Patient A’s notes, she knew his diagnosis, and she wrote in the notes. The Ability Matters assessor would have had access to the clinical notes. If he was assessing the patient, he would have read them.

36. Particular 1c had been denied. This was that the Registrant did not ensure that the relevant equipment was ordered or follow up on the ordering after Patient A’s clinic appointment on 26 October 2016. The Registrant accepted, following input from the panel, that this related to ordering a wheelchair. She stated that the clinic appointment had not been with her, but with Ability Matters. She said that when someone has done an assessment, the next step is to place an order. She just expected that this was what they were going to do. JB had stated in evidence that Ability Matters’ role was to identify a product. They were supposed to provide the Registrant with a quote to sign off. The Registrant did not believe she was sent a quote. Had she been sent a quote, she would have been prompted to know when the wheelchair was ordered. What happened was that Ability Matters had not placed the order. She should have chased that up. ‘Admin’ would normally chase up to say a quote had not been received. The Registrant did not ensure that the equipment was ordered as she believed it was Ability Matters role. In terms of follow up, that was for admin, and the admin was not great. If admin had been functioning, it would have been followed up.

37. In cross-examination it was put to the Registrant that her job description included to ‘arrange the provision of standard and non-standard specialist disability equipment’. She accepted that this was part of her job.

38. Particular 1d was also denied. This was that the Registrant did not arrange a follow up appointment with Patient A between 26 October 2016 and 30 January 2017. The Registrant stated that Patient A was seen by an engineer on 18 January. The Registrant did not arrange a follow up, but she did see Patient A on that date. She had to follow him up due to the pressure sore being reported. Patient A was brought into clinic on 18 January, but that was not to assess him functionally, it was because the seat canvas and backrest for his old wheelchair had come in. The person fitting those items wanted the Registrant to be present as they were not a clinician.

39. In cross examination the Registrant was asked whether she accepted she did not make a follow-up appointment. She replied that she did arrange follow up because she saw Patient A on 18 January. She then appeared to accept that she did not arrange that appointment, and when asked whether she thought to arrange follow up, replied that she did not, as she did not have the skills to assess Patient A in the first place.

40. The facts of particular 2 had been admitted. The Registrant accepted that she did not carry out a postural management assessment for Patient B. She stated that this was because she had no experience, knowledge or skills in paediatrics. This was a development need as noted in her PDR (personal development review). She had attended a postural management course, but this was a preliminary course, not a post-graduate level one. SG had reported that the Registrant had told a technician to do the assessment, and she (SG) had therefore stepped in and done the assessment herself. The Registrant stated that she had not told the technician to undertake the assessment, although his role included performing assessments. The Registrant believed that Ability Matters would have screened him for skills. The difference between the Registrant and SG was that SG came from a neuro and wheelchair background. She was competent. The Registrant was not competent or confident. Further, the Registrant did not believe that the course she had done had included children. MB had said it related to adults and children, but that was not consistent with her certificate which mentioned “persons”. Indeed, the Registrant’s lack of knowledge meant that she questioned whether such an assessment was needed or not despite Patient B having a growth spurt and being in a lower leg cast for a fracture. She did not equate that with a need for a postural assessment.

41. The Registrant called AC, former Senior Secretary to MB. AC confirmed that she had worked as MB’s secretary and doing administration for the wheelchair clinic between June 2015 and January 2016. She stated that when she arrived, the administration was ‘a bit chaotic’. She put in place a spreadsheet with clients awaiting wheelchairs or parts for wheelchairs. Anyone could look at that and see where orders were up to. Ability Matters were the assessors who came in once a month. They would assess what patients needed, and when wheelchairs arrived, they would sit the patient in the chair and see if any adjustments were needed. AC stated she would see the Registrant taking notes on what patients needed. In terms of ordering, Ability Matters were the people who looked at patients and decided what they required. After a clinic AC would get the notes, type them up and put in a requisition for whichever parts or equipment that was needed.

Closing Submissions on Facts and Ground

42. Mr Ross submitted that the facts save for those in particulars 1a(v), 1c and 1d have been admitted. In respect of the facts not admitted, the Panel have evidence to find, more likely than not, that the events happened. According to the Registrant’s record, there was no assessment of Patient A’s engagement with the service or of his behaviour. The Registrant should have been aware of his history of non-compliance, but she was not. Her evidence had been unsatisfactory; you cannot assess something you don’t know exists. The Panel was invited to find that the Registrant had not read the patients’ case notes and therefore did not assess what had been an obvious issue.

43. In respect of ordering equipment, whilst there was some confusion as to the roles of the engineers and the clinical lead, the Registrant, as the clinician, the band 7 specialist, should have ordered or followed up the order of equipment. Her job description referred to it being her responsibility to arrange the provision of equipment. She had been in the job over 18 months when she saw Patient A.

44. With regard to arranging a follow up appointment with Patient A, the Registrant accepts that she did not do this, but says the responsibility lay with Ability Matters. It was the Registrant who was responsible for patient care, she was the clinician. Engineers brought product knowledge. This was a patient with patchy engagement. The Registrant had him in clinic. A reasonable OT would have used that opportunity to arrange a further appointment.

45. With regard to misconduct Mr Ross submitted that both the facts admitted and those referred to above amount to misconduct. Indeed, the admissions alone justified a finding of misconduct. Misconduct must relate to the profession and be serious. The Registrant’s conduct was a failure to assess and provide care or follow up care. She had breached standards 1-
4 and 10 of the HCPC’s Standards of Conduct and standard 8 of the Standards of Proficiency. The Registrant had referred to a staffing issue, however there was no objective evidence that any staffing issue had an impact on the assessments of Patients A or B.

46. The Registrant’s main defence was that she was not trained to undertake the assessments set out in the allegations. This was not credible for a number of reasons. There were five references in the job description to the post-holder being responsible for assessing patients. There had been an expectation that she would fulfil the requirements of the role by 12-18 months in the job; by August 2016. SG had given evidence that some of the competencies were rather basic, such as assessing transfers and assessing skin. These were rudimentary aspects of the role of an OT. The second reason this assertion was not credible was common sense. The job of an OT is to assess patients and record those assessments. The Registrant was a senior clinician, band 7, she had been in the job for over 18 months and had 9 years’ experience as an OT previously. There had been a group of professionals who all had concerns that the Registrant was not assessing patients. The Panel had not heard from a qualified clinician who defended the Registrant’s actions.

47. With regard to Patient B, the Panel was invited to conclude that the Registrant was trained to conduct postural management assessments of children. SG had attended the same 4-day course and had been clear that it covered children. If the course was limited to assessing adults, this would have been stated title or on the certificate. The Registrant asserted that the course had been updated to include children, but there was no evidence of that.

48. The Registrant’s failures in relation to Patients A and B fell far below what was proper in the circumstances. The seriousness threshold was met, the Panel was invited to find misconduct.

49. The Registrant submitted that wheelchair provision is a specialist area of OT practice. Due to her lack of skills until she trained to an intermediate level, Ability Matters assessed patients as part of their role. Due to the Registrant’s lack of training in complex neurological matters, she made the decision that Ability Matters should assess these patients as she could not do so safely or effectively.

50. The Registrant disputed that her omissions amounted to misconduct. In relation to skin checks, she had never seen those being undertaken at the clinic. As for assessing ability to transfer, not all patients had transfer assessments at every clinic. Her failure to assess Patient A’s pressure care requirements was her biggest regret. It had not, however, occurred to her that Patient A would not be checking his own cushion. The Registrant looked at Patient A’s diagnosis and made the decision to delegate the assessment to Ability Matters. It was also their role to order the equipment. It was also their role to decide whether Patient A needed a follow up appointment for further assessment. Patient A was an Ability Matters patient. The Registrant was not competent or confident to assess Patient B. She was further hindered in relation to Patient B as she had no paediatric experience. With regard to Patient B the Registrant stated that it was her that had checked Patient B’s pressure cushion and had prescribed anti- tippers for the wheelchair demonstrating that she had learned from the incident with Patient A.

51. In relation to the witnesses, the internal investigation that had been referred to and provided to the panel was based on opinion and not fact. Witnesses had said that the reason the Registrant should have carried out assessments was that she was an OT, but they reached this conclusion with no knowledge of the areas/specialty she had previously worked in. The Registrant invited the Panel to carefully consider MB’s credibility as the Registrant had raised a grievance against MB. The supervision documents that MB had provided did not tell the full story. The Registrant also asked the Panel to consider the apology she gave to AS during the investigation and the actions she had taken after the incident of Patient A.

Decision on Facts

52. The Panel was aware, in view of the legal advice it had received, that the burden of proof lies with the HCPC and that where facts were disputed, it must apply the civil standard of proof, the balance of probabilities. The Panel began by considering the documentary evidence, on the basis that this was produced relatively close in time to the events giving rise to the allegations. The Investigation Report, containing interviews with a number of people who had been called as witnesses, and some who had not, was dated July 2017. The Panel was cognisant of the point made by the Registrant as to the credibility of MB, and bore that in mind in its decision making. The Panel was further aware that witnesses had been asked to recall events over 6 years ago, and therefore it placed greater reliance on the documentary evidence, which included the contemporaneous notes, where there was uncertainty.

53. The Panel needed to make a determination, on the evidence before it, as to whether each particular was proven. The Panel rejected the Registrant’s evidence that the wheelchair technician, who she referred to as an assessor, was responsible for the clinical assessment of patients. It went through the particulars in turn and found as follows:

54. Particular 1a(i) had been admitted. The Registrant had made no note of any such assessments, and stated that she had not carried them out. She had explained that she had made the decision not to conduct an assessment of Patient A’s functional, cognitive or physical abilities as this was the role of Ability Matters. The evidence from the internal investigation additionally supported a finding that the Registrant did not carry out such assessments. The Panel found this particular proven.

55. Particular 1a(ii) had also been admitted the Registrant had stated that she did not know that she should carry out a skin check, she had not seen this performed by any other practitioners, and it was not something that normally happened. The Panel accepted the Registrant’s evidence and found this particular proven.

56. Particular 1a(iii) was that the Registrant did not assess or record an assessment of Patient A’s ability to transfer. In her evidence to the Panel, the Registrant had said that she did not think such an assessment was necessary, as Patient A had attended because he needed his wheelchair replacing. The Panel had no evidence before it that this assessment was carried out, and found this particular proven.

57. Particular 1a(iv) related to pressure care. The Registrant had admitted this and said that her failure to carry out this assessment was her biggest regret. Her evidence had been that it did not cross her mind to perform an assessment as Patient A had not raised any issues with his pressure cushion. The Panel was satisfied that this particular was proven.

58. Particular 1a(v) had not been admitted, however in her evidence the Registrant had stated that she did not conduct a formal assessment of Patient A’s behaviour or engagement. She said she observed his behaviour and had no concerns, so made no note in this respect. In terms of engagement, Patient A had attended the clinic voluntarily and there was nothing in his attitude to suggest he did not want to be there. The Panel concluded that as the Registrant had not reviewed Patient A’s notes (see particular 1b), she was not in a position to carry out this assessment as she was not aware that engagement and behaviour had been issues in the past. It determined that the Registrant did not equip herself to make these assessments, because she did not ascertain Patient A’s history, and therefore she did not perform an assessment of Patient A’s behaviour or engagement. The Panel found this particular proven.

59. Particular 1b, that the notes were not reviewed, had been admitted. In her evidence, the Registrant had stated that she did not review the notes. The Panel found that the Registrant read the referral form, and she then made the decision to delegate the assessment to Ability Matters. The Panel found, in view of the Registrant’s admitted lack of knowledge as to Patient
A’s history, that she could not have read the notes, and as such, it found this particular proven.

60. Particular 1c related to the ordering of equipment. The Panel agreed with the HCPC’s submission that there was confusion as to where the role of Ability Matters ended and the role of the service lead, the Registrant, started in this regard. The Panel determined that, in accordance with her job description, as the lead for the service, the Registrant was ultimately accountable for the provision of equipment, so she was responsible for ensuring that there was a system in place to ensure that orders were placed and followed up. As the equipment had not been ordered after the appointment, the Panel therefore found this particular proven.

61. Particular 1d was not admitted and the Panel found this particular not proven. The Registrant contacted Patient A and made arrangements for him to come to the clinic on 18 January. The Panel considered that it was not clear how or when the Registrant would have been expected to arrange follow up prior to having confirmation of when the wheelchair was to arrive. Whilst in the event, the follow up which took place on 18 January 2017 was due to Patient A’s pressure sore, it was follow up which had been arranged by the Registrant.

62. Particular 2 which related to the Registrant’s failure to carry out a postural management assessment for Patient B, had been admitted. The Registrant’s evidence has been that she was not competent or confident to perform this assessment, and SG gave evidence that she performed the assessment, as the Registrant delegated this to a wheelchair technician who did not have the necessary clinical skills. The Registrant has maintained that the course she attended did not relate to children. The Panel accepted the evidence of MB that the course related to both adults and children, and that it was likely to have been very similar in content to the course subsequently attended by SG. The Panel found this particular proven.

63. In summary, each particular of the allegations were found proven, save for 1d.

Decision on Grounds

64. The Panel was aware, in view of the legal advice it received, that whether the facts found proven amount to misconduct, is a matter for its own independent judgement. It accepted the Legal Assessor’s advice that:

• Misconduct involves some act or omission which falls short of what would be proper in the circumstances, and that the standard of propriety my be found by reference to the standards ordinarily required – Roylance v GMC [2001] 1 AC 311;

• In Doughty v General Dental Council [1988] AC 164 misconduct was described as conduct that has fallen short, by omission or commission, of the standards of conduct expected among dentists, and that such falling short as is established should be serious.

• Negligence does not constitute misconduct, however negligent acts or omissions that are particularly serious may amount to misconduct. A single act is less likely to cross the threshold than multiple acts or omissions – Calhaem v GMC [2007] EWCH 2606 (Admin);

• It is possible that a number of acts or omissions which in themselves are not serious enough to amount to misconduct may cumulatively be regarded as serious misconduct – Schodlok v GMC [2015] EWCA Civ 769.

65. The Panel began by referring to the HCPC’s Standards of Conduct, Performance and Ethics. It considered standard 1.3 was not met:

1.3 You must encourage and help service users, where appropriate, to maintain their own health and well-being, and support them so they can make informed decisions.

66. This was because the Registrant had failed to assess Patients A and B and as such, was not in a position to advise them or support them in relation to their health needs or decisions. As the lead clinician, her role was to provide clinical input to patients, something which wheelchair technicians were not trained to do.

67. Moving to standard 2, the Panel was of the view that standards 2.5 and 2.6 were not met. These were:

2.5 You must work in partnership with colleagues, sharing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.

2.6 You must share relevant information, where appropriate, with colleagues involved in the care, treatment or other services provided to a service user.

68. The Panel considered that the Registrant inappropriately passed work onto colleagues, when they were not trained or skilled to carry it out. This was not partnership working, indeed, the Registrant failed to fulfil her role in what should have been a partnership, in that she should have conducted the clinical aspects of assessments. As a consequence, she did not ascertain, and could not share, clinical information with colleagues, which would likely have been relevant to their role in a patient’s overall assessment and to the provision of equipment to meet individual patient’s needs.

69. The Panel noted that the Registrant had sought to rely on standard 3.1 effectively as a defence, to justify her omissions:

3.1 You must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience for.

70. The Registrant had repeatedly and consistently stated that she did not have the knowledge and skills for her role. The Panel determined that, given her previous experience as an OT, the Registrant had the core skills of the role, and those were transferrable to her role as a specialist wheelchair practitioner. The particulars regarding Patient A related to basic OT skills, which did not require specialist wheelchair knowledge. The Panel accepted the evidence of MB that the Registrant was at no point asked to deliver care outside her OT skills. The Registrant should have recognised the need to consider pressure care requirements and conduct skin checks on a patient who was paraplegic and confined to a wheelchair.

71. The Panel additionally found that the Registrant had failed to meet standards 3.2 and 3.3:

3.2 You must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice.

3.3 You must keep your knowledge and skills up to date and relevant to your scope of practice through continuing professional development.

72. In relation to Patient B, the Panel considered that the Registrant, having been on a postural management course, did have the skills to assess patient B, notwithstanding that Patient B was a child. However, in the event that she did not have either the skills or the confidence to conduct the assessment, she had a duty to make arrangements for an OT with the required skills to do so. The Registrant failed in this respect, and had SG not been present, Patient B would not have been assessed by a clinician.

73. Moving to standard 4, neither standard was met:

4.1 You must only delegate work to someone who has the knowledge, skills and experience needed to carry it out safely and effectively.

4.2 You must continue to provide appropriate supervision and support to those you delegate work to.

74. The reasons were those outlined above. The Registrant delegated assessments which she was or should have been competent to undertake, to colleagues who did not have clinical skills.

75. Finally in relation to the standards, the Panel considered that stands 6.1 and 6.2 were not met:

6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.

6.2 You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.

76. This was because the Registrant’s failures to perform essential aspects of her role directly placed patients at risk of harm.

77. The Panel went on to consider the HCPC’s standards of Proficiency. It determined that the Registrant did not meet standard 1:

1.1 know the limits of their practice and when to seek advice or refer to another professional.

1.2 recognise the need to manage their own workload and resources effectively and be able to practise accordingly.

78. The Registrant referred patients inappropriately, to wheelchair technicians who did not have the clinical skills, failed to refer patients whom she deemed to be beyond her level of competence to appropriately trained and skilled practitioners, and did not therefore effectively manage the resources of the service she led.

79. The Registrant also breached the following parts of standard 2:

2.1 understand the need to act in the best interests of service users at all times.

2.2 understand what is required of them by the Health and Care Professions Council.

2.8 be able to exercise a professional duty of care.

80. The Registrant had made no mention in her evidence or submissions as to the risks posed to patients by her omissions and inappropriate referrals. She had not shown that she understood that she had a duty of care to them, or what that involved. She failed to act in the best interests of patients when she failed to recognise the need for the patient to be seen by an OT and the need for clinical assessments. She showed no appreciation that delegation to technicians, not registered with the HCPC, of clinical duties was not in the patients’ best interests and that she failed in her duty of care as a registered healthcare professional. Nor did she appreciate that her role as the clinical specialist, leading the service, required her to take responsibility for patients.

81. The Panel found the Registrant to be in breach of the requirement of standard 3.3:

3.3 understand both the need to keep skills and knowledge up to date and the importance of career-long learning.

82. The Registrant had not taken responsibility for her own learning and development. She did not understand the need to develop her skills. She made clear that she wanted knowledge from formal courses, but she had not persuaded the panel that she could implement the knowledge gained, into her day to day practice. The Panel was concerned that having taken on this specialist role, which required the Registrant to develop her knowledge and skills, she had undertaken no self-directed learning. The Panel was particularly concerned that the Registrant described the Postural Management course as having ‘gone over her head’. The fact that the Registrant had been unable to transfer core OT skills to her new role was further evidence that she had not kept her skills up to date.

83. The Panel found that standard 4 was not met in its entirety:

4.1 be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem.

4.2 be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately.

4.3 be able to initiate resolution of problems and be able to exercise personal initiative.

4.4 recognise that they are personally responsible for and must be able to justify their decisions.

4.5 be able to make and receive appropriate referrals.

4.6 understand the importance of participation in training, supervision and mentoring.

84. The Registrant had demonstrated through her evidence that she was not able to distinguish between the roles of an OT and a wheelchair technician. As the service lead, she needed the skills to practise autonomously. The Panel found that the development opportunities provided by the employer were appropriate to enable her to develop the skills required for the role, assess patients clinically, make decisions as to their needs, and record those in the clinical notes. The Registrant’s delegation of her duties to wheelchair technicians demonstrated a failure to meet this standard.

85. The Panel determined, that the Registrant’s failings, in relation to particular 1a(i) were serious. The Registrant had a clinical duty to conduct an assessment, and failed to recognise the need for this. A failure to assess meant there was no opportunity to identify clinical risks. The Registrant had given contradictory reasons for not assessing, she had said that she did not do so because this was not a new patient, and had also said that these assessments were outside the scope of her practice. This indicated that there was not a clear or justifiable reason for the Registrants failure, and the failure fell far below the standards expected of a band 7 OT. This failure was therefore serious and amounts to misconduct.

86. Particulars 1a(ii), (iii) and (iv) relate to basic requirements of the role of an OT. Failing to check the skin or assess the pressure care requirements of a paraplegic patient who lacked feeling in those areas created a clear risk, particularly in a patient who was not seen regularly by the service and who had a history of patchy engagement. Patient A’s ability to transfer was an important consideration, given his level of disability and the time which had elapsed since his previous contact with the service. The Panel determined that these assessments were inherent to the role and an essential aspect of it. Each of these failures were, in themselves, sufficiently serious to amount to misconduct. They went far beyond minor breaches of standards.

87. Particular 1a(v) was a falling short of the expected standards, in view of Patient A’s history, which would have been known to the Registrant had she reviewed his records. However, the Panel considered that this falling short was not sufficiently serious to amount to misconduct.

88. Particular 1b, and the Registrant’s failure to review Patient A’s records at any point, meant that she did not have a benchmark against which to assess him. She could not determine whether his condition had deteriorated. This was a patient who the Registrant had no prior knowledge of, and who had not been seen by the service for some two years. In order to be able to conduct a meaningful assessment, the Registrant was required to review the notes. Her failure to do so meant that she could not have performed a focussed or complete assessment, as she could not have known about, for example, previously identified risks or positives in relation to the patient. The Panel therefore determined that this failure was a serious falling short, and amounts to misconduct.

89. Particular 1c on its own was not serious misconduct. The Panel took into account that there were other people, such as Ability Matters and the administration team who were involved in the ordering of equipment. Whilst the Registrant should have had oversight of this, her failures in this respect were not sufficiently serious to meet the threshold for misconduct.

90. Particular 1d was not found proven, so not considered.

91. In summary, the Registrant’s failure, as set out in particular 1a to carry out an adequate assessment of Patient A was serious and amounts to misconduct.

92. Particular 2 and the Registrant’s failure to carry out the required assessment was particularly serious due to the risks posed to the patient by not having a clinical assessment when they had grown, had a fractured leg, and had a wheelchair that was no longer meeting their needs. The Registrant acknowledged that usually the OT would take the lead in such an assessment, but said she could not as she was a ‘novice’. The Panel did not find this explanation credible. The Registrant had been in the role for around two years. She had undertaken a four-day course on Postural Management. If this had not provided her with the necessary knowledge and skills, she had a duty to identify opportunities and methods of further learning, to ensure that she was competent in her role. The Registrant could not be a novice indefinitely, and should have been competent by this point. Her evidence demonstrated a failure to understand why an assessment was needed, in circumstances which should have been obvious to an OT with the Registrant’s level of experience. Her failure in this regard fell far short of the standards expected of a competent professional, and amount to misconduct.

Submissions on Impairment

93. Mr Ross on behalf of the HCPC submitted that the Registrant is currently impaired. He submitted that the Panel needs to look at the past misconduct it has found, then look to the present in its consideration of impairment. He noted that the Registrant has shown some remorse in respect of Patient A. She has no previous fitness to practise history and there have been no interim conditions on her practice.

94. The concerns about the Registrants practice are matters that can be remedied. However the Registrant has shown little or no evidence of remediation. She has provided no evidence of CPD or self development since the concerns about her practice arose. There has been a complete lack of insight, which in turn means that there is a risk of repetition of the misconduct. The allegations were serious, particularly in relation to Patient
A. The allegations related to the care of two patients within a 6 month period, so this was not a one-off act. He submitted that the public would not be protected if the Registrant were faced with a similar position in the future. In terms of the public interest, he asked the Panel to consider what an informed member of the public would make of the allegations admitted and found proven. In addition a finding of no impairment would negatively impact on the reputation of both the profession and the Regulator.

95. The Registrant submitted that she has shown true remorse. In relation to CPD, her first PDP (Performance Development Plan) referred to all the things she had done in that year, such as the referral sheet she had developed. She had made reference in her supervisions to the lack of training she was receiving from her employer. She told the Panel that her CPD portfolio was audited by the HCPC and that she had “passed” this audit. She stated that over the last 6 years her CPD has involved preparing for this hearing.

96. The Registrant stated that she would want to return to the OT profession, but would not wish to work in wheelchairs. She had not undertaken CPD in relation to wheelchairs since she had left her job. The Registrant submitted that she would feel confident to work as an OT. She was extremely good in orthopaedics for 8 years, however she feels she is more of a community OT. She submitted that she would not pose a danger if she were to return to working as an OT. Whether she is currently impaired would depend on the role she went into. If the wheelchair service accepted her back she would make sure she did not begin the role until a standardised assessment form was in place. She would ensure that included checking cushions and assessing transfers.

97. In terms of whether the Registrant would repeat her actions, she asked the Panel to look at the rehabilitation notes (for Patient A). She did everything in her power to make sure that the same thing did not happen to another patient. Physios were picking out pressure cushions. The Registrant put a stop to that and told them they had to go through the wheelchair service. She submitted that she has full insight.

98. As for Patient B, the Registrant submitted that no harm came to him. He could have come to harm if she had not told SG to put anti-tippers on his wheelchair. However the Registrant could not have assessed Patient B as she was not skilled or trained. She did however check Patient B’s cushion to ensure he did not sustain a pressure injury. The Registrant continued in the service for a further 6 weeks after Patient B, and there were no more incidents. She assured the Panel that she will not repeat past acts in relation to pressure care.

99. Going forward, where the Registrant does not feel that she has the skills, training, knowledge or competence, she will decline to treat the patient. That’s what she did in relation to Patients A and B. There was a failure in relation to the cushion with Patient A, which she had admitted to. If she found herself in a similar position again, she did not know what more she could do, however if she had had a clinical supervisor things would have been better.

100. Finally, the Registrant referred the Panel to the two character references that she had provided.

Decision on Impairment

101. The Panel accepted the Legal Assessor’s advice. It was aware that an assessment of current impairment must be made by reference to past conduct, and that the purpose of regulation is not to punish a practitioner, but to protect the public, maintain standards, and uphold public confidence. It was aware of the test in Cohen v General Medical Council [2008] EWHC 581 (Admin), that at the impairment stage the tribunal should take account of evidence and submissions that the conduct (i) is easily remediable, (ii) has already been remedied; and (iii) is highly unlikely to be repeated. It was aware of the case of Council for Health and Regulatory Excellence v Nursing and Midwifery Council and Grant [2011] EWHC 927 (Admin) and whether a registrant has in the past and/or is liable in the future (a) to put

service users at unwarranted risk of harm; (b) to bring the profession into disrepute; (c) to breach one of the fundamental tenets of the profession; and/or (d) to act dishonestly. Additionally, it must consider whether the need to uphold professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the circumstances.

102. The Panel began by considering the environment in which the Registrant worked, in view of her submission that she was unsupported. It was of the view, given all the evidence it had heard, that the Registrant in fact had a supportive employer. This was because the employer maintained a contract with Ability Matters during and following the Registrant’s induction period, and it provided her with a number of training courses. In addition, she shadowed an OT experienced in the service for her first 5 weeks in the role. The Panel concluded that the Registrant had, despite this, been unable to draw on her previous significant OT experience, and transfer her skills and knowledge to her new role. She had also been unable to consolidate her learning, indeed, she had described the course that she had attended on postural management assessments as going ‘over her head’.

103. The Panel reviewed the two references the Registrant had provided, from DK and KB neither related to her work as an OT. These stated that she is hardworking and trustworthy. The Panel had no reason to doubt these testimonials.

104. However, the Panel determined that the Registrant had not accepted responsibility as an OT for the patients in her care. She had not been able to draw on her core skills to inform her practice in the wheelchair setting. The concerns about her practice were remediable, as they in the main went to basic OT skills, and in so far as specialist knowledge was required, training and development opportunities were available, such as those provided to the Registrant by her employer. Therefore the misconduct is remediable.

105. The Panel considered whether the Registrant has remediated her misconduct. It determined that she has not. She has shown no insight into how her failures created risk to patients. Whilst she has shown remorse that Patient A developed a pressure sore, her reflection has been limited to this. The Panel was concerned that she did not see how her failure to undertake clinical assessments, and instead delegate these to wheelchair technicians, posed real risks to patients, as those technicians do not have the specialist clinical skills of an OT. The Panel was particularly concerned at the Registrant’s statement that no harm came to Patient B. This demonstrated that she had failed to appreciate the risks, which should have been clear to a band 7 OT, that could arise from failing to assess, or arrange for an assessment by a competent OT, of a person in Patient B’s position.

106. This complete lack of insight was further demonstrated by the Registrant’s assertion that she would be confident to return to practice as an OT. She has not worked as an OT, or, from the information before the Panel, in a healthcare setting, since 2017. The Registrant made no reference to the likelihood of de-skilling, and not being familiar with changes in practice, that are likely to have taken place in that period. She made no reference to any sort of refresher or return to practice training. This was further reflected in her apparent lack of appreciation of what CPD involves. The Registrant had stated that her CPD over the last 6 years had been preparing for this hearing. Whilst the Panel appreciated that this will have taken time, it cannot accurately be described as CPD. Additional evidence of lack of insight was the Registrant’s assertion that she would continue to practise in the same way, that she did not know, beyond checking pressure cushions, what she could do differently.

107. The Panel therefore concluded that the Registrant’s misconduct has not been remediated, and it follows that there is a high risk of repetition. The Panel found the Registrant to be currently impaired on the personal limb.

108. The Panel went on to consider the public limb of impairment, and determined, in light of its findings above, that an informed member of the public would be shocked if no finding of impairment were made. The Registrant had failed to maintain professional standards, and as such, fellow professionals would expect a finding of impairment to be made in the circumstances of this case. Public confidence in the profession and in the regulator would be seriously undermined if no finding of current impairment were made in this case. The Panel found the Registrant currently impaired on the public component.

Submissions on sanction

109. Ms Sheridan on behalf of the HCPC submitted that the Panel should have regard to the HCPC’s Sanctions Policy, which states that the primary purpose of sanction is to protect the public. Whilst sanctions are not intended to punish, they may be punitive in effect. She submitted that the Panel should have regard to the wider public interest, including any risk the Registrant poses to service users, as well as regard to public confidence in the profession and the regulatory process. She submitted that although the option of taking no action was open to the Panel, there is clear guidance on when that would be appropriate, and that to take no action is exceptional.

110. Ms Sheridan did not have instructions to ‘bid’ for any particular sanction, however she referred the Panel to paragraph 106 of the Sanctions Policy which sets out when conditions of practice are likely to be appropriate, notably where a registrant has insight; where a panel is satisfied that there are no persistent failures, and where appropriate, realistic and verifiable conditions can be formulated. Ms Sheridan noted that the Panel had found that the Registrant had failed to perform essential aspects of her OT role and that it had concerns about her ability to integrate knowledge from courses into her daily work.

111. In terms of mitigating factors, Ms Sheridan submitted that the Registrant had made some admissions, she had engaged with the regulatory process and had no previous fitness to practise history. She noted that the Panel had identified some, limited insight. However, Ms Sheridan submitted that there are also aggravating factors in this case, namely that the Registrant’s failures were basic, serious and repeated. A risk of harm was posed to patients by inappropriate referrals, and there was a pattern of poor performance. The allegations involved two patients in 6 months. The Registrant had only limited insight in relation to any risk of harm to Patient B. There was no real evidence of remediation and hence a high risk of repetition.

112. The Registrant submitted that the Panel should take into account that she was not an advanced wheelchair therapist, she had suddenly been put into the wheelchair unit. She had no previous experience of assessing wheelchair patients. The Registrant submitted that she had already expressed that the outcome for Patient A was her biggest regret, however she did not make an active decision not to check his cushion. She submitted that she had remediated in that she tried to put things right for Patient A after his pressure sore was discovered.

113. The Registrant submitted that she had demonstrated learning from Patient A’s case, in that she checked Patient B’s cushion, and she recognised the need for anti-tippers for Patient B’s wheelchair. She was not trained in postural management or in paediatrics, and had no clinical supervision.

114. With regard to Ms Sheridan’s submission of a repeat of conduct, the Registrant submitted that she had 900 clients on the books, and Patients A and B were two of those.

115. With regard to what sanction the Panel should impose, the Registrant submitted that a caution would be appropriate, however she accepted that the issue in relation to Patient A was not minor. The Registrant submitted that there is a low risk of repetition, as evidenced by her notes for Patient A after the pressure sore was diagnosed. Patient B was not a repetition of what happened with Patient A, as pressure sores were not the issue in that case, it was postural management.

116. The Registrant submitted that conditions of practice would not be appropriate as she is not currently in practice. She does not intend leaving the Isle of Man, and therefore is not planning to look for a job in the UK. The Registrant submitted that suspension would be disproportionate as she has effectively been suspended for 6 years, since the events relating to Patient B. Strike off would also be disproportionate.

The Panel accepted the advice of the Legal Assessor. It was aware that it should:

a. Consider whether there are any particular mitigating or aggravating features;
b. Have regard to the HCPC’s over-arching objective of protecting the public, maintain standards and upholding public confidence in the profession;
c. Have regard to the sanctions guidance, and work through the sanctions in order, starting with least restrictive, until it reaches the sanction that adequately protects the public and meets the public interest;
d. Ensure that any sanction is proportionate, weighing the interests of the public against the interests of the Registrant;
e. Be cognisant that the purpose of sanction is not punitive, but to protect patients and the wider public interest (Meadow v General Medical Council [2006] EWCA Civ. 1390), although sanction may have a punitive effect;
f. Bear in mind that the reputation of the profession is more important than the fortunes of any individual member (Bolton v Law Society (1994) 1 WLR 512).

Decision on sanction

117. The Panel began by considering mitigating factors. It took into account the admissions that the Registrant has made and that she has fully engaged with the Regulator and the hearing process. She has no previous fitness to practise history. The Panel noted that the Registrant has shown remorse for Patient A and it was cognisant of the fact that the events took place after the Registrant had been moved to a role in a service in which she had no prior experience and where there was no clear line of clinical supervision. This had to be balanced against the fact that the Registrant had been in the role for some 18 months by the time she saw Patient A and that she had a number of transferable skills.

118. Moving to aggravating factors, the Panel took into account that more than one patient was involved, and patients were put at risk because the Registrant allowed wheelchair technicians, who were not OTs, to carry out clinical assessments of patients. The Registrant lacked insight in relation to the risk of harm posed to Patient B by failing to arrange for a qualified OT to assess him if she was not competent to do so. Further, the Registrant had not provided the Panel with any real evidence of remediation. Whilst she has referred to the notes of Patient A and how she worked with him to try to put matters right, she had not demonstrated to the Panel that she understood the bigger picture in relation to the risks posed by her actions, or what she would do differently in the future.

119. The Panel then considered the sanctions open to it. It took the view that taking no action was not an option as it had found that the Registrant poses a current risk to the public.

120. The Panel moved on to consider a caution, but again determined that this was not an appropriate sanction as the case did not involve an isolated incident, or minor issues. Further, the Registrant lacked insight into the need to take responsibility for ensuring that she was competent to do her job or to find an alternative qualified OT to treat patients whose needs were beyond her competence, and as such, there remained a real risk of repetition.

121. Moving to conditions of practice, the Panel considered that the Registrant’s failures were capable of being remedied; they were not so persistent or generalised as to prevent remediation. In principle therefore, conditions of practice could be formulated. However, for conditions to be workable, the Registrant would need to recognise the need for supervision and the Panel had concerns that the Registrant appears to be of the view that abrogating her responsibility for patients is acceptable. The Panel was not confident that the Registrant would comply with conditions for this reason. Further, due to the Registrant’s very limited insight and lack of judgement as to how patients may be exposed to harm, any conditions would need to be stringent in relation to oversight and supervision, such that they may effectively be tantamount to suspension. For these reasons the Panel determined that conditions of practice are not appropriate in this case.

122. The next sanction the Panel considered was suspension. It had found a number of serious breaches of the HCPC’s Standards of conduct, performance and ethics, as set out above. The Panel had also determined that there is a real risk of repetition due to the limited insight the Registrant has shown, although balanced this against its finding that the failings are capable of being remedied.

123. The Panel went on to consider whether strike off would be the appropriate sanction given the Registrant’s limited insight and the lack of action she has taken to address her shortcomings. The Panel considered that had the Registrant been in a less specialist OT role, strike off may well have been appropriate. However, the Panel was aware of the need to act in a proportionate manner, and took into account the Registrant’s genuinely held belief that she didn’t have the competence or knowledge to perform the role. It took into account that the Registrant did work with one of the Patients involved after the incidents and as such had shown a willingness to resolve matters.

124. On balance, the Panel determined that strike off would be disproportionate, as it must impose the least restrictive sanction which would adequately protect the public and uphold the public interest. The Panel concluded that a suspension order is the appropriate sanction in this case. Such an order would allow the Registrant a period of time to more fully develop her insight and remediate, with a view to a potential return to practice in the future. A suspension order would also meet the public interest as such an order would give members of the public confidence that the matters in this case have been taken seriously and that the Registrant would not be permitted to return to practice until her shortcomings have been addressed.

125. The Panel therefore imposed a suspension order for a period of 12 months. This order will be reviewed prior to its termination, and the Panel considered that the reviewing panel will be assisted by the Registrant providing evidence of

• up to date CPD, and
• a critical reflection of the incidents involving Patients A and B.

That the Registrar is directed to suspend the registration of Maria Efthymiou for a period of 12 months from the date this order comes into effect.

Interim Order

1. In light of its findings on sanction, the Panel next considered an application by Ms Sheridan for an interim suspension order to cover the appeal period before the final order becomes effective.
2. Ms Sheridan submitted that an interim order should be made to cover the appeal period in light of the panel’s finding that a suspension order is necessary to protect the public and in the public interest. She submitted that an interim order is necessary on both these grounds. She asked for an interim order for 18 months to cover the time taken to deal with any appeal.
3. Ms Efthymiou submitted that she was neutral on the matter but that she disputed that she posed a risk to patients or the public.
4. The legal adviser advised the Panel that it could make an interim order if doing so was necessary for protection of the public, otherwise in the public interest or in the interests of the Registrant. The Panel should bear in mind its previous findings and also consider the appropriate form and duration of any interim order.
5. The aPnel next considered whether to impose an interim order. It was mindful of its earlier findings and that it had found there was a risk of repetition of the misconduct and therefore a risk of harm. The panel decided that it would be wholly incompatible with those earlier findings if there was no interim order in place.
6. Accordingly, the panel concluded that an interim suspension order is necessary for the protection of the public and in the public interest. It made the interim order for 18 months, to allow for any appeal. When the appeal period expires this interim order will come to an end unless an appeal has been filed with the High Court. If there is no appeal, the final order shall take effect when the appeal period expires.

History of Hearings for Maria Efthymiou