Judith A Calvin

Preliminary Matters

Amendment of the Allegation

1.The HCPC made an application to amend the Allegation. Notice of their intention to do so was set out in an Amended Notice of Allegation letter dated 21 September 2022.

2. The HCPC stated that the amendments were purely to address and correct typographical errors.

· Particular 1(a) - ‘the’ replaced by ‘a’ before the word ‘letter’
· Particular 3 – replace ‘records’ with ‘notes’ after the word ‘patient’.
· Particular 8 – delete ‘4’ and replace ‘5-7’ with ‘5, 6, 7’.

3. The Registrant raised no objection to those amendments.

4. The Panel received legal advice in which the Legal Assessor confirmed that there is no statutory basis for an amendment to the Allegation, however, she went on to refer to the High Court case of Ireland and Ma v HCPC [2015] EWHC 846 Admin and the Court of Appeal decision in the case of PSA v HCPC and Doree [2017] EWCA Civ 31,9 both of which support the Panel in making an amendment based on common law principles. In making any amendments to the Allegation the Panel should take into account and balance the interests of a registrant and the public.

5. The Panel considered that these proposed amendments were not material in nature and did not adversely affect the Registrant. The proposed amendments gave better clarity and accuracy as to what is alleged and so they were approved.

Further amendment

6. At the start of day four of the hearing, an error in the wording of Particular 6 of the Allegation was identified by the Panel. The evidence is that the Registrant resigned from her position at the Trust in November 2019 and ceased working for the Trust in early December 2019. At that time the Registrant would have ceased to have access to the Paris system. The particular as drafted states that the Registrant made retrospective amendments to records during a period between December 2018 to December 2020, a period which extends beyond the Registrant’s term of employment. The Parties accepted that this was incorrect, and the Panel, of its own volition, amended the particular to better reflect and accurately record the end of that period to be ‘December 2019’.

Hearing stages

7. The Panel received an application from the HCPC for the findings on facts, misconduct, and impairment to be considered separately. The HCPC submitted that the Panel’s decision on the issue of dishonesty would be crucial to the nature and extent of the representations made by the parties at the misconduct and impairment stages. It was therefore likely that taking the factual findings separately could result in some time being saved in that the representatives would not have to address and canvass multiple potential outcomes in their submissions.

8. The Registrant’s Representative did not object to this course of action. He stated that he considered that it was in his client’s best interests to present all of her evidence in one period of testimony, notwithstanding that the information given may relate to matters to be considered at a later stage.

9. The Panel noted that the Practice Note on Fitness of Practise gave the Panel a discretion to move away from the protocol of taking all three stages together. The Legal Assessor confirmed that it was a matter for the Panel’s case management of the hearing and each case would revolve on its own merits.

10. The Panel approved this application on the basis that a decision on the facts may assist the Panel, as well as the parties, in focusing more clearly on the issues to be considered at grounds and impairment stages.

Background

11. The Registrant is a Dietitian who was employed by Belfast Health and Social Care Trust (the Trust) as a Band 6 Paediatric Dietitian within the Nutrition and Dietetics Paediatric Department. The Registrant was employed in this role from February 2011, within Royal Belfast Hospital for sick children (the Hospital), until December 2019. The Registrant had previously been employed in a Dietitian role within the Trust since 15 June 2004.

12. Concerns regarding the Registrant’s practice were initially raised by one of the Registrant’s colleagues in December 2018. The initial concern related to the Registrant writing a letter on behalf of a friend, to her child’s GP, in which the Registrant made a product recommendation for her friend’s child. This letter was on the Trust’s letter headed paper, which was contrary to the Trust’s Referral Process. The child, the subject of the letter to the GP, is referred to within the Allegation as Person 6, had not been the subject of a referral to the Trust in accordance with the Trust’s Referral Criteria.

13. Following this, a Consultant raised different and further concerns regarding the Registrant’s handling of cases during the period February to December 2018. The Trust carried out a review of the Registrant’s cases and specific concerns were identified in respect of the Registrant’s clinical judgment and record keeping for five patients. These are identified within the Allegation as Patients 1-5. The Registrant is alleged to have provided inappropriate treatment for those patients and made retrospective amendments to the dietetic records for a number of these patients on the electronic recording system used by the Trust known as ‘PARIS’.

14. The HCPC received a referral from the Hospital in relation to the Registrant’s conduct on 8 April 2019. That referral was made in relation to the sending of the letter recommending a nutrition supplement for Person 6, and the five cases involving patients 1-5. The referral states that:

‘This information has been provided as J Calvin provides a private dietetic paediatric practice and we would have concerns that this private practice may not have supervision in place.’

15. That referral was made whilst the Registrant was on sickness absence, which started on 7 January 2019, and continued till the 15 April 2019.

16. The Trust subsequently commenced an informal capability process into those concerns on the 30 April 2019 which resulted in a Disciplinary Hearing on 28 May 2019. That Hearing concluded with the recommendation on 31 May 2019 that the Registrant continue working under supervision.

17. The Registrant was referred to Occupational Health on the 13 August 2019 and was deemed unfit to work and she subsequently resigned from her role at the Hospital on 4 November 2019 and cased to be employed by the Trust on 6 December 2019.

18. On 28 November 2019 the HCPC received additional information from the Trust regarding concerns that the Registrant had retrospectively amended patient records contrary to the Trust’s Record Keeping Policy. Those concerns relate to Patient 6.

Decision on Facts

Admissions

19. At the outset of the hearing the Registrant made admissions to all of the Particulars with the exception of:

· Particular 1(b) relating to Person 6.
· Particulars 2(a) and 3(a) and relating to Patient 1.
· Particular 3(c)(iii) relating to Patient 5.
· Particular 3(e)(iii) relating to Patient 3
· Particular 8, allegation relating to dishonesty arising from Particulars 1,5, 6, and 7.

20. The Panel appreciated that notwithstanding those admissions the burden remained on the HCPC to produce evidence that supports each and every element of the Particulars of the Allegation. That burden on the HCPC was to the common law standard of balance of probabilities.

Evidence and submissions

21. The Panel had received one hearing bundle from the HCPC and three sets of documents from the Registrant which contained details of training courses, copies of her online professional blogs and published articles, together with two references.

22. The Panel heard from four HCPC witnesses and the Registrant.

· CM is the Lead Paediatric Dietitian for the Trust. She was the team leader for the Registrant and was her line manager. CM was the colleague to whom the Registrant made, at a work-related social event on Saturday 1 December 2018, the disclosure that she had written on the previous Thursday at the request of Person 6’s mother to Person 6’s GP. On 5 December 2018 CM attended a meeting with BN and Dr SC at which concerns about the Registrant’s practice were brought to her attention by Dr SC. Following that meeting CM brought to BN’s attention the sending of the letter to Person 6s GP on 29 November 2018.

· BN is a Band 8A Assistant Dietetic Manager at the Trust. This is a purely operational role, and she undertook visits to the Hospital site on Wednesday afternoons, a day when the Registrant did not work. Following her discussion with CM on 5 December 2018, BN had established further details relating to the letter’s creation and publication and requested JD to undertake a review of the Registrant’s files which Dr SC had expressed concern about.

· JD is a Band 8A Advanced Paediatric Dietitian but at the time of these events was a Band 7 Clinical Specialist Paediatrics Dietitian. She was the Registrant’s clinical supervisor. JD undertook the review of the five cases that had been identified by Dr SC as being a cause for concern.

· LH is Operational and Professional Head of Nutrition and Dietetics for the Trust. LH had been involved in transferral of the Registrant from the Community dietetic team (following its splitting into two teams) and into paediatric work at the hospital in February 2011. LH was also involved with the Registrant’s second capability process during 2019, conducting ‘end of week reviews’ with the Registrant.

· The Registrant qualified in 2001. She started work for the Trust in June 2004 working initially within the community before moving to Paediatrics in February 2011 in a Band 6 capacity. The Registrant chose to give oral evidence without the aid of a previous sworn written statement. The Registrant, having made numerous admissions gave evidence in relation to the matters that remained in contention as well as speaking to issues relating to her conduct and current skills.

Decisions on facts

23. The Panel had received the parties’ detailed submissions on facts on the matters that remain in contention. The Panel received the advice of the Legal Assessor which included detailed advice on the approach to be taken to the allegation of dishonesty and in this regard, she directed the Panel to the case of Ivey v Genting Casinos (UK) Ltd [2017] UKSC 67.

24. As stated previously, the burden of proving the matters alleged remained with the HCPC notwithstanding the admissions and so the Panel undertook a full review of the matters alleged.

Particular 1 relating to Person 6 – Proven in full.

1. When writing a letter for Person 6 to their General Practitioner (GP) recommending a feeding product on or around 29 November 2018:

a. You used Belfast Health and Social Care Trust (BHSCT) headed paper to write a letter despite Person 6 not being a patient of the dietetics team at BHSCT.

b. You did not carry out an assessment of the child before writing the letter

c. You did not follow the referral protocol before writing the letter

d. You did not complete records of your involvement with Person 6

25. The Registrant made admissions to limbs (a), (c) and (d) but challenged limb (b), relating to undertaking an assessment.

26. The unchallenged evidence is that Person 6 was the child of a former colleague and friend of the Registrant. Person 6 was a few months old, had not been the subject of a referral to the Trust and was under the care of her GP who was allegedly treating her for eczema and reflux. Referrals for dietary and allergy treatment were only accepted by the Trust from consultants and not directly from GPs. The Registrant had seen this child in the presence of her mother on one occasion within a social setting. All information relating to the child was obtained from the mother, a former fellow paediatric dietitian, there having been no access to medical records relating to Person 6 nor sight of her Red Book. The GP had prescribed a supplement for Person 6’s diet of milac Ailimentum. Person 6’s mother was seeking help from the Registrant to have this changed to Neocate Syneo. The Registrant had been told that the GP would not accept Person 6’s mother’s dietetic opinion for the change and required a letter from an independent source to support this change of prescription.

27. The Registrant told the Panel that she had mentally noted details of the child’s condition from a telephone call that she had received whilst travelling back to Belfast from a training course in London on the evening of 28 November 2018. The Registrant acknowledged that she had not made a physical note of the information supplied.

28. Person 6’s mother had then telephoned the Registrant at work the next day and asked if she had produced a letter for the GP yet. The Registrant stated that she felt harassed and under pressure and had a lot of work to get through that day. She stated that she had composed the letter during her lunch break. In the covering email to the GPs surgery the Registrant stated that she was sending the letter subsequent to telephone calls (plural) to the surgery. In evidence the Registrant was unable to recall making those telephone calls to the surgery until referred to the covering email. At the time of writing the letter the Registrant did not have details of the child’s height and weight, something that would have formed part of an assessment in view of the information supplied to the Registrant by the child’s mother that the child’s growth had faltered.

29. The letter sent by the Registrant to Person 6’s GP was on Trust headed paper and sent by email to the surgery by the Registrant using her NHS email address. The letter had been drafted and stored on her personal drive within her work computer. The letter stated:

Person 6 has been exclusively breast fed from birth. She presented with reflux symptoms shortly after birth which caused her to become extremely unsettled with persistent crying all day. She developed eczema with flare up of skin redness and irritation after feeds. Mum also reports a drop in her growth centiles. Mum eliminated dairy from her diet and Person 6 is now thriving and settled and her eczema is much reduced.

Mum has challenged her own diet with dairy on several occasions with return of symptoms presenting immediately after feeding. I suspect Person 6 may have an IgE mediated allergy to cow’s milk. I understand that you have prescribed Person 6 milac Ailimentum, however Mum explained that this caused a return of symptoms also. Mum plans to continue breast feeding but is keen to introduce formula as top ups.

I therefore recommend as per the IMAP guidelines you prescribe Neocate Syneo, 2 tins per week.

I have advised Mum on appropriate dairy free replacements and suggested she take a calcium supplement.

30. The Panel had sight of the letter and the fact that it was printed on Trust headed notepapers. Limb 1(a) is therefore found proven on the evidence, as well as by admission.

31. In relation to limb 1(b), the Panel heard evidence from two of the HCPC witnesses as to what would constitute sufficient information to form the basis of an assessment. They made reference to the standards, known as ABCDE, (relating to Anthropology, Biochemistry, Clinical information, Dietary and Environmental matters) set out in guidance issued by the British Dietitian Association and which are to be followed when undertaking a clinical assessment. The information gathered and the way it was obtained did not fulfil those requirements, not only in relation to not noting weight and height, but there being no reference to a full previous medical history. Further the Registrant had no referral on which to base past history and she had relied exclusively upon Person 6’s mother for the information relating to the issues of faltering growth, reflux, allergies and behavioural issues. The Registrant had only noted that the child when seen by her had eczema, something which would not alone indicate a protein allergy. Additionally, the Registrant had made no notes of the telephone consultation conversation with Person 6’s mother on which she could subsequently rely in support of the exercise of her clinical judgment. The Panel has therefore concluded that the Registrant has not undertaken an assessment in the form or to the standard expected, and so find limb 1(b) proven.

32. In relation to limb 1(c), the Panel find that the Registrant could not follow the referral protocol, as there had not been a referral, and this limb is therefore found proven.

33. As Person 6 had not been a patient of the Trust the Registrant was unable to complete records for Person 6. The Panel noted that any subsequent enquiries from the GPs surgery to the Hospital would prove fruitless as there was no accessible record of the letter. The Panel therefore find limb 1(d) proven.

Particular 2

Between January 2018 and December 2018, you did not adequately assess and/or provide adequate treatment and/or advice to;

34. The Panel noted that in relation to the five patients identified in this Particular it is required to undertake a review of the evidence to establish the adequacy of three things: assessment, treatment and advice. The Panel noted that in relation to the issue of treatment and advice there is capacity for an overlap of these two issues.

Limb 2(a) relating to Patient 1 – proven in relation to the two elements of treatment and advice, and found not proven in relation to assessment

35. Patient 1 was a 6-year-old boy with a history of constipation, multiple food avoidances, as well as non-IGE allergies (allergies to particular foods where a patient’s reaction does not appear immediately after the ingestion of that food). Patient 1 was referred to the Trust by Dr LM by letter typed on 9 August 2017 and received on the 15 August 2017, specifically for assistance with weight gain. At the time of his initial assessment by the Registrant, Patient 1 was on the second centile growth level and weighed 16.45 kgs. It was noted that Patient 1 had not been referred to the Belfast Trust as an allergy clinic patient, having been previously treated by the Ulster Trust for allergies and discharged from that Trust’s care two years previously. The Registrant assessed Patient 1 on 23 February 2018, 4 May 2018, 7 June 2018 and 27 July 2018 and at the end of this period Patient 1’s weight had remained fairly static and on this last assessment was described by the Registrant as ‘sickly and weak’.

36. The Panel noted that at the assessment on 4 May 2018 the Registrant recommended ‘the few foods diet’ which is a very restrictive dietary regime and contrary to the objective of Patient 1’s referral which was to promote weight gain. The Registrant failed to inform the referring consultant of Patient 1’s current dietary management plan, something which the Registrant admitted in her evidence.

37. At a subsequent assessment of Patient 1 on 7 June 2018, Patient 1’s weight had fallen to 16.45kg (from 16.65kg at the previous assessment) and the Registrant advised Patient 1’s mother to reintroduce one food at a time.

38. The Registrant’s treatment of Patient 1 included a recommendation at the assessment on 27 July 2018, that Patient 1 should commence a FODMAPs (fermentable oligosaccharides disaccharides monosaccharides and polyols) diet during. The Registrant provided Patient 1’s mother with the relevant information. The FODMAPs diet was not ‘commissioned’ for use by the Trust for paediatrics, and the Registrant had not been trained in the principles of this diet. The panel notes that Patient 1 had not been referred for management of IBS related symptoms, which the FODMAPS diet is used for in adults, and additionally the FODMAPs diet is not evidenced for use in a paediatric population. The consultant was not informed of this further dietary management decision.

39. On 28 August 2018, the Registrant emailed the referring consultant regarding Patient 1’s treatment. The Registrant stated she was ‘very worried about his overall nutritional intake and his weight’ and set out her approach to Patient 1’s treatment and the patient’s response to it. The Registrant had concluded the email by asking whether Patient 1 should be admitted for NG feeding. This was the first time that the Registrant had contacted the referring consultant.

40. Patient 1 was ultimately admitted to nasogastric (‘NG’) tube feed sometime in October 2018. NG tube feed is an invasive procedure by which nutrients are delivered to a patient by a tube placed through their nostril and into their stomach.

41. JD had discussed the Registrant’s treatment of Patient 1 with her at an informal review session in or around December 2018. During that meeting, the Registrant admitted that she should not have embarked on FODMPs diet without speaking to the referring consultant and should have discussed the case with them sooner.

42. JD had concern regarding the Registrant’s treatment of Patient 1 and identified that the Registrant’s recommendation of the supplement ‘Paediasure Plus Jus BD’ on 23 February 2018. She stated that this supplement was not appropriate as Patient 1’s diet was mostly cow’s milk protein free, with the exception of a small amount of baked milk. An alternative supplement, ‘Neocate Junior’ was, according to JD, more appropriate and should have been recommended.

43. JD was also concerned about the Registrant’s record-keeping of this assessment of Patient 1 as she had failed to plot Patient 1’s weight on his growth chart. Plotting a child patient’s weight and height on the growth chart is an essential part of any Paediatric Dietic assessment and ensures that dieticians can identify if a patient’s growth has faltered and to implement the most appropriate nutritional plan. The Panel was however able to find a record of this on the growth chart, albeit after careful review and cross referencing of dates of assessment.

44. Whilst the Panel considered that there was room for improvement of the Registrant’s assessment recordings, those that were before the Panel were of an adequate standard.

45. The Panel considered that the treatment and advice given to Patient 1 was not adequate and did not meet the needs of this patient. Indeed, it appeared from the records before the Panel that this Patient had deteriorated during the time he was under the Registrant’s care. There was no basis for the decision of placing this child in a few foods diet or adopting the principles of the FODMAP diet. The Panel therefore find this particular proven in respect of these elements of the allegation.

Limb 2(b) relating to Patient 2 – proven in relation to the two elements of treatment and advice, and found not proven in relation to assessment

46. Patient 2 was a 3-year-old girl with a nut allergy. The Registrant undertook an initial assessment of Patient 2 on 2 October 2018. Patient 2 had a confirmed allergy to peanuts and had also previously reacted to hazelnuts. Patient 2 is recorded by the Registrant as not having an EpiPen at home. The Registrant told the Panel that this family relied heavily upon nuts in their dietary regime.

47. The Registrant advised Patient 2’s mother on 2 October 2018. to ‘…rub a little pinenut in the inside of her lip and leave it a few hours then give her a tiny bit to try. Leave it a few days and double the amount everyday until Mum is certain that she is unlikely to react. I advised to have oral antihistamine available if symptoms appear.’ She also recorded ‘2. I also advised Mum to do the same process as above for nuts that she has not had before’ and ‘4. Avoid hazelnuts’. The Registrant failed to record in her notes of this assessment session that she had advised Patient 2’s mother to request an EpiPen from her GP.

48. On 4 October 2018, the Registrant sent an email to Dr SC regarding Patient 2. In that email, the Registrant set out Patient 2’s clinical history and her advice. She stated in that letter to Dr SC ‘I worry that she doesn’t have an EpiPen at home or nursery and would need an action plan. Also, should I ring Mum to tell her not to try other nuts until she is checked’. Dr SC did not respond to the Registrant’s email of 4 October 2018. The HCPC has maintained that the Registrant should have followed up with Dr SC, which she did not.

49. On the 8 October 2018 the Registrant sent a letter to the GP’s practice confirming the need for an EpiPen for this patient. That was six days after giving oral advice to Patient 2’s mother to try nuts out in a limited fashion at home.

50. On 11 January 2019, Patient 2’s mother contacted the Hospital and reported that her daughter had reacted to a walnut. Another dietitian advised Patient 2’s mother to avoid all nuts and that she would add Patient 2 to the allergy consultant’s list for an urgent new patient review. Following this referral, Dr SC confirmed that Patient 2 had an allergy to other nuts. Patient 2 therefore remained at risk of inappropriate and dangerous advice, with potentially fatal consequences, for the period from October to January, over three months.

51. The Panel has considered the assessment undertaken, whilst capable of improvement in terms of record keeping, it was as a whole adequate and so this limb of the particular is not found.

52. In relation to the advice and clinical judgment behind that advice to expose the child to nuts and to do so whilst there was no EpiPen in the home was inappropriate for this Patient and could have been fatal. This limb is found proven in relation to inadequate treatment and advice.

Limb 2(c) relating to Patient 3 – proven in full

53. Patient 3 was a 15-year-old boy with a history of epilepsy and poor weight gain, who had been treated by the Trust since birth. On 30 November 2018 he was transferred to the Paediatric Intensive Care Unit (‘ICU’) with a lower respiratory tract infection and was placed on a nutritional tube feed. On 10 December 2018, he was transferred from the ICU to the Paul Ward at the Hospital. The Registrant assessed Patient 3’s nutritional status in the Paul Ward on that date. A copy of Patient 3’s hand written medical records are before the Panel and show the Registrant’s entries for his food intake that day. Entries which the Registrant states were based on information supplied by an assistant on the ward. The Registrant accepted and acknowledged that she had not got the notes with her as she visited this ward and was unaware that this Patient had been admitted to this ward. She had undertaken the assessment without the notes to hand.

54. The Registrant’s assessment of Patient 3 on 10 December 2018 failed to properly review his notes and conduct the assessment since she had inaccurately recorded that Patient 3 had his “tube out” (the subject of Particular 4). Patient 3’s notes recorded that he had been placed on a ‘PEG’ tube, which delivers nutrients through a patient’s abdominal wall directly into their stomach, and that this tube was in place both before and after the Registrant’s assessment. Accordingly, the PEG tube would have been in place during the Registrant’s assessment and have been easily identifiable.

55. A review of those notes shows that Registrant’s record keeping in relation to her assessment of Patient 3 on 10 December 2018 had:

(i) failed to record the time and location of her assessment;
(ii) failed to specify the quantities of what Patient 3 had eaten (recording only ‘eating everything – had 2x Weetabix this morning’ and all ‘meat + pot + veg + gravy, as written on FBC’);
(iii) failed to record Patient 3’s weight or reasons why she was unable to obtain their weight; and
(iv) failed to set out a planned review for a vulnerable patient recording only ‘PLAN R/v on request’.

56. On 13 December 2018, Patient 3 was referred to the dietetic service again. Another dietician assessed Patient 3. Following that assessment, it was identified that Patient 3 weighed 37 kilos and had therefore lost 5 kgs during their treatment in the ICU.

57. The Panel heard from the Registrant that this patient was non-verbal and that at the time of her visit there had been no nurse or relative available to ask questions of. Her assessment was, as identified above inadequate and in relation to her treatment and advice as recorded were potentially harmful to the Patient in that no further oversight was being undertaken by the dietetic team until a further review was requested. This advice and treatment were inadequate.

Limb 2(d) relating to Patient 4 – admitted but found not proven by the Panel in relation to the issue of assessment, treatment and advice

58. Patient 4 was a 4-year-old girl who suffered with allergies from egg, diary, wheat, oats, soya and several berries. The Registrant assessed Patient 4 on 20 July 2018.

59. The Registrant’s assessment of Patient 4 on 20 July 2018 shows that she had, according to JD failed to:

(i) assess Patient’s 4 weight and height, or to follow up this information subsequently, and to plot her growth on a growth chart.
(ii) request updated biochemistry results or discuss the most recent biochemistry results with a consultant as those results indicated that Patient 4 was at risk of insufficient iron; and
(iii) identify the brand of coconut milk that Patient 4 was taking, and whether Patient 4 was at risk of insufficient calcium or other nutritional deficiencies.

60. On 30 November 2018, some four months later, the Registrant recorded that Patient 4 had been booked into her allergy clinic on 15 January 2019. The HCPC maintained that given the lack of nutritional adequacy of her diet, Patient 4 required a more urgent review than 6 months.

61. On 19 April 2019, Patient 4 was assessed by a different dietician. Following this assessment, it was identified that Patient 4’s was not gaining weight appropriately for her age and that her height had deviated from the 91st centile to the 0.4th centile. She was subsequently diagnosed with profound hypothyroidism.

62. The Registrant told the Panel that this patient had been added to the Consultant’s list for the clinic that day, and so was unaware that she would be expected to assess this child. She told the Panel that the child was unsettled, did not like people in uniforms and wanted to go home. The Registrant also told the Panel of the physical restrictions of this clinical setting and the difficulties of taking measurements and having a quiet place in which to undertake the assessment.

63. The Panel noted that the Registrant’s notes record that this child required a ‘full assessment in the allergy clinic’ as she had been unable to undertake this on that date. There had been no change to the treatment plan. The Panel therefore concluded that in the particular circumstances, and, given the later failings to follow through on the Registrant’s recorded note that this child should be seen for a full assessment in the allergy clinic, there had not been, on that date, an inadequate assessment, nor inadequate treatment or advice.

Limb 2(e) relating to Patient 5 – proven in full

64. Patient 5 was a 3-year-old girl who suffered with allergies from beef, soya, milk, wheat, fish, tomatoes, berries and peanuts. The Registrant assessed Patient 5 on 25 May 2018.

65. JD’s concerns upon reviewing this patient’s note were that during the Registrant’s assessment of Patient 5 on 25 May 2018, she had failed to:

(i) assess Patient 5’s weight or height, or to record the same on a growth chart;
(ii) obtain information regarding Patient 5’s intake of Neocate Junior, a supplement which Patient 5 had been recommended at her previous assessment;
(iii) take a full detailed diet history, and
(iv) record time and location of the assessment

66. The Panel has reviewed these notes and noted that this was the first interaction of the Registrant with this child and the only advice recorded was for the preparation of well-cooked eggs. Salient points required to fulfil the ABCDE criteria for undertaking an assessment were missing. The Panel considers that the assessment, treatment and advice were therefore inadequate.

Particular 3 You did not record adequate information within your patient notes for:

67. The Panel noted that this particular related to the same five patients as identified in particular 2 above, albeit in a different order, but in this instance in relation to the issue of failings in record-keeping.

Limb 3(a) relating to Patient 1, not proven

in that you did not plot Patient 1’s weight at the appointment on 23 February 2018 on a growth chart;

68. Details of this child’s clinical history are set out above under 2(a). Within that the Panel has noted that as part of the review of the Registrant’s assessment process the Panel was able to identify a recording of height and weight within the Growth Chart albeit with some difficulty in cross referencing the markings on that chart as relating to that particular assessment review. The evidence from BN and JD is that it was acceptable to record this information on the growth chart. Further, in her evidence JD had, when taken to the chart accepted that the crosses were consistent with the date of the assessment. The Panel therefore finds this limb not proven.

Limb 3(b) relating to Patient 4 – 3(b)(i), 3(b)(iii), 3(b)(iv) proven and 3(b)(ii) not proven

Patient 4 in that in respect of the appointment on 20 July 2018, you did not record:

(i) Patient 4’s weight and/or height or the reason why these were not recorded;
(ii) The blood work results;
(iii) The brand of milk Patient 4 was taking;
(iv) The time and location of the assessment.

69. The clinical history of Patient 4 is set out above in the Panel’s findings on 2(d), which are matters that have been found as not proven. For the same reasons, the Panel does not find these elements of the Registrant’s record keeping as being proven as she had recorded that a full assessment was to be undertaken in a future allergy clinic

70. The Panel notes that the awkward wording of the allegation in relation to ‘the blood work’ which presumably is to that taking of bloods to identify the biochemistry of this patient. No bloods were taken and therefore there was nothing to record in this respect.

Limb 3(c) relating to patient 5 – 3(c)(i), (ii) and (iv) found proven and 3(c)(iii) not proven

Patient 5 in that following your assessment on 25 May 2018, you did not record:

(i) The time and location of the assessment;
(ii) Patient 5’s weight and/or height;
(iii) Information relating to how Patient 5 was reacting to the newly recommended formula;
(iv) Information relating to diet history.

71. Patient 5 clinical history is set out under the Panel’s findings on 2(e) above. The Panel has found that in relation to the issues of recording time and location, weight and height, diet history are not recorded and so these are found proven.

72. According to the Registrant this was an unexpected patient, and she did not have the notes before her and so was unaware that there had been a change in the formulation only a week before. Given that this was such a short time since the change it was perhaps not unreasonable for there to be no enquiry about reaction. The Panel has concluded that in relation to this limb, it was reasonable not to have sought this information and so find it unproven.

Limb 3(d) relating to patient 2 found proven

Patient 2 in that you did not record your advice to request an Epipen.

73. There is no mention within the notes of the Registrant informing the mother of the need to obtain an EpiPen and so this limb is found proven.
Limb 3(e)relating to patient 3 – found proven in full

Patient 3 in that following the assessment on 10 December 2018, you did not record:

(i) The time and location of the assessment;
(ii) Patient 3’s weight or the reason this could not be taken;
(iii) Adequate information regarding Patient 3’s food intake;
(iv) A treatment plan.

74. The clinical history and the information given by the Registrant are set out above in the Panel’s decision in relation to 2(c). The only information recorded in relation to this patient’s food intake was a list of foods on a fluid balance chart. There is no other information recorded other than the statement that this Patient’s PEG tube was out. There is no further information recorded in relation to the matters set out above in (i), (ii) and (iv) and what had been recorded in relation to (iii) was incorrect. The Panel therefore find this limb of the allegation proven in full.

Particular 4 relating to Patient 3 – found proven

75. There is only piece of information relating to this patient mode of feeding and that is that he has had his PEG tube had been removed. This was not the case. The Panel therefore find this particular proven.

Amendments of Patient notes

76. The Panel has had the benefit of seeing a screen print of the PARIS audit undertaken by BN and therefore able to see the number of occasions on which the Registrant had accessed and amended Patient’s notes retrospective by revision, additions, and deletions.

77. The Panel had evidence from BN and LH that the correct way to undertake an amendment to a record that had already been made and saved on the PARIS system is to make an additional entry in which the proposed amendment is noted and then recorded by whom this was done. The PARIS system will automatically record the date and time of the amendment.

78. BN stated that going into past records and revising them is not appropriate as it alters the information that was available at that time to other clinicians. Those subsequent amendments of an existing record would not be obvious on the face of the entry to other clinicians and so misleading as to the clinical record at the time of the first entry being made. It was only through the audit process that those subsequent amendments would be identified.

79. The Panel noted that the Registrant was timed going into and out of some entries only a minute or two after starting an entry. This could be as a result of the Registrant continually saving information as she entered the data into the PARIS system and the Registrant gave evidence that this was the case.

80. The Panel noted that the record keeping policies of the Trust and BDA guidelines outlined that the standard expected of a practitioner are that all entries should be completed by a practitioner before going off duty. This was required to ensure that all notes were complete and contemporaneous and avoided the risk of a practitioner not being able to return and complete them on another occasion.

81. The Panel further noted that the Registrant’s working practice on recording assessments, treatment and advice reflected her working week. On Mondays she was on Hospital ward rounds. On Tuesday afternoons she attended the Allergy Clinic. The Registrant did not work on a Wednesday and on Thursday was working at a general outpatient clinic. The Registrant had the Multidisciplinary Team meeting on Friday mornings. The Registrant appeared to have utilised Tuesday mornings and Thursdays to write up her notes. There was a consistent pattern of the notes being some four or five days late in being recorded which reflected this working pattern.

Particular 5 relating to Patient 1 – found proven

82. The Registrant saw Patient 1 on a number of occasions over a period of 6 months and from the screenshots before the Panel recorded multiple amendments. These include:

· 23 February 2018 - 3 amendments
· 4 May 2018 – 7 amendments
· 7 June 2018 – 5 amendments
· 27 July 2018 – 5 amendments

83. A number of these amendments reflect the Registrant’s multiple saves at the time of recording notes. However, there are some entries which were made some time after the event. None of those amendments were made by creating a fresh entry but by going into past records and changing what is recorded within that historic note. These amendments having been made in this way do not denote when they were amended or who made those amendments. The Panel has therefore found this particular proven.

Particular 6 relating to Patient 3 – found proven

84. The Registrant saw Patient 3 on the Paul Ward on 10 December 2018 and then on 17 December 2018 for a joint review with Speech and Language therapy. The notes for this patient were in paper format. The Registrant made one amendment to the record she had previously made on 17 December 2018 by correcting the supplement name that was prescribed. This amendment had not been noted as being made after the event. The Panel therefore find this particular proven.

Particular 7 relating to Patient 6 – found proven

85. The Panel was able to identify from the screenshots that 4 records relating to this Patient had been amended 20 times.

86. The amendments to this Patient’s notes were identified by LH after the initial referral to the HCPC had been made. The information relating to this patient is that he was a 1-year-old boy who suffered from autism and had been referred to the Hospital by a GP for oral nutritional support on 25 October 2016. Patient 6 was first assessed by the Registrant on 23 August 2018. The Registrant subsequently reviewed this patient on 7 September 2018, 4 October 2018, 15 November 2018 and 10 September 2019.

87. A review of Patient 6’s PARIS records identified that multiple amendments had been made by the Registrant to these notes. These included:

· 24 August 2018 – 2 amendments
· 15 November 2018 – 5 amendments
· 10 September 2019 – 8 amendments
· 17 September 2019 – 5 amendments

88. These alterations were discussed with the Registrant during the capability process on 12 September 2019 and again on the 24 September 2019. An entry on 9 October 2018, which was made 5 days after seeing this patient on 4 October 2018 had multiple additions to the narrative and had included a retrospective note of the patient’s weight and height.

89. The Panel noted that one of the amendments made to this patient’s records included a deletion. Deletion within notes could be an indication that the information should not have been there in the first place, for instance, that the entry related to another patient and recorded on the wrong patient record. However, there should be no need for a deletion but an amendment. Any such amendment which records that something had erroneously been recorded should denote the reason and the name of the person doing this. The deletion made by the Registrant within this patient’s records was to remove reference to a referral for psychiatric services. This deletion reflected the fact that the Registrant had identified that this referral for psychiatric services had already been completed by a third party.

90. The Panel has noted the number and extent of these amendments and that none of them had been created in the correct way by an additional entry and that none were identified as having been done by the Registrant. The Panel therefore find this particular proven.

Allegation 8 (dishonesty) relating to Particular 1, letter to Person 6’s GP – found proven.

91. The Panel was aware that it was undertaking a subjective assessment of the Registrant’s state of knowledge and belief at the time and applying to that an objective test of whether an ordinary decent person would consider the Registrant’s conduct as dishonest.

92. The Registrant has stated that she was under pressure from her friend but in cross examination agreed that the friend probably would have accepted that she was too busy and would be content to wait. The Registrant agreed that she could have sent the letter from her personal practice address from her home either the evening before or later that day.

93. The Registrant stated that she had noted that on 1 December 2018, CM had ‘appeared shocked’ when she heard that the Registrant had sent the letter. The Registrant had stated that she had been ‘relieved’ when she found that on the Monday morning it had bounced back. She had told the Panel that she had not attempted to resend the emailed letter to Person 6’s GP.

94. The Registrant stated that she had contacted with the GP surgery and undertaken the drafting of the letter in her lunchtime. The Registrant had been able to access the letter some time later from her personal section of her work computer and had provided BN with a copy of the letter.

95. The Panel noted that the only evidence of the email and the attached letter had not being received by the GPs surgery and had bounced back was from the Registrant. The Trust had taken no steps to establish whether this was true and had taken this information supplied by the Registrant at face value.

96. At the time of preparing and sending the letter the Registrant was aware that:

· she was using her NHS email address to send the email and the accompanying letter;
· that the letter was on Trust headed paper;
· that the email and letter would in all probability be received by the GP practice;
· that the letter would be considered to have come from the Trust;
· that these actions were contrary to the Trust’s policies;
· that there would be no trace of this letter should there be any need for it to be referred to by anyone else;
· that there was no patient referral for Person 6;
· that no other clinician had been consulted before sending this letter;
· that no other clinician was aware of her actions at the time of sending and so would not able to answer any questions should the GP surgery revert to the Trust;
· that this was a misuse of the Hospital’s facilities for a personal matter;
· that there was a benefit for her friend of having this letter sent to Person 6’s GP immediately and on office note paper.

97. The Panel considered that there were alternative courses of action the Registrant could have taken had she chosen to do so. For example, she could have delayed sending anything until she was at home and using her own headed note paper and personal or professional email accounts. The Panel noted that the Registrant did not raise this issue with her supervisor as soon as she had realised her error.

98. From the above it is clear that subjectively the Registrant was aware of what she was doing and had taken no steps to avoid or correct the misleading information from being sent to and received by Person 6’s GP. Having identified so many features which would have informed the Registrant’s knowledge and belief the Panel considered what a decent ordinary person would make of that conduct. The Panel has concluded that objectively what the Registrant did would be considered dishonest. The letter would mislead the GP into taking action he would not otherwise have taken and anyone reading that letter would be misled into thinking that Person 6 was a patient of the Trust’s which was not the case. The Panel therefore find dishonesty in relation to Particular 1.

Allegation 8 dishonesty in relation to particular 5 relating to Patient 1 – not proven.

99. Above the Panel has set out its observations in relation to the Registrant’s recording of assessments, treatment and advice as reflecting hesitant recording process and poor notation of assessment information plus delay in recording events on the day. This recording style led to constant amendment and revision of previously incomplete notes. The amendments had consistently been performed by the Registrant in the wrong way and sometimes after an unacceptable period of time had elapsed. For example, the Panel noted that amendments were made to all records on 28 August 2018 prior to emailing concerns to Patient 1’s consultant.

100. The HCPC position is that the Registrant had undertaken these amendments to avoid detection of her errors in record keeping and clinical assessments.

101. It appeared to the Panel that the amendments reflected a very chaotic way of working and very little understanding of correct record keeping. The Registrant accepted that she had been subject to a capability process in 2014 which had concluded in 2016, and that had been given copies of the BDA Guidance for Dietitians for Records and Record keeping [August 2015 edition] and was aware of the Trust’s Clinical Record Keeping Policy [2017] but admitted that she had not read them. The Panel has stated above that those assessments and notes made by the Registrant which were considered ‘adequate’ could be improved. The constant need for amendment reflected this poor standard of note recording.

102. The Panel considers that this particular deletion was of little material significance and may reflect the Registrant being in a state of panic following her meeting with BN. There seems to have been little benefit from making this further amendment, as it shows a deletion which in itself indicated that something had erroneously been entered in the first place. The Panel considers that a member of the public aware of the pattern of the Registrant’s behaviour in relation to her notes recording would consider this, along with other amendments, as symptomatic of a disorganised person who had been challenged on her record keeping and so had panicked, but not of a person who was consistently and intentionally making amendments with a dishonest intent.

103. For these reasons, the Panel does not find her actions in relation to the amendments to this patient’s notes dishonest.

Allegation 8 (dishonesty) in relation to Particular 6 and relating to Patient 3 - not proven

104. The amendment referred to here is the correcting of the supplement prescribed into the handwritten notes.

105. This was in fact an erroneous insertion. Following from the Panel’s observations above about the pattern and standard of the Registrant’s note recording, the fact that the Registrant amends a record by hand recording with the wrong information is reflective of the Registrant practice at this time. Again, this Panel considers that objectively this insertion would be considered to be part of the Registrant’s chaotic approach rather than dishonest. The Panel therefore do not make a finding of dishonesty in relation to Particular 6.

Allegation 8 in relation to particular 7 relating to Patient 6 - not proven

106. The Panel has noted that the records for this Patient have been significantly alerted over a long period of time. Having heard the Registrant’s approach to making amendments there is no indication that she made these amendments knowing that in so doing she was not correcting, but distorting the information she was recording. There is no indication that she believed that her actions were concealing her amendments. From cross examination of the Registrant over a period of two and a half days it appears that she did not understand that she was consistently making amendments in completely the wrong way.

107. For the reasons set out the Panel has come to the view that the Registrant would not be considered dishonest in making these amendments.

Decision on Grounds

108. The Panel received submissions from the Parties on the grounds, as to whether, and to what extent, the Panel’s findings on facts amounted to either a lack of competence and/or misconduct. The Panel’s decisions on facts having aided clarity to the issues that remained in question, the parties agreed to provide their further submissions in relation to the matter of current impairment now, rather than at a later stage.

109. The Panel at this stage is concentrated upon the issues found proven which still involved various elements of practice in relation to the six patients and Person 6.

110. The Panel received detailed legal advice on the issues to be considered. Whilst the Panel is taking matters in the round, the Panel should consider and decide the two elements of fitness to practise, the grounds and current impairment, separately and consecutively. The Panel was directed to the HCPTS Practice Note on Fitness to Practise: Impairment, and to the guidance issued by the HCPC for practitioner in relation to Standards of Conduct, Performance and Ethics and Standards of Proficiency published for Dietetic Practitioners.

111. The Panel noted the legal advice it received in relation to the distinction to be drawn between lack of competence and misconduct. Lack of competence deriving from insufficient knowledge, understanding or judgment as to what is required to be done. Misconduct derives from a knowledge of what is required to be done but through intent, neglect or recklessness a registrant does not do so.

112. When considering the issue of lack of competence, the Panel was mindful that the Registrant is a practitioner with over 22 years of experience and who had undergone a capability process in 2014 in relation to her record keeping. In her work within the NHS, she had been within a supervised profession, working within teams and alongside colleagues as an autonomous practitioner. She now ran her own private practice. Before these events that led to the matters within the Allegation, the Registrant had undergone periodic and appropriate training within the NHS.

113. The Panel noted the argument made on behalf of the Registrant that she had had scant training for her additional specialist role within the allergy clinic, an area which it was argued required additional skills. The Panel took this into consideration, however noted that the patients involved in these cases were not all allergy patients. In fact, 3 out of the 6 patients were from the allergy clinic and the others 3 patients were those that she would have seen during her original post within the Trust.

114. Whilst the Panel had a sufficient sample of the Registrant’s work to demonstrate a lack of the required skills it noted that the errors and omissions did not stem from a lack of knowing the processes but a deviation outside of her skill and a continuing inability, despite retraining, to make accurate and complete notes. There appeared from the Registrant’s actions to be a falsely misplaced confidence in her abilities to extend her knowledge and skills into fields that were inappropriate and not authorised. The nature and variety of failings were numerous and stemmed on several occasion from the Registrant working beyond her scope of practice and skills, without seeking appropriate supervision to discuss this. There appears to be a lack of understanding of the extent and limit of her role and duties that it is behaviour that constitutes misconduct.

Person 6

115. Allegation 1. At this hearing the Registrant presented the sending of the letter as an aberration, an act of the moment. Her actions were in contravention of the Trust’s guidelines. CM’s shock at hearing what the Registrant had done was evidence of what another practitioner would consider of the Registrant’s actions. The Panel considers that her actions would be considered deplorable by fellow practitioners and do amount to serious misconduct.

116. Allegation 8. The Panel has found this conduct by the Registrant to be dishonest and whilst undertaking consideration of this, the Panel considered the Registrant could have taken an alternative course of action to avoid using NHS facilities for this personal task. It was clear to the Panel that this series of actions, from telephoning the GPs surgery, preparation of the letter and its sending was a series of intentional actions undertaken in full knowledge that the presentation in which this recommendation for a change of prescription would be received with the imprimatur of a specialist within the NHS dedicated allergy service. This was an intentional distortion of the true situation which was that this was a private referral for a personal friend. This was serious misconduct using and taking advantage of NHS facilities and its reputation.

Patient 1, (allegation 3(a) ignored having been found not proven)

117. Allegation 2(a). This patient has variously been described as a complex case. This, in the Panel’s view, is not a reflection of the situation. This child had been seen by a variety of practitioners over an extended period of time. However, his allergic reaction to certain foods had already been identified and controlled and he had not been referred for this but nutritional support. This Patient had been specifically referred for weight gain, something that would not be unusual for a practitioner of the Registrant’s experience. The Panel has found that the treatment and advice were inadequate and had been unsuccessful and may also have been detrimental to this patient’s long-term development. The Registrant’s actions moved her outside of her skills and knowledge. She adopted processes which were contrary to the referral information and also not indicated from the information available to her. From what the Registrant told the Panel, she was not exercising her individual judgment but trying to appease and please a persistent parent who had a focused viewpoint in relation to allergies being the underlying cause of this patient’s inability to gain weight. This patient had not been referred for his allergies but for weight gain, and yet the majority of the steps adopted by the Registrant resulted in there being initially further weight loss, and limited increase in weight over the period of treatment by her. The evidence is that the Registrant did not seek advice for six months, a delay which may further have been detrimental to his development. The Panel considers that this is serious misconduct.

118. Allegation 5. There had been numerous alterations to these notes at a variety of times. The Panel noted that in relation to alterations to all four treatment records for this patient they were, after a period of six months, accessed and altered on 28 August 2018. This was not the date on which the Registrant saw the patient but the date she wrote to the Consultant expressing her concerns. The Registrant had told this Panel that she had not kept notes of her sessions and so it is unclear to this Panel as to how she could have remembered details of her assessments in February, May, June, and July, in late August 2018. The Panel did not find the Registrant guilty of dishonesty in relation to this pattern of alterations but has grave concerns as to how those amendments are supportable. That concern extends to the fact that those exceptionally late further alterations would not, on the face of those entries, indicate to a fellow practitioner that they had been further revised. A practitioner would quite rightly find this series of unsupportable alterations deplorable, and this Panel finds that it is serious misconduct.

Patient 2

119. Allegation 2(b). (consideration of assessment ignored having been found to be adequate). This is a patient that had been referred for a specific allergy to nuts. The advice therefore to expose the child to limited amounts of nuts over a period of months was potentially lethal. To give this advice before an EpiPen had been issued was reckless and dangerous. The lack of follow up of the Registrant’s letter to the consultant in October 2018 compounded her initial errors and contributed to the situation which ended with the child having an adverse allergic reaction to a nut in the following January. This child could have died due to the Registrant’s treatment and advice. The Panel consider this a very serious case of misconduct.

120. Allegation 3(d). The Panel has found that there was no record of advice to this mother to immediately secure an EpiPen from her GP and to do so before starting the testing of nut allergies. Further, there is therefore no evidence that the mother had been told or understood that she was required to do this. It was six days before the confusion surrounding the prescription of the EpiPen by the GP was resolved. The Panel heard that the family was from a racial background that stored and used nuts extensively in the home environment, it being a core part of their diet. This was why the mother had concerns about the child’s potential allergy to all forms of nuts, as it would be impractical to keep her away from them at home. During this six-day period it was possible that the child had been exposed to nuts through the trial of testing with rubbing inside the mouth. This was a risk that the Registrant’s action exposed her to. The Registrant’s poor treatment advice and then case management placed this child at continuous risk, one that could have been fatal. The Panel consider this to be serious misconduct.

Patient 3

121. Allegation 2(c). This patient had not been referred to the allergy clinic, he was in a general paediatrics’ ward and his notes were handwritten. The result of the Registrant’s action of retaining this patient on his current eating regime and recording only ‘PLAN R/v on request’ created a situation where this non-speaking patient’s significant weight loss went unidentified and untreated before there was appropriate intervention by a Dietician. The Registrant had not sought the appropriate information from a fellow clinician nor from a nurse before making her assessment. Had the Registrant’s colleague not have identified and put in an appropriate plan to support this patient, their ongoing weight loss may have had a long-term impact. In the Panel’s view this is serious misconduct.

Patient 4 (allegation 2(d) ignored having been found not proven)

122. Allegation 3(b)(i), (ii), and (iv). (3(b)(iii) ignored as not found proven) This Registrant’s lack of recording of information had resulted she stated from the circumstances in which the one interaction she had with this child was unexpected and difficult, with the child being in an extreme state of upset. These omissions were examples of further failings by the Registrant but in the circumstances of this assessment of this Patient in the Panel’s view does not amount to serious misconduct.

Patient 5

123. Allegation 2(e). As recorded in its decision above, there had been inadequate assessment, treatment and advice for this child that had a wide range of allergies and had been referred to the allergy clinic. The totality of the Registrant’s recorded advice was to feed this patient ‘well cooked eggs’. There was no noting of the considerations that had led to the exercise of her clinical judgment. There appeared to have been no seeking of advice from a fellow clinical practitioner nor was this case subsequently raised in supervision by the Registrant for further guidance. The Panel considers that a fellow practitioner would find this lax approach to undertaking an assessment, which left the child wanting in the specialist advice and treatment she required, deplorable. The Panel find this is serious misconduct.

124. Allegation 3(c)(i), (ii) and (iv) (3(c)(ii) not found proven). The Registrant stated that there were practical problems in taking weight and height within this clinic. These two elements are crucial pieces of information required to assess a child’s development. The Registrant’s practice of not taking any personal notes of any information supplied, which she could then transfer to the records, resulted in voids even of the simplest details such as time and location of the assessment. Other clinicians would consider this lax way of working deplorable. The Panel find that this is serious misconduct.

Patient 6

125. Allegation 6. The Panel noted that it had limited information about this Patient and the only allegation relating to him is in relation to the alterations which had been made to his records. The Panel has seen screen shots of these amendments some of which are extensive. The information shown in those amendments is quite detailed and given the Registrant’s statement that she does not take personal notes the Panel has concerns as to how accurate they could be after a lapse of time. This going back and further perfecting and changing notes is, as stated previously, part of the Registrant’s chaotic way of working, a style of practice that fellow practitioners would find difficult with work with and alongside. The Panel consider this serious misconduct.

Breach of standards

126. The Panel having made those decisions identified that this pattern of behaviour was in breach of the Standards of Proficiency for Dietitians and the Standards of Conduct, Performance and Ethics as follows:

Standards of Conduct, Performance and Ethics

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.

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.

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.

7.1 - You must report any concerns about the safety or well-being of service users promptly and appropriately.

7.5 - You must follow up concerns you have reported and, if necessary, escalate them.

9 - Be honest and trustworthy

10.1 - You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

10.2 - You must complete all records promptly and as soon as possible after providing care, treatment or other services.

Standards of Proficiency for Dietitians (March 2013)

1 - be able to practise safely and effectively within their scope of practice.

2.6 - know about policy, ethical and research frameworks that underpin, inform, and influence the practice of dietetics.

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

9 - be able to work appropriately with others.

9.4 - be able to contribute effectively to work undertaken as part of a multi-disciplinary team.

10.1 - be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines.

12.1 - be able to engage in evidence-based practice, evaluate practice systematically and participate in audit procedures.

13.8 - understand, in the context of nutrition and dietetic practice:
- biochemistry
- clinical dietetics
- clinical medicine
- epidemiology
- genetics
- immunology
- microbiology
- nutritional sciences
- pathophysiology
- pharmacology
- physiology
- public health nutrition

14.1 - be able to accurately assess nutritional needs of individuals, groups and populations, in a sensitive and detailed way using appropriate techniques and resources.

14.9 - be able to monitor the progress of nutrition and dietetic interventions using appropriate information, techniques and measures.

127. The Panel consider that the Registrant’s behaviour has breached those provisions and supports the Panel’s conclusion that her conduct has fallen below the standards expected of a registered Dietitian.

Impairment

128. The Panel received legal advice that in relation to impairment, the Panel is undertaking an assessment of the Registrant’s ‘current’ fitness to practise. The Panel at this stage is able to take into consideration all information before it, including details of training and the personal and professional references produced by the Registrant.

129. The Panel noted that this assessment was in two-stages. First looking at the personal component and secondly the public interest element. In relation to the personal component, the Panel will be considering the Registrant’s current state of knowledge and skills, and whether the Registrant’s former failings were capable of being remediated, had been remediated and whether there was a likelihood of a repetition of the misconduct found. In relation to the public element, the Panel will be considering whether the Registrant’s actions had brought the profession into disrepute, and in so doing undermined the public confidence in the regulatory process.

The personal component

130. The Panel noted that the Registrant has continued to run her private practice which focuses on early years advice and treatment. The Registrant had published an article for the Trust in 2018, and it appears that she has continued with this aspect of practice by now having a blog in which she has published several articles relating to child dietary issues. These were, the Registrant stated, evidenced based articles but were not referenced. The Panel has several blog-based articles before it.

131. The evidence of training undertaken by the Registrant were 5 certificates relating to courses run by the BDA during the period 2019 to 2022. A certificate from a course run by Great Ormond Street relating to Child Colic and two further certificates relating online training.

132. The Panel noted the two references provided by the Registrant. One was from a former colleague who was now a friend and in which she testifies to the Registrant’s honesty and the accuracy of her record keeping. The second is from a doctor who has recently worked alongside the Registrant in her private practice. She too attests to the Registrant’s honesty.

133. In relation to record keeping, the Panel has before it examples of records maintained for three of her patients. The recordings made by the Registrant are inputted into a practice focused online programme. The Registrant advised that she now had more time with patients and therefore further ability to ensure her record keeping is of the right standard.

134. In relation to the issue of whether all of the matters found to constitute serious misconduct are capable of being remedied by the Registrant, the Panel had some concerns. The Panel noted the Registrant’s lack of sound clinical judgment. In this regard the Panel noted that the Registrant had displayed limited ability to appreciate that there were serious failings in her clinical judgment. During these proceedings she has stated that she would not do the same again but had displayed limited understanding of the issues that had played a key factor into her misconduct.

135. In terms of reflection and insight the Panel noted that in relation to Particular 1, the sending of the letter, the Registrant has had nearly 5 years in which to reflect on her actions and there had still been only limited understanding of the magnitude of her conduct and how it would appear to others. Having found dishonesty, the Panel appreciates that it is difficult to demonstrate remediation, however fully understanding and accepting her actions and appreciating that she did not have to do what she did in the way that she did, would be a first step.

136. The Panel considered the issue of whether the conduct alleged being repeated. There is evidence that the Registrant is easily influenced by parents and friends and not able to assert her individual judgment. There is no evidence that this would not happen again, and lead to a repetition of that misconduct.

137. This Panel heard that at this stage, when before her regulator, she was only able to confirm that she was aware of guidelines and had admitted that she had not actually read them. The Registrant had arrived at this hearing having not read the BDA guidelines. These are guidelines which she requires for her private practice to inform her advice and treatment.

138. The Registrant had not put in place a programme of supervision and had told the panel that she relied upon an online peer group for support. When asked why she had not put in place a formal process of supervision she told the Panel that it had not occurred to her. This shows a lax approach to her professional responsibilities and duties.

139. The Panel had not been assisted by a reflective piece of writing. There is therefore limited information as to the extent, and the way in which, the Registrant has reflected upon her practice. From the matters before this Panel, there appeared to have been at the time little or no reflection upon her daily working practice. There has been no evidence as to how that has changed.

140. The Panel noted that there has been little or no expression of remorse. Limited expression of understanding the extent and the impact her conduct had on others. In the Panel’s view there is a high likelihood of repetition of the misconduct and so finds lack of fitness to practise on the personal component.

Public component

141. In the Panel’s view members of the public, aware of the full details of this case, would be rightly concerned. The finding of dishonesty and the publication of a letter using her employer’s facilities and identity to present her personal advice would be considered appalling. To suggest that a child is given nuts without any supporting advice from a suitably trained clinician, and at a time when the child had not recourse to an adrenaline based EpiPen was dangerous and would be seen as such by the public. The Public would be very concerned about patient safety from her advice and care for the two non-allergy clinic patients (patients 1 and 3) whose development may have been adversely affected by her chaotic way of working. The public would consider that this type of conduct and treatment had undermined it confidence in the profession of dieticians. The Panel finds that the Registrant’s fitness to practise is also impaired on this public component.

Interim Order

142. At the conclusion of the hearing on Friday 15 September 2023, following the handing down by the Panel of its determination on current impairment, the HCPC made an application for an interim order to cover the period till this final hearing is reconvened and concluded.

143. The HCPC application was on two bases. First, that it is in the public interest given the Panel’s findings in respect of its findings of dishonesty, Secondly, that such an order was necessary for public protection given the Panel’s determinations in relation to the risk of repetition and the risk of potential harm to services user. In this regard the HCPC referred the Panel to its findings in respect of patients 1 to 6.

144. The Registrant’s Representative acknowledged that given the Panel’s findings, some form of interim order would be in the interests of public protection and the wider public interest. He acknowledged that given the terms of the Panel’s findings it would be difficult for him to propose and construct conditions of practice that would be capable of being fulfilled by the Registrant within her current private practice capacity.

Decision

145. The Panel noted that the Registrant was properly served with notice of the Panel’s ability to impose such an interim order, as this had been included in the Notice of hearing to the Registrant. The Panel has seen a copy of the Notice letter which contains all relevant information.

146. The Panel’s powers to impose an interim order arise from Article 31 of the Health Professions Order 2001 as amended.

147. The Panel has accepted and applied the advice of the Legal Assessor as to the proper approach it should adopt. In particular:

· It has to be satisfied that an Order is required for all or any one of the three statutory grounds namely, necessary for the protection of service-users; otherwise in the wider public interest; or, in the interests of the Registrant concerned.
· As part of its consideration, the Panel has to have regard to the impact of any order on the Registrant. It has to be satisfied that the consequences of any such order are not disproportionate to the risk from which the public needed to be protected.
· If the circumstances require an interim order, the Panel should first consider whether interim conditions of practice would offer sufficient protection. Only if they would not, should an Interim Suspension Order be made.
· The maximum period for such an order can be made for is eighteen months.
· In exercising its functions, the Panel must apply the principle of proportionality balancing the interests of the Registrant with the public interest.

148. The Panel has taken into account the representations of the parties and noted the guidance set out in the relevant Practice Note issued by the HCPTS.

149. The matters raised are serious ones and the Panel’s determination has identified the risks which the public may be exposed to given the current level of the Registrant’s knowledge and skills. The Panel has considered whether there is a likelihood of a repetition of the behaviour found proven and decided that there is. It has also considered the public perception of the Registrant and their profession in the circumstances found proven and the reputational damage that may flow from this should an order not be made.

150. The Panel has therefore concluded that it is in the public interest for an Interim Order to be made. The Panel has identified that given that the Registrant is solely employed within her private practice and is not currently under any formal supervision process there are no conditions that it could identify that would not be a suspension by another means.

151. In the Panel’s view the appropriate and proportionate Order is an Interim Suspension Order. In coming to its conclusion that an Interim Suspension Order is appropriate and proportionate; the Panel considered the professional and financial impact that such an Order might have on the Registrant, but it concluded that the public interest in this instance outweighed that of the Registrant.

152. The Panel determined that a period of twelve months was sufficient, and although the Panel would be reconvening and concluding this hearing before then, such a period would provide public protection should there be any unforeseen delay in this panel hearing this case or a reconstituted panel being so required to do so.

153. Should the Registrant’s circumstances change, and she and her representative considers that provisions of conditions of practice could be fashioned to suit her changed situation, then she is at liberty to apply for an early review under Article 31(2) of the Order.

Decision on Sanction

154. The hearing resumed on Tuesday 14 November 2023. The Panel had imposed an Interim Suspension Order at the close of the hearing on Friday 15 September 2023. That order will come to an end at the completion of this substantive hearing.

155. The Registrant presented the Panel with the following:

· A reflective piece of writing.
· Letter from her recently appointed professional supervisor.
· Four references, three of which stated to have knowledge of the HCPC proceedings.

I. The first, from the Access Coordinator at the Northern Regional College who attested to the Registrant’s knowledge and skills in ensuring that students at the college ‘fulfil their potential’.
II. The second was from a Lead Practitioner at the Royal Manchester Children’s Hospital, who was able to attest to the Registrant’s personal skills and that they had confidence in referring patients to the Registrant for treatment. The Panel noted that this practitioner had not, however, ever worked with the Registrant.
III. The third was from Impact Network NI, where the referee was able to attest to the Registrant’s abilities in giving talks on nutritional to local communities, which she has done since 2020.
IV. The fourth was the Health Improvement Officer for the Northern Area Community Network, where the Registrant has also delivered talks on nutrition by zoom and face-to-face since 2020.

· Two articles written by the Registrant in March and May 2023 for the Network Digest. One on ‘Faltering growth’ and the other on ‘Insulin resistance’.

156. In her reflective piece of writing, and also confirmed by her in questioning, the Registrant stated that since the interim order had been imposed, she had been working in the capacity of a nutritionist, a role which does not require her registration. She has accordingly limited her future practice to weight management or fussy eating. Going forward this was something she would continue to pursue. She stated that she would not seek complex cases which might take her outside of her professional skills boundaries.

157. Since the last hearing the Registrant has secured the services of a supervisor. The Panel has before it a letter from the supervisor setting out her previous professional experience. This included the supervisor working as a senior manager within the NHS for many years before setting up her own private practice. The supervisor had reviewed a portion of the Registrant’s files and stated that in her opinion she was able to identify only some very small issues, which were discussed with the Registrant. The supervisor confirmed that she had given advice on the more general issue of case management and record keeping. The Panel had not been provided with a copy of any formal supervision notes of that supervision session.

158. The Registrant confirmed that the supervisor will be undertaking monthly supervision and will be reviewing cases as well as being there to provide more general professional support and advice, something which as a ‘lonely sole practitioner’ is helpful. The Registrant will also be relying on the supervisor for advice beyond private case work, for instance, in the preparation of speeches and presentations. She will also be relying upon the supervisor to assess and confirm whether cases were within the Registrant’s knowledge, skills and experience.

159. The arrangement with the supervisor is an informal agreement for the provision of supervisory services. There is no formal written agreement setting out the terms of appointment or the structure for supervision. The Registrant told the Panel that the Supervisor was not being paid and at this time it was envisaged that this supervisory arrangement would last for 6 to 12 months, or ‘as long as it was required’.

160. The Registrant stated that she had incorporated within her client documentation permission for the clients’ details and case notes to be shared with a supervisor. That would now be a named person. In the absence of any formal agreement with the Supervisor there was nothing in place regarding the use by the supervisor of this client and case information which was being shared. The cases which had been reviewed by the supervisor in the one review meeting that had taken place had been cases that predate the conclusion of the last hearing, and so were matters which demonstrated the Registrant’s dietetic skills and knowledge, rather than nutritional advice.

161. The Registrant stated within her reflective piece of writing:

‘The recent HCPC Panel Decision has served as a critical juncture in my professional journey, prompting intense reflection and a commitment to change.’

‘This report aims to articulate my genuine remorse, outline the changes implemented in my practice since my suspension, and demonstrate my commitment to ongoing improvement and accountability.’

‘In light of the HCPC Panel’s decision, I now fully understand the distinction between lack of competence and misconduct and acknowledge that my actions were a result of the latter. Despite my considerable experience, I must admit that I stepped outside of my professional boundaries and overreached my expertise, which constitutes serious misconduct.

Upon reflection, I see that I did not meet the professional standards expected of a dietetic Practitioner. My work suffered because I took on tasks that exceeded my skill set without seeking appropriate support or oversight. This misstep not only put my patients at risk but also compromised the professional trust vested in me.’

162. The Registrant further in her reflective piece of writing states that ‘This was not an intentional act to deceive but I see that with hindsight and reflection that this was dishonest and I would be ashamed if my dietetic colleagues and the public were to know about it.’ In questioning the Registrant maintained that she had not intended to be dishonest, but she could now see how it would be viewed. In answer to questioning as to what assurance she could give that this would never happen again, she responded by saying that she was no longer in that situation where she could use an employer’s facilities, and she now had her own private facilities which she could utilise.

163. In relation to the issue of her failure to seek advice, whilst working at the Trust, the Registrant stated that she had felt ashamed and embarrassed at having to seek advice and guidance. This was something which, in conjunction with a feeling that she should be able to handle things, had resulted in misplaced confidence. She stated that she had not, in the subsequent five years, had any problems, and she does not in her private practice see complex cases which she acknowledge would be beyond her skills.

Submissions

164. The Panel received the HCPC’s representations on the topic of sanction: submissions which recognised that the decision on the level of sanction to be imposed, was a matter for the Panel’s judgment.

165. The HCPC reminded the Panel of the overarching principles and drew the Panel’s attention to the fact that there were issues relating to service user safety, as well as the issue of dishonesty. In relation to the issue of record keeping there had been several instances in which the Registrant had gone back and further altered records.

166. The HCPC considered that these were very serious matters and referred the Panel to the case of Igboaka v GMC [2016] EWHC 2728 (Admin) in which Simler J stated:

'that however excellent a clinician the Appellant is or was, that does not and cannot mitigate findings of dishonesty. Medical professionalism requires honestly and integrity as well as clinical competence. The profession itself depends on the relationship of trust. Patients, and the public more generally, are entitled to expect medical professionals to be fully competent and honest. In cases of proven dishonesty, a severe sanction is to be expected because the balance will generally fall down on the side of maintaining public confidence in the profession, notwithstanding the fact that the practitioner has had an exemplary professional career.'

167. The HCPC emphasised that there were very basic serious failings of a wide-ranging nature which showed not only poor practice, but poor clinical judgment. The Panel should take into account that there had been repetition of that conduct, and that there was a failure in her clinical decision making which could have resulted in a service user fatality. Further, in relation to the issue of dishonesty, whilst this was a single episode it was premeditated and one which the Registrant had undertaken an active role. The sanction to be applied should therefore reflect the degree of seriousness of this conduct.

168. The Registrant’s Representative accepted that these were serious matters, and given the circumstances of this case he had limited his submissions to the upper end of the spectrum of sanctions available to the Panel.

169. The Registrant’s Representative emphasised that the issue of dishonesty related to a single incident, and one which the Registrant had, the very next day, disclosed to a colleague. It was that disclosure that led to these proceedings. It was a dishonest act which had provided no personal gain, and which may result in the loss of her career.

170. The Registrant has demonstrated that she is taking steps to address her failings and should be given credit for the arrangements that she has put in place in recent weeks.

171. The Panel was reminded that the Registrant had fully engaged in the HCPC process, and at the start of these proceedings had made a number of admissions which had then been followed by further admissions in evidence. The Registrant has demonstrated a willingness to work on her failings and to be able to fully remediate.

172. It was submitted that in relation to the issue of insight the Registrant could be considered to be at the start of her journey to full insight. There were signs of insight developing, however there was still work to be done on this, and a period of suspension would allow that personal journey to continue. This was a finely balanced case, and one where the Registrant should be allowed to continue to take forward her personal and professional development.

Panel decision

173. The Legal Assessor reminded the Panel that these proceedings are not intended to be a punishment for a registrant’s past actions but are aimed at protecting service users and fellow professionals, as well as upholding standards within the profession and the reputation of the profession. Sanctions were also required for maintaining confidence in the regulatory process and as a deterrent to others in acting in the same way.

174. In undertaking its task, the Panel identified the following aggravating and mitigating factors in this case.

Mitigating factors

· The registrant has demonstrated active engagement in the HCPC process throughout.
· There was no evidence of repetitions of the misconduct over the following 5 years.
· There was no personal gain from the letter to the GP.
· The Registrant voluntarily disclosed to her manager the following day that she had sent the letter.
· The letter was not delivered and the Registrant did not attempt to re-send the letter.
· Admissions made at the start of the hearing and during it.

Aggravating factors

· Case notes were inadequate and did not fully record on the system service users case histories.
· Not made contemporaneous notes of sessions with service users.
· Returned to case notes to make significant changes to them at a distance in time. The case of Patient 1, being a case where the Registrant had returned at the end of August to make changes to previous sessions going back as far as the previous February.
· Poor clinical judgment. For instance, a non-complex case of ensuring that a child’s weight and body mass increased, produced a result at the end of the treatment programme of a negligible weight gain. In the interim this service user had been subjected to a limited food diet and had lost weight.
· Dishonest behaviour in using her employer’s facilities to make contact with a GP surgery and establish how to send a letter confirming her recommendation for treatment. This letter had been sent on NHS Trust headed paper therefore deceiving the recipient into believing that this was a referral from her place of employment.
· A continued denial of intentional wrongdoing, despite, an element of planning in that there had been some premeditation in arranging for the letter to be sent to the right email address within the GP practice.
· The potential risk of serious harm that flowed from the Registrant’s actions. Service users could, and possibly already have, suffered long term impacts as a result of the Registrant’s acts and omissions.
· In one case there could have been a fatality resulting from her advice to test nuts without there being an EpiPen available to deal with an adverse reaction.

175. The Panel referred to the Indicative Sanctions guidance issued by the HCPTS which it appreciated was persuasive guidance only, and it was a case sensitive decision for the Panel. The Panel noted the contents of paragraphs 56 and 57 of the guidance relating to dishonesty which includes:

‘…Dishonesty undermines public confidence in the profession and can, in some cases, impact the public’s safety.
Dishonesty both in and outside the workplace can have a significant impact on the trust placed in those who have been dishonest, and potentially on public safety. It is likely to lead to more serious sanctions. The following are illustrative of such dishonesty.
· Putting false information in a service user’s record (including in an attempt to cover up misconduct or a lack of competence)’.

176. This Panel agrees with the emphasis within that guidance on the impact upon the public, and the public perception of the profession and its regulator. The Registrant’s actions have damaged the reputation of her profession and if there were no mark of censure for her conduct there would be further damage to the confidence in the regulatory process.

177. This Panel has also found that a significant number of entries on service users’ records had been made without aid of notes and were not contemporaneous and further, they could be considered to have been made in an attempt to cover earlier failings and omissions. The Panel therefore considered that this was not a case in which it could take no further action, nor was the option of mediation appropriate.

178. The imposition of a Caution Order would not provide any service user protection, which was required in this case, involving as it did, findings of repetitive failings in advice and case management as well as dishonesty conduct.

179. The Panel noted the further guidance within the Sanctions Policy relating to the seriousness of the dishonesty set out a paragraph 58, which states:

Given the seriousness of dishonesty, cases are likely to result in more serious sanctions. However, panels should bear in mind that there are different forms and different degrees of dishonesty, that need to be considered in an appropriately nuanced way. Factors that panels should take into account in this regard include:

· Whether the relative behaviour took the form of a single act, or occurred on multiple occasions;
· The duration of the dishonesty;
· Whether the registrant took a passive or active role in it;
· Any early admission of dishonesty on the registrant’s behalf; and
· Any other relevant mitigating factors.

180. The Panel noted that there was only one occasion on which the Registrant had been found to be dishonest. She had however been proactive in constructing, and then executing, the act of dishonesty and so there was an element of planning which made this premeditated dishonesty. There has not been an early admission of dishonesty, and at this hearing the Registrant maintained that she had never intended to be dishonest even though she appreciated that her actions would be considered by others to be dishonest. This Panel took particular note that in response to the Panel’s questions about a repetition the Registrant stated that she would in future use other own facilities therefore there was no reason, nor opportunity, to use her employer’s facilities for sending a letter. This response ignores the fact that the Registrant had her own private practice facilities at the time but had, she stated in response to pressure, resorted to using her employer’s facilities. The Panel considers that the Registrant has not fully understood the illogicality of her actions, nor has she fully accepted the seriousness of those actions.

181. In relation to the matters which emanate from the Registrant’s poor advice and case management, the Panel noted that the Registrant had not, at the time, nor until this hearing, acknowledged that her conduct, knowledge and skills had been at fault or below standard. There remains, in the Panel’s view, a lack of full insight into her level of expertise and her professional abilities. The Panel was most concerned about the Registrant’s actions in relation to these matters rather than the use of hospital facilities and name to influence a GP’s decision-making process.

182. In relation to Patient 2, the nut-allergy case, this was completely avoidable, and was a situation that should not have been allowed to occur under any circumstances. This was the Registrant relying solely upon her mistaken confidence in her knowledge and skills. In relation to the repeated changing of service user records it is uncertain what harm could have resulted from fellow practitioners relying upon the information recorded by the Registrant and whilst she has now put in place systems to ensure that there are records of meetings and clinical observations, she has only now, after the Panel’s findings realised the need for fellow practitioner oversight of her decision making. This being the case, until there has been further reflection, study and training coupled with a change in the Registrant’s view of herself and her abilities there remains a real risk of repetition.

183. Having made those observations, the Panel considered the guidance relating to when a Conditions of Practice Order would be appropriate and identified in particular the following sections of paragraph 106, 107, 108 and 109 as pertinent in this case:

106
‘The registrant has insight.’
‘The registrant does not pose a risk of harm by being in restricted practice.’

107
Conditions will only be effective in cases where the registrant is genuinely committed to resolving the concerns raised and the panel is confident they will do so. Therefore, conditions of practice are unlikely to be suitable in cases in which the Registrant has failed to engage with the fitness to practise process or where there are serious or persistent failings,

108
Conditions are less likely to be appropriate in more serious cases, for example those involving:
· dishonesty

109
There may be circumstances in which a panel considers it appropriate to impose a conditions of practice order in the above cases. However, it should only do so when it is satisfied that the registrant’s conduct was minor, out of character, capable of remediation and unlikely to be repeated. The Panel should take care to provide robust reasoning in these cases.’

184. The Panel has identified that the Registrant has only limited insight into her conduct. Whilst appreciating how other practitioners may view her actions, she has not been able to identify fully that her actions were inappropriate, unsafe, and potentially causing service user harm.

185. For these reasons the Panel has concluded that a Conditions of Practice Order, would not be an effective way to address the Registrant’s clinical judgment failings. Her lack of insight into her professional abilities and boundaries are such that further reflection and professional development is required. Further, a Conditions of Practice Order is, in the Panel’s view, not sufficient to reflect the impact on the profession’s reputation that arises from the Registrant’s dishonest behaviour. Additionally, with the Registrant remaining a sole practitioner, with historically only informal peer supervision through a Facebook group, until recent formal supervisory structures were put in place. On such an uncertain basis a Conditions of Practice Order would not produce an effective working procedure.

186. The Panel noted the guidance at paragraph 121 which states:

‘A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a condition of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:

· The concerns represent a serious breach of the Standards of conduct, performance and ethics;
The registrant has insight;
· The issues are unlikely to be repeated; and
· There is evidence to suggest the registrant is likely to be able to resolve or remedy their failings.’

187. As stated above, the Panel considers that the Registrant has not gained sufficient insight into her clinical failings nor into her dishonest conduct. The Panel however has appreciated that there have not been any subsequent concerns about the Registrant’s behaviour during the last 5 years and that from her actions and testimony it appears that she is willing to address her failings and is passionate about her profession. It is clear from the Registrant’s reflective piece of writing that the HCPC process, where her practice has been reviewed and questioned and the resultant decision have had a significant impact on the Registrant. She has noted and expressed her previous over confidence in her abilities and has appreciated her working practices were wrong and could have led to very serious consequences. Her acceptance of her poor practice of record keeping had created a situation where fellow practitioners were misled at to the true situation.

188. From the Registrant’s initial presentation to this Panel there has been a noticeable shift in her level of understanding. It remains a matter of concern to this Panel that it took five years and a hearing for the realisation of the true extent of the misconduct to be appreciated and addressed. As her Representative stated, her full realisation of her previous failings is very recent and she does require further time for mature reflection and further steps to ensure that she will never again have an overly confident reliance on her professional skills and knowledge. The fact that the Registrant has now read, and is conversant with the standards and codes she is expected to adhere to, is a start that the Panel considers she can build upon.

189. Further reflection and consideration of her duties and responsibilities as an autonomous practitioner will enable the Registrant to continue to gain the insight she requires. A period of suspension would, in the Panel’s view, be appropriate in this case, where the Registrant has been able to demonstrate the starting signs of gaining insight into the nature of her conduct and her clinical failings.

190. In reaching its decision, the Panel took into account the guidance in paragraphs 130 and 131 which stated that:

130
‘A striking off order is a sanction of last resort for serious persistent deliberate or reckless acts involving…..
…..dishonesty.’

131
‘A striking off order is likely to be appropriate where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the profession, and public confidence in the regulatory process. In particular where the registrant;
· Lacks insight;
· Continues to repeat the misconduct,…..
· Is unwilling to resolve matters.’

191. Although the dishonest act had been active rather than passive, it was an isolated incident and there is no evidence of persistent dishonesty, nor was it undertaken for any personal gain. As stated above, the Registrant has restricted herself to matters within her current professional abilities by firstly not attempting to treat complex cases and then, during her period of suspension, restricting her practice to unregulated nutritional work. Further, she has demonstrated a willingness to undertake steps towards remediation of her failings. This being the case, the Panel has considered that this is not a case which requires the ultimate sanction of a striking off order. Such a measure would in this Panel’s view be disproportionate in all the circumstances.

192. In imposing a suspension order for the maximum period of twelve months the Panel has concluded that a lesser period would not be appropriate for the Registrant to develop her insight and to undertake the necessary steps to enable her to return to practice as an autonomous practitioner. As part of that consideration the Panel concluded that it would impose a restriction upon the Registrant such that she cannot seek the early review, variation or revocation of the order before the conclusion of 10 months. Any lesser time in the Panel’s judgment would be insufficient for the Registrant to gain insight into the circumstances in which she had allowed herself to go beyond her skills, expertise and knowledge.

193. The Panel having decided that a period of suspension is the proportionate and appropriate sanction, the Panel considered what guidance it could give to the Registrant to be able to provide a future reviewing panel with evidence of remediation and understanding. The Registrant should understand that she is not limited to the following suggestions and should appreciate that this Panel cannot bind or restrict the evidence that a future reviewing panel may wish to see.

194. Evidence which this Panel considers would assist would be:

· Further reflection on remediation undertaken;
· Written evidence of systems in place for record keeping in line with HCPC standards;
· Written evidence of supervision arrangements in place, to include a formal agreement with supervisor and a confidentiality agreement for the supervisor’s access to notes;
· Undertake CPD on record management and data protection.

ORDER: That the Registrar is directed to suspend the registration of Miss Judith A Calvin for a period of 12 months from the date this order comes into effect.

Interim Order

1.At the conclusion of the hearing on 15 November 2023, the HCPC made an application for an interim order to cover the period in which an appeal can be lodged, or for such an appeal to the High Court to be concluded. The application was for the maximum period of eighteen months.

2. The HCPC application was on two bases. First, that it is in the interests of service user protection, given the Panel’s findings in respect of misconduct, Secondly, that such an order was necessary in the wider public interest given the Panel’s determinations in respect of the impact the Registrant’s misconduct has had on the reputation of the profession.

Decision

3. The Panel noted that the Registrant was properly served with notice of the Panel’s ability to impose such an interim order, as this had been included in the Notice of hearing to the Registrant. The Panel has seen a copy of the Notice letter which contains all relevant information.

4. The Panel’s powers to impose an interim order arise from Article 31 of the Health Professions Order 2001 as amended.

5. The Panel has accepted and applied the advice of the Legal Assessor as to the proper approach it should adopt. In particular:

6. It has to be satisfied that an Order is required for all or any one of the three statutory grounds namely, necessary for the protection of service-users; otherwise in the wider public interest; or, in the interests of the Registrant concerned.

7. As part of its consideration, the Panel has to have regard to the impact of any order on the Registrant. It has to be satisfied that the consequences of any such order are not disproportionate to the risk from which the public needed to be protected.

8. If the circumstances require an interim order, the Panel should first consider whether interim conditions of practice would offer sufficient protection. Only if they would not, should an Interim Suspension Order be made.

9. The maximum period for such an order can be made for is eighteen months.

10. In exercising its functions, the Panel must apply the principle of proportionality balancing the interests of the Registrant with the public interest.

11. The Panel has taken into account the representations of the parties and noted the guidance set out in the relevant Practice Note issued by the HCPTS.

12. The matters raised are serious ones and the Panel’s determination has identified the risks which the public may be exposed to given the current level of the Registrant’s insight into the events that led to these proceedings. The Panel has considered whether there is a likelihood of a repetition of the behaviour found proven and decided that there is. It has also considered the public perception of the Registrant and their profession in the circumstances of a proven incident of dishonesty and advice that could have resulted in a fatality. The Panel has also considered the reputational damage that may flow from this should an order not be made.

13. The Panel has concluded that it is in the public interest for an Interim Order to be made. The Registrant is currently involved in the provision of private services. For the reasons given previously, it is in the Panel’s view neither appropriate not practicable in terms of compliance to impose an Interim Conditions of Practice Order. Further, for the reasons given above, this level of restriction is insufficient in relation to the wider public interest.

14. In the Panel’s view the appropriate and proportionate Order is an Interim Suspension Order. In coming to its conclusion that an Interim Suspension Order is appropriate and proportionate; the Panel considered the professional and financial impact that such an Order might have on the Registrant, but it concluded that the public interest in this instance outweighed that of the Registrant. Further, the Panel has evidence that the Registrant’s financial loss is mitigated by her being able to continue to provide private nutritional services.

15. The Panel determined that a period of eighteen months was sufficient to cover any potential appeal period.

History of Hearings for Judith A Calvin

Date	Panel	Hearing type	Outcomes / Status
14/11/2023	Conduct and Competence Committee	Final Hearing	Suspended
04/09/2023	Conduct and Competence Committee	Final Hearing	Adjourned part heard