Billy Law

Preliminary Matters

Service

1. The Panel first considered whether notice of the proceedings had been served on the Registrant in accordance with the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules).

2. The Panel was provided with documentary evidence that Notice of this hearing indicated that the Registrant was served by email to the Registrant’s registered email address on 4 November 2024, more than 28 days in advance of this hearing including the date of service which, in email service, is regarded as being done instantly. The Notice of Hearing advised the Registrant of the dates for this hearing. The Registrant was also advised of his right to attend and participate in the hearing and to make written representations.

3. In all of the circumstances, the Panel considered that the notice requirements had been met and accordingly that good service had been effected in accordance with Rules 3, 3A, and 6.

Proceeding in the absence of the Registrant

4. The Panel accepted the Legal Assessor’s advice. In accordance with the HCPTS Practice Note Proceeding in the Absence of the Registrant last updated in June 2022, the Panel must;

• first consider whether notice of the proceedings has been served on the Registrant,

• have consideration of all the circumstances of the case when taking the decision to proceed in absence,

• balancing fairness to the Registrant with fairness to the HCPC and

• the interests of the public.

5. Rules 11. The Panel recognised that its discretion to proceed in the absence of the Registrant must be exercised with care and caution. Fairness to the Registrant and the risks of an injustice arising were at the forefront of the Panel’s decision making. The Panel understood the guidance provided to it by the Court of Appeal in General Medical Council v Adeogba [2016] EWCA Civ. 162, that it has no power to compel the Registrant’s participation and should act fairly but always holding in mind the obligation to protect the public in a hearing decision. In considering a decision to proceed in the absence of the Registrant, the Panel must balance fairness to the Registrant with fairness to the HCPC and the interests of the public.

6. The Panel noted that the Registrant had responded to the Notice of the hearing in an email dated 12 November 2024 stating, ‘I will not be able to attend the hearing. Thank you for your support.’ The Registrant was invited to consider whether he was content for the hearing to proceed in his absence in an email to him dated 20 November 2024. On 23 November 2024, the Registrant responded by email stating ‘Please proceed in my absence. Thanks for your support’.

7. The Registrant had not asked for a postponement of the hearing. There was no material available to suggest that the Registrant would attend or participate effectively in the hearing were the Panel to delay these proceedings. The Panel decided that all reasonable steps had been taken to notify the Registrant of the date, time, and means to participate effectively in this hearing. The Panel found that by responding as he had done, the Registrant had elected to voluntarily absent himself from these proceedings. This is a hearing to consider the grounds of the Registrant’s alleged misconduct and if so, current impairment and any sanction that may be necessary to protect the public under Article 27 of the Health Professions Order 2001 (the Order). It is in the public interest for this hearing to take place as scheduled in the absence of the Registrant.

8. The Panel decided to proceed in the absence of the Registrant.

Documents for the final hearing

9. At the outset of the hearing, the Chair confirmed that the Panel had been provided with the following documentation:

i) Redacted bundle for final hearing – 384 pages;

ii) Service bundle – 8 pages;

iii) Registrant’s response bundle – 5 pages;

iv) Registrant response regarding proceeding in absence and updates on courses attended – 6 pages; and

v) Case summary – 11 pages.

Proceeding partly in private

10. Mr Bellis explained to the Panel that there may be occasions in the course of the hearing where matters relating to the Registrant’s health and private personal life had to be raised, in order to provide context, and promote a fair hearing for the Registrant. On behalf of the HCPC, he invited the Panel to conduct those parts of the hearing in private in order to protect the Registrant’s right to a private life.

Panel’s Approach

11. The Panel accepted the Legal Assessor’s advice which had drawn its attention to Rule 10 of the Conduct and Competence Procedure Rules 2003 (the Rules). The Panel also had regard to the HCPTS Practice Note Conducting Hearings in Private. The Panel also carefully considered the public interest grounds in the case being heard in public

Panel decisions in respect of privacy applications

12. The Panel was satisfied that the matters relating to the Registrant’s health and private life should be heard in private to maintain the Registrant’s right to a private life. The Panel was satisfied, having considered the matter carefully, that the Registrant, who is absent, might have supported the application by Mr Bellis. In any event, it was fair to the Registrant to allow the Registrant’s private and personal matters to be considered in private in order to facilitate a full hearing with necessary context.

13. The Panel therefore decided that the matters concerning the Registrant’s health be conducted in private.

Ancillary observations on typesetting of the allegation

14. Mr Bellis noted that the typesetting of a small part of the allegation had been re-formatted slightly to make it clearer. There was no material (or any real) change to the allegation. In these circumstances, Mr Bellis invited the Panel to consider that an application to amend the allegation was unnecessary. The Panel agreed with this having compared the current typesetting of the allegation to that sent to the Registrant in the Notice of Hearing. There was no discernible unfairness or disadvantage to the Registrant in adopting this course.

Background

15. The Registrant is a registered Dietitian. He had been employed as a Band 6 Community Diabetes Dietitian at the Diabetes Care for You Service (‘The Service’) between January 2017 and October 2021. The Registrant was not qualified or employed to act as a medicines prescriber. Such activities lay outside of the scope of his practice and his employment contract with the Service.

16. The Service raised concerns about the Registrant after a Service User called the Service to clarify changes to his insulin prescription made by the Registrant. This call prompted the Service to investigate and to conduct a review of the Registrant’s work. The review revealed concerns that the Registrant had:

• provided incorrect diet advice to service users

• improperly suggested VLCDs

• requested changes to medication beyond the scope of his professional practice; and that

• this had all continued despite the Registrant being advised not to do this, in person, and in writing, following a meeting with his clinical supervisor on 29 August 2019.

17. The Service User group seen by the Registrant were vulnerable. They included persons who had type 1 diabetes and type 2 diabetes. Changes in the provision of insulin medications and dietary changes including very sudden and substantial reductions in calorie intake daily could have serious adverse impacts for the Service Users.

18. The interactions of insulin dose, delivery, and frequency, and a daily deficit in calories all had the potential to cause the service users to experience unanticipated and unpredictable hyperglycaemia or hypoglycaemia episodes.

19. In circumstances where the service users were operating machinery or were driving, or were at risk of falls, the risks to the service users, and to other members of the public were high.

20. For these reasons, changes to a Service User’s insulin medication, or diet regime had to be discussed with team members with expertise in the area including nurse prescribers and consultant physicians.

21. The issues for the Panel in this case were therefore:

i. is the Registrant’s fitness to practise currently impaired

ii. as a consequence of his alleged misconduct and/or

iii. alleged lack of professional competence

iv. because it is proved that in all or some Particulars of the Allegation, the Registrant had acted outside of the scope of his practice on a number of occasions, with consequent risks of serious harm to service users and to the public, contrary to the HCPC’s Standards of Conduct, Performance, and Ethics, and/or the HCPC’s Standards of Proficiency for Dietitians.

22. Mr Bellis, on behalf of the HCPC called the following witnesses to give evidence:

1) AO, Professional Lead of Diabetes for the Service, the Registrant’s senior management colleague.

2) JR, Diabetes Nurse Consultant, a professional colleague of the Registrant at the Service.

3) Dr Blades, an HCPC registered Dietitian, and an expert in dietetics in the management of diabetes.

Witness AO

23. AO affirmed and adopted her witness statement as her evidence in chief. Her evidence, taken from her statement, and her live testimony was as follows.

24. AO explained to the Panel that she is a registered Dietitian and is currently the Professional Lead Diabetes Dietitian, this role involves working two and a half days each week at Diabetes Care for You (the Service), a service for patients with Type 1 and Type 2 diabetes provided by Sussex Community NHS Foundation Trust (“the Trust”), and two days in the Professional Leadership team for the Trust. She has held these roles since March 2017, although there have been changes to her working hours in this time. At the Service, she is the team lead for five diabetes specialist Dietitians.

25. AO said that the Registrant was a Band 6 Community Diabetes Dietitian at the Service and he held this role from 3 January 2017 until handing in his notice on 6 October 2021, following which he had an 8 week notice period until his employment ceased. AO managed the Registrant and worked with him directly for the relevant period she was at the Service. The allegations that have been referred to the HCPC in respect of the Registrant’s practice cover conduct that took place in 2019, 2020, and 2021.

26. AO structured her evidence in relation to the timeline of events and the relevant concerns for each of the Service Users.

The 2019 concerns

Service User A

27. On 13 August 2019, Consultant Nurse JR telephoned AO regarding Service User A who had been attempting to contact the Service to confirm the correct dosages for a new insulin he had been prescribed. JR and AO reviewed the record for Service User A which AO produced which revealed concerns.

The Registrant had advised and requested a change to Service User A’s medication

28. The Registrant had a consultation booked with Service User A on 25 July 2019. AO produced the relevant pre-clinic appointment letter. A review of the patient record showed that the Registrant had recommended that the Service User change his current insulin medication from Levemir to Toujeo and Humalog 100 units/ml to Humalog Kiwkpen 200 units/ml.

29. AO explained that some Registered Dietitians have supplementary prescribing rights. This means they are qualified to prescribe some drugs within their scope of practice and in accordance with a patient's clinical management plan agreed with an independent prescriber. Dietitians without this qualification may at times suggest changes to doses or types of certain medications, as long as this is within their scope of practice, and there is local agreement.

30. None of the Dietitians at the Service were supplementary prescribers, and the Registrant did not have this qualification while he was employed at the Service. Some of the Dietitians at the Service are competent to make small adjustments (usually a maximum of 20%) to insulin doses. Some of these Dietitians may also discuss changes to types and doses of diabetes medications with the nurses or consultants in the team, but they will not action any changes without authorisation from them. This included the Registrant.

31. On 20 August 2019, once the concerns regarding Service User A emerged, AO sent an email to the Registrant confirming that Dietitians cannot remove or ask GPs to prescribe new medications except for nutrition supplements. A copy of the email was produced to the Panel. AO said that on 28 August 2019, the Registrant confirmed that he had read this email.

32. The Registrant wrote to Service User A’s GP on 26 July 2019 requesting this change. AO said that the first and third paragraphs, which dealt with the patient’s weight loss goals, blood glucose, and carbohydrate consumption, were within the Registrant’s scope of practice as a Dietitian. However, the second paragraph did raise concerns when it was reviewed. The Registrant ended the request for the new medications with a question mark, which might reasonably be interpreted as a query rather than an instruction. However, the request to discontinue Service User A’s existing medications is more difficult to read favourably.

33. AO said that JR, Dr DL, the Clinical Lead for the Service, and a consultant Diabetologist, and AO all concluded that, taken in its entirety, the second paragraph was an instruction, and that the Registrant was therefore acting beyond his scope of practice.

34. AO said that even if the GP had ignored the Registrant’s instruction, and not changed the patient’s prescriptions, this would not affect the seriousness of this concern. It would still mean that the Registrant was acting outside of his scope of practice because Dietitians are not competent to advise on medication changes without the aforementioned competencies.

35. The Registrant has recorded in Service User A’s treatment notes that his rationale for recommending this medication change was that the patient had concerns about his current injection sites. AO said that in the event that a patient raised this kind of concern, Dietitians will come up with ideas depending on their level of expertise. The Registrant might verbalise that a certain form of insulin may suit Service User A better. However, a change in medication can only be carried out by a qualified prescriber or a person who is competent to so, so the Registrant should have discussed with one of the Service’s consultant physicians or nurses.

The Registrant had provided inadequate dosage instructions

36. The Dietitians at the Service deliver an education course targeted at patients called BHITE Type 1 Education (Brighton, High Weald, and Havens Intensive Type 1 Diabetes Education). Within this course, insulin dosage is covered to the extent that a Dietitian might advise a patient to make a small adjustment to their dosage based on what can be observed from their blood glucose readings. For example, if a patient takes 6 units of Humalog with a meal, but it is observed that their blood glucose is still on the high side two hours later, it would be reasonable for their Dietitian to suggest increasing the dosage to 7 units or to amend their insulin to carbohydrate ratio.

37. This is a complicated area and there are other steps Dietitians would normally take such as checking that the patients are counting their carbohydrates in their meals correctly to ensure they have not mistaken their intake of carbohydrates and given too little or too much rapid insulin.

38. Alternatively, a patient might have variable dosage instructions built into the care plan that has been written by a Nurse such as “If your blood glucose is above 10 millimoles per litre, then add 2 more units of X medication”. A Dietitian could then ask the patient whether they are following the dosage instructions in the care plan. The competency to make small dosage adjustments is not something that is captured in any policy, so individual practitioners need to use their professional judgement as to whether the advice they are giving is minimal enough to remain within their scope of practice.

39. However, Dietitians would not advise on dosage if a patient was changing to a new medication. The Registrant was not competent to recommend that Service User A change his medication, nor should he have given instructions as to the dosage of that new medication.

40. AO said that Service User A appears not to have suffered harm, although having to chase the Service for dosage instructions multiple times would likely have been inconvenient and may have made the Service User anxious about what he should do.

41. When the concern in respect of Service User A came to light, AO took advice from the Head of Therapy, who confirmed that a Datix incident report should be submitted, which AO produced to the Panel. There was a concern that the Registrant may have taken a similar step in respect of other patients. Accordingly, a Band 7 Dietitian, and AO conducted a review of the Registrant’s patients. This review revealed concerns in respect of the Registrant’s treatment of Service User B.

Service User B

42. The Registrant had written to Service User B’s GP on 12 July 2019 requesting that the Service User be prescribed an additional medication. AO produced this letter. The first and third paragraphs, which deal with the patient’s weight loss, blood glucose results, and carbohydrate consumption, are within the Registrant’s scope of practice as a Dietitian. However, the Registrant is not competent to instruct that the GP prescribe Service User B an additional medication.

Risk of hypoglycaemia

43. Gliclazide, the medication requested by the Registrant for Service User B, is used to treat hyperglycemia, so it has the effect of reducing blood glucose levels. This means Gliclazide can cause hypoglycaemia which is when the blood glucose concentration goes below 4 millimoles per litre. Different individuals have different levels of sensitivity to their blood glucose concentration dropping. For example, some might start to feel shaky, wobbly, and sweaty with a reading of between 3.5 and 4, or at higher readings, while others might not experience those symptoms until their reading is lower. Once a patient’s blood glucose concentration drops to below 3 they are more likely to become unaware of what they are doing and they might fall over and injure themselves or be more predisposed to other accidents.

44. Usually patients who commence taking this medication are advised by the prescriber about hypoglycaemia and how to treat it. Patients are also given advice about safety while they are driving.

45. When this concern was noticed we arranged for Service User B to be seen by Dr DL on 28 August 2019. Service User B reported that he had felt ‘…peculiar while gardening’, and experienced heart palpitations, and felt unsteady when his blood glucose reading was at 5.5 millimoles per litre. Dr DL took the decision to take the patient off Gliclazide.

46. AO met with the Registrant on 19 August 2019. He expressed regret for his actions and said that it would not happen again. AO sent the Registrant an email summarising the discussion, which AO produced to the Panel.

47. AO indicated that the matter was suitable to be dealt with informally at the Service, based on the fact that the Registrant was a valued member of the team. He was trusted when he said that he understood what he had done wrong and would not repeat the mistake. AO produced a letter for the Panel dated 3 October 2019 reiterating the concerns and the Registrant’s position.

48. [Redacted].

Service User G

49. Further concerns came to light in relation to Service User G after a colleague went through the patient records completed by the Registrant, probably during August 2019.

50. Concerns surrounding Service User G’s treatment emerged because the Registrant did not have the competence to recommend that the patient increased the intake of Metformin dose in the evenings to 1000mg to improve Service User G’s diabetes control. Metformin is a medication used to treat diabetes. AO referred the Panel to Service User G’s records and a copy of a letter from the Registrant to Service User G’s GP confirming he advised this alteration of medication. The Registrant was supposed to seek advice of one of our nursing team staff or consultants at the Service if he thought that there was a need for an adjustment to Service User G’s medication.

51. The Service is not aware that any harm to the patient was caused but the Registrant had acted outside his scope of practice.

Service User H

52. Additional concerns also arose regarding the Registrant’s treatment of Service User H. These concerns were also a result of a review of patient records. The Registrant had changed the type of insulin from Lantus to Levemir as shown in Service User H’s records and the letter dated 15 February 2018 from the Registrant to Service User H’s GP requesting this medication change. The Registrant was not competent to do this, and he was supposed to consult a nurse or a consultant if he thought that the change would benefit the patient.

Service User I

53. Concerns also emerged in respect of Service User I. The Registrant had changed the type of insulin for Service User I from Novorapid to Fiasp. The doses of the new insulin were not documented in the Service User’s records. AO produced a copy of the letter dated 3 June 2019 from the Registrant to Service User I’s GP. The Registrant was not competent to change the type of insulin that was administered to the patient. Although no harm was caused to the patient, from what can be seen by looking at the records, the Registrant did not consult a nurse, or a consultant first.

Service User J

54. Further concerns were noticed in relation to the treatment of Service User J, also as a result of a review of patient records. Concerns related to the fact that the Registrant changed the type of insulin from Lantus to Levemir. The Registrant was not competent to do this. The dose of the new insulin was not documented in the records. AO referred the Panel to Service User J’s records. AO said that no harm was caused to the patient from what can be seen by looking at the records. Nevertheless, the Registrant was supposed to consult a nurse or a consultant before making the change. AO produced a letter from the Registrant to Service User J’s GP.

The 2020 and 2021 concerns:

55. The concerns in respect of Service Users C, D, E, and F came to light in 2021, when the Registrant was on sick leave between 3 February and 2 March 2021. At that time, the Registrant was seeing approximately ten to fifteen patients each week. A Band 6 Dietitian such as the Registrant would usually see at least 15 patients each week. In order to ensure that these patients continued to receive care while the Registrant was on leave, a Band 7 Dietitian who had recently joined the Service, and AO reviewed the Registrant’s patients. Immediately it became clear that at least one case was a cause for concern, the Registrant’s treatment of Service User F.

56. The Registrant had commenced patients on Very Low- Calorie Diets (Service Users C-E), and one case (Service User F) where a request was made for a GP to change the type of insulin. This was a breach of the terms and conditions of the letter sent to the Registrant on 3 October 2019.

Commencing patients on Very Low Calorie Diets (VLCDs) and recommending medication adjustments

57. AO explained that a VLCD is where patients are instructed to reduce their daily calorie intake to approximately 800 calories per day. The recommended daily calorie intake for an adult is usually between 2,000 and 2,500, and so a VLCD involves a substantial reduction. The diet derived from a study conducted at Newcastle University, in which Professor Roy Taylor tested whether patients with Type 2 diabetes could be put into remission through a drastic daily calorie restriction.

58. AO produced the guidance document used by the Trust at the time of the incidents in question. This booklet is designed to be used by Dietitians and patients. The VLCD approach is used rarely in the Trust, primarily because it requires a high level of supervision on the part of practitioners and the Trust does not have the necessary capacity to provide this supervision. AO believed that the Service had approximately 2,000 patients with type 2 diabetes and less than eight patients have ever been placed on a VLCD.

59. The Investigation revealed that the Registrant supervised the following patients commencing a VCLD on the following dates;

• Service User C was commenced on the VLCD on 17 January 2020,

• Service User D was commenced on the VLCD on 13 January 2021,

• Service User E was commenced on the VLCD on 2 February 2021.

Screening for eating disorders

60. Before a patient is commenced on a VLCD it is necessary for that patient to be screened for any existing eating disorders. This is prescribed in the Diabetes UK guidelines from 2019 for Type 2 Diabetes Remission. This is something that is within a Dietitian’s scope of practice, and the Registrant was instrumental in designing the questionnaires that the Trust uses in order to screen patients for eating disorders. AO stated that Service Users C to E were not screened for eating disorders prior to being commenced on the VLCD, as shown by the absence of this screening in the patients’ records.

Medical screening

61. Before a patient is commenced on a VLCD it is necessary for that patient to also be screened by a physician. A Dietitian at the Service was expected to discuss this with a consultant before commencing the patient on a VLCD. A VLCD may not be compatible with certain medical conditions or with a particular drug. Screening “red flags” would need to be reviewed before a patient is commenced on a VLCD. Further, a review of a patient’s current medication would be required because their insulin prescription and dosage would be based on their current diet.

62. If a patient were prescribed a medication that reduces their blood glucose, and the patient substantially reduced the carbohydrate in their diet, the medication may cause their blood glucose to drop too low and they would be at risk of hypoglycaemia. The actual medication screening would need to be completed by a physician, however the Dietitians at the Service would be aware of these documents.

63. The Registrant confirmed in the meeting AO held with him on 9 March 2021 that he was aware that guidelines were available in the shared drive.

64. A Dietitian should know that any review of a patient’s medication would be beyond their scope of practice. Diabetes UK also produces resources for healthcare professionals, called “information prescriptions”. This document was published in 2019 so would have been available to the Registrant before he commenced Services Users C, D, and E on a VLCD. This safety note should prompt a Dietitian to seek advice as none of them are competent to adjust patient medication.

Service User C

65. Service User C was commenced on a VLCD on 17 January 2020. The patient records entry written by the Registrant for 17 January 2020 describes a diet plan involving two nutrition shakes plus an evening meal each day. Although the term “VLCD” does not appear in this entry, it is common that VLCD plans are comprised of two nutritionally complete meal replacement shakes plus a third meal. AO confirmed that this patient was put on a VLCD. The calories are not listed on the patient record, and so AO could not confirm that this patient was placed on a substantially reduced calorie diet.

66. In relation to potential patient harm to Service User C, the patient reported experiencing several episodes of hypoglycaemia after 17 January 2020, as recorded in her treatment notes. The Registrant did the right thing in advising her to telephone the Service if she had any doubts, and he also advised her to reduce her insulin by 2 to 4 units in the event that her blood glucose dropped below 4mmol/l. This is only a reduction of 5 to 10% which may not have been sufficient considering the substantial reduction in calorie intake. AO stated that she would not have given this advice without confirming with a consultant physician or nurse.
67. A letter the Registrant wrote to Service User C’s GP on 6 December 2019 was available to the Panel. This letter confirms that the Registrant was aware that the patient may experience hypoglycaemia symptoms should she alter her diet. If the Registrant wished to place Service User C on a VLCD the Registrant was supposed to discuss this with the nurse or a consultant.

Service User D

68. Service User D was commenced on a VLCD on 13 January 2021 as recorded in the patient notes for 13 January 2021. The Registrant recorded that Service User D was advised “to stop sitagliptin/reduce metformin when blood glucose regularly 4.5mmok/l”. AO’s evidence was that advising a patient to stop a medication is outside the Registrant’s competency. The patient notes suggest that it was the patient who initiated the VLCD, and the Registrant’s response was to offer information and “as much support as possible but not as fully as on the Direct Trial”. While reasonable, the concern still stands that the Registrant did not liaise with a consultant nurse or physician to screen the patient medically. It would appear that no harm came to this patient.

Service User E

69. Service User E was commenced on the VLCD on 2 February 2021, as set out in the relevant patient record for this patient. In the patient notes for 2 February 2021, the Registrant recorded that Service User E was advised “to reduce her Novorapid dose to 6 units at breakfast and lunch when she starts her shakes”. The Registrant should have discussed this with a nurse or a consultant before doing so. AO would not have given this advice without confirming with a consultant physician or nurse. It would appear that no harm came to this patient.

Concerns in respect of Service User F

70. On a review of the Registrant’s patient files, it was discovered that the Registrant had written to Service User F’s GP on 14 January 2021. The Registrant was not competent to instruct that the GP change the patient’s insulin prescription from Novorapid cartridges to Fiasp cartridges. The Registrant recorded in this letter, and in Service User F’s treatment notes at Exhibit 7 Appendix 1, that his rationale for recommending this medication change was to better complement the patient’s busy daily routine. When AO questioned the Registrant about Service User F, he said that he thought the medication change was minor and therefore safe. However, a change in medication can only be carried out by a qualified prescriber or someone deemed competent to do so, so the Registrant should have referred to one of the Service’s consultant physicians or nurses. A Datix incident report was submitted for this incident.

71. What concerned AO the most in respect of Service User F was that it was an unequivocal breach of the very explicit instructions that had been set out in the letter of 3 October 2019. The Registrant had repeated the conduct that he had assured the Trust that he understood was wrong in 2019.

72. It would appear that no harm came to this patient.

Maintaining treatment records and updating service users’ care plans

73. The requirement to maintain accurate treatment records is a basic competency for a Dietitian and is covered by both the HCPC Standards of Conduct, Performance and Ethics (2016) and the BDA Code of Professional Conduct. The Trust also has a Health Record Keeping Policy which AO produced. During or following any consultation, the practitioner will make notes on a patient’s treatment record. These notes will then inform any updates that need to be made to a patient’s care plan. There is no prescribed format for care plans, and they can vary between different practitioners, but what matters is that they should contain a treatment strategy that is clinically reasoned and is linked to a proper assessment of the patient.

74. The investigation carried out by the Trust in respect of Services Users A, B, C, D, E, and F found that the Registrant had completed the patients’ treatment notes and, in some cases, issued instructions to the patients, and/or their GP.

75. Upon review it was identified that there may have been cases in which GPs should have received a letter from the Registrant but did not. All record keeping entries appear on the software used by the Trust called “SystmOne”. The only evidence we have for what a health professional within the Service has done is what is recorded on SystmOne; if it does not appear on SystmOne, it has not been done. This is the basis for understanding that in some cases the GP should have received a letter. AO had no other concerns about the Registrant’s record keeping.

76. AO stated that the Registrant entered his rationale for requesting the medication change for Service User A on this patient’s record. AO would say the Registrant had entered notes for all patients and is obliged to assume that all appropriate action has been taken and that the rationale for such actions was also recorded. AO observed that some Dietitians keep more thorough records than others. When AO discussed record keeping with Dietitians AO reminds them that the only evidence we have for their actions and rationale is what they have written on the patient records. AO would say the Registrant has entered notes for all patients.

Follow up letters to Service Users/ Service Users’ GPs

77. In respect of the requirement for practitioners to prepare and submit letters to patients and/or their GPs following clinical appointments, the requirement to issue the patient with a letter is not absolute. It was also reasonable for a practitioner to just agree verbally with a patient what their treatment plan is. However, the requirement to ensure a patient’s GP is made aware of any agreed changes to a patient’s treatment is more crucial, although there is no written policy, there is a general expectation that a GP will receive a letter informing them if there is a significant change to patient’s treatment.

78. In the case of the Service Users who the Registrant had commenced on a VLCD, namely Service Users C, D, and E, the Registrant should have informed the patients’ GP that there had been a substantial change to their diet because, should the patient have attended their GP practice with any concerns, their physician would have needed to have had a full picture of their current diabetes management plan.

79. On 17 January 2020, Service User C was commenced on a VLCD. The Registrant, again did not write a follow up letter to the GP or Service User C.

80. On 13 January 2021, Service User D was commenced on a VLCD. There was no follow up letter written by the Registrant to Service User D or their GP.

81. On 2 February 2021, Service User E was commenced on a VLCD, The Registrant did not write a follow up letter to the patient or GP. The Registrant went off sick from the next day.

Witness JR

82. JR affirmed and adopted her witness statement as her evidence in chief. Her evidence, taken from her statement, and her live testimony was as follows.

83. JR explained to the Panel that she is registered with the Nursing and Midwifery Council as a nurse. She is employed as a Diabetes Nurse Consultant at Sussex Community NHS Foundation Trust (the Trust) from 1 July 2018 to date. For some of this period, she worked within the Diabetes Care For You team (the Service), which is a commissioned service that forms part of the diabetes care provided by the Trust. Ms Downey now works across the Trust as a whole.

84. As a Diabetes Nurse Consultant, JR had her own clinical caseload, and was also an advisory clinician at the Trust for anything diabetes related. She was part of the Multidisciplinary Team (MDT) which included the Registrant and was a point of contact for nursing colleagues and other allied health professionals within the MDT if they need advice (including the Registrant). The MDT was made up of colleagues of numerous different levels and disciplines, including diabetes nurses, Dietitians, podiatrists, medical consultant colleagues and healthcare assistants (HCAs).

85. The Service is commissioned to provide MDT support for diabetic patients referred in from the area (often from GPs) who fall within the referral criteria. This includes type 1 and type 2 patients living with diabetes. For type 1 population, the Service will often assist, and support the management and control of the condition throughout the lifetime of the diabetes. For type 2 diabetes patients, the referrals will often be for specific optimisation of the control of the condition before referral back to the GP.

86. JR recalled the Registrant who she met as a diabetes Dietitian at the Service. The Registrant was a colleague as a part of the MDT but she did not manage him nor deal with specific cases with him. JR was available to assist him with support if necessary. The Registrant was responsible for the management and providing support to patients in relation to diet and food as part of their diabetic condition.

87. JR raised concerns to AO, the Professional Lead Diabetes Dietitian at the Service in relation to a review that JR conducted in relation of the notes to a patient, Service User A. At the time of her patient notes review, there were no guidelines, or documents in place regarding changes to insulin regimes by Dietitians. This was because making these changes is not in a Dietitian’s job description. There were also no guidelines on providing care plans that JR was aware of because this is standard care that is provided to all patients and so this sits within the British Dietetic Association’s Code of Conduct and Competencies.

JR ’s review of Service User A’s notes in respect of change to medication

88. JR was asked to review Service User A’s notes by nursing colleagues after Service User A contacted the duty nurse (who is responsible for managing calls in to the Service) to query a recommendation made regarding a change to his insulin medication by the Registrant. Service User A was unsure about the new insulin medication that had been recommended. JR ’s role included the review of cases such as these.

89. JR was unclear from Service User A’s notes whether they were a type 1 or type 2 diabetes patient, although for the purpose of her review, this was not relevant. Service User A had a recent history of hypoglycaemic episodes and a decision had been made to reduce the patient’s insulin doses.

90. The patient notes disclosed that Service User A was seen by the Registrant on 25 July 2019. Service User A’s medication was:

• Levemir 42 units in the morning and 24 units in the afternoon and

• Humalog U100 (this is a food based insulin).

91. The Registrant had documented that he changed Service User A’s medication by requesting:

• the introduction of Toujeo U300 and

• Humalog U200 and

• the discontinuance of the existing Levemir 42+24 and Humalog U100.

92. JR explained to the Panel that decisions to change a patient’s insulin medication are made by Diabetes Consultants or by Diabetes Specialist Nurses and not by Dietitians. There are open channels for colleagues to discuss with Diabetes Consultants and Diabetes Specialist Nurses any concerns that they may have about a patient’s medication. JR said that the Registrant should have used these channels or taken the matter to the weekly MDT meeting to discuss changing the medication. The Registrant should not have made the decision himself.

93. This procedure was the practice followed across the Service and the Registrant should have been familiar with that and the limitations on the scope of his practice. Accordingly, JR spoke to AO after reviewing Service User A’s notes JR later observed that the Registrant’s job description states that he is responsible for nutrition and dietary management. Any references to treating or managing diabetes refer to nutrition and dietetic management. The Registrant would need to look at dietary changes and nutritional counselling for the patient. Nutritional supplements and changes to a patient’s dietary intake can be altered by a Dietitian but the Registrant would not have been responsible for making changes to a patient’s medication.

Profile of new medication

94. JR observed that the new medication introduced by the Registrant (Toujeo U300) to replace Levemir, has a completely different profile. Toujeo is administered once daily, as opposed to the twice-daily administration of the Levemir and has a very different absorption rate. Toujeo would likely be in the patient’s system for over 24 hours whereas Levemir would be in the patient’s system for around 18 hours. They are not ‘like-for-like’ medications. Toujeo requires a much more structured form of care planning and support for administration than Levemir.

95. JR noted that the medication change made by the Registrant from Humalog 100 to Humalog 200, was a change only in respect of volume, and insulin concentration within the insulin pen. The two medications are chemically identical.

96. JR was unable to say if the medication changes were clinically indicated for Service User A, as there was not enough information in the patient’s notes. It would be necessary to see the patient’s ‘moment- by-moment’ glucose levels throughout the course of the day.

97. JR observed that the Registrant had put that Service User A’s “blood glucose results are stable 5 – 12” but had not clarified the time of day, such as whether the blood sugar levels are 5 – 12 in the morning, 5 – 12 in the evening, or 5 in the morning, and 12 in the evening. The Registrant’s notes stated that he had discussed injection sites with Service User A but he had not recorded that he has felt the injection sites to examine the absorption of insulin or what the injection sites physically looked like. These are important observations to take into account in discussing any change in medications.

98. The Registrant had also recorded meal size portions as 30 – 40g of carbohydrates per meal but had not clarified this further and had not specified the types of food being eaten which is relevant in the rate of glucose absorption. The Registrant’s notes also record ‘6-16 units Humalog lunch’ but had not recorded in the notes that he had explored and clarified this with Service User A, such as what is different on days when only 6 units are taken as opposed to 16 units. If the notes stated that the meals were all 30-40g carbohydrate then the wide variation in insulin doses would not be needed and in JR ’s view, it was unclear why there was such a variation in the doses.

99. The information within the notes is unclear or missing and thus makes it harder to understand the rational for the change.

100. The Registrant’s notes provide no sufficient clinical justification to indicate a change in medication to Toujeo. JR had been unable to find specific guidance on this. She said that from experience, the basal insulin (Levemir) being administered to Service User A case was less than 45 units of insulin per injection. This dose did not greatly compromise the effectiveness of the insulin. Therefore, a change might only be warranted if a single injection added up to more than 45 units of insulin or if the patient wanted to reduce the injection burden. The notes do not record any such discussion. The Registrant’s notes indicated that Service User A had been suffering hypoglycaemic episodes. Standard practice would have been to reduce the quantity of insulin by around 20%. Levemir for Service User A had been administered at 66 units over two injections. Toujeo administered 60 units, resulting in a reduction of only 10%. JR said that these reductions in insulin doses and the changes of the insulin should have been undertaken by either

• a Diabetes specialist nurse or

• a Diabetes medical consultant

• so that the correct reduction of insulin doses is made.

101. JR explained that the differences in profile between Toujeo and Levemir meant that standard practice created an expectation that the clinical notes for Service User A recorded a justification for such a change. The Registrant’s notes were not clear why he had made the change from Levemir to Toujeo. The Registrant had recorded that that the change was for better absorption of insulins, the evidence for this with the small doses of Levemir does not reflect this need. JR said that the Registrant should not make decisions on medication changes as a Dietitian. Any decision and potential medication change to a medication of such a different profile should have clear clinical reasoning recorded in the notes and discussed with an appropriate clinician before agreement.

102. JR explained that there is always a risk of hypoglycaemia or hyperglycaemia when insulin medications are changed. In Service User A’s case, because the change is to a new medication with a very different profile, this risk is more prevalent and, a risk of harm to the patient in the form of hypoglycaemia or hyperglycaemia became more likely.

103. For these reasons, these medication decisions should have been passed to the relevant clinician who is able to make these recommendations. Standard practice to guard against such risks would have been for the Registrant to create a safety net for Service User A by scheduling follow-up calls and appointments with the patient to revisit the state of their symptoms. The Registrant’s notes state that Mr Law would follow up with the patient in “2-3 months”, a significant medication change should be followed up in two to three weeks. Two to three months would be a standard follow up for dietary advice only.

The change from Humalog U100 to U200

104. Service User A was having 1 unit of insulin per 10g of carbohydrate and was consuming only around 30 – 40g of carbohydrates per meal. This equates to around 3 or 4 units of insulin per meal. JR said that consideration of a change in the type of insulin would be warranted if the number of units of insulin to be administered is more than 35 – 45. The U200 is the same insulin as U100. There are no trust guidelines in place for Dietitians to make changes to insulin types as this in not in their job role. JR stated that for Service User A, the change to Humalog U200 was unnecessary as the number of units of insulin being given was not more than 35 – 45. The Registrant’s notes provided no clinical indication to warrant the discontinuation of Humalog U100. In JR ’s view, the Registrant should not have been making these decisions in regard to Service User A’s medication at all.

105. JR observed that, generally for any patient in Service User A’s category, there is a risk of patient harm in the form of an episode of hypoglycaemia and/ or hyperglycaemia when changes are made to insulin regimes. These episodes can lead to patient:

• falls,

• confusion,

• infections and

• other diabetes complications due to poor diabetes control.

Care plan/ information provided to Service User A

106. JR noted that the Registrant did not provide Service User A with a care plan which gave the patient information on how to manage the change of insulins. Such template care plans are available in the Service’s system to populate with patient specific information and support. Service User A’s notes do not record that one had been given in response to the medication changes made by the Registrant.

107. JR said that the Registrant’s notes for Service User A record in respect of next steps: “Follow up 2-3 months”, indicating that the next contact with the patient would be in 2 – 3 months. In her experience, this is a long period of time for a patient to manage their own insulin, particularly after there has been a change in the patient’s medication. Where there has been a change of this nature, the Registrant should have provided a care plan to Service User A in the form of the template used by the Service, which would contain the expected glucose level readings to guide the patient in respect of their insulin management.

108. JR considered that the information provided to Service User A did not necessarily have to be provided in this format but it must be sufficiently clear and complete. Service User A might struggle to absorb all of the information. A follow up appointment should have been booked soon after the appointment on 25 July 2019 and usual practice indicated:

• without a care plan in place a follow up one week afterwards and

• with a care plan in place, two to three weeks afterwards.

This, JR said, is important to provide a safety net in order to minimise any risk of patient harm caused by the patient not understanding the insulin doses and how to manage their insulin.

109. Service User A’s records show that that Service User A contacted the Service by telephone numerous times on 5, 6, and 7 August 2019 to seek clarification on the doses of the new insulin medication. Service User A “Wanted clarification on new insulin regime prescribe ratios”. The ratios relate to Humalog insulin and support with insulin to carbohydrates eaten. This information ought to have been provided by the Registrant in a care plan, had he written one. Service User A also “wanted to know how much insulin to give as new to [Toujeo].” This information would also have been expected to have been contained in a care plan provided to Service User A in the care plan.

110. Service User A had found it necessary to contact the Service to clarify these matters. Accordingly, JR said, the Registrant had not ensured an adequate safety net was in place, which increased the risk of Service User A mismanaging their insulin and causing them harm as a result.

Dr Blades

111. Dr Blades affirmed and adopted her expert report dated 10 February 2023 and its addendum dated 14 February 2023 as her evidence in chief. Her evidence, taken from her statement, and her live testimony was as follows.

112. Dr Blades explained that she was a registered Dietitian with the HCPC and held a doctorate degree in diabetes and diet management. Having worked for the NHS for 20 years she took ill-health retirement and now works privately following her recovery. Dr Blades still works with Dietitians generally and is a trustee of an independent diabetes trust, holding a personal portfolio of complex diabetes cases. She is not a prescriber because she has no access to a health service budget for that purpose.

113. Dr Blades emphasised the importance of Dietitians working collaboratively and always within the scope of their practice unless exceptionally in emergencies, such as wartime conditions in Ukraine. A Dietitian’s work will normally require the rapid assimilation of key points from a Service User’s medical records and any changes. The records are reviewed with a note of height and weight, blood sugar levels, and any relevant updates. Discussions with the patient regarding their current wellbeing are important but it is not the role of the Dietitian to change medications. Any issues with medications are referred to the nursing consultants.

114. Dr Blades had no information regarding the Registrant’s work history prior to 2017 when he joined the Service. She did not know him and relied on the papers provided to her by the HCPC. Dr Blades observed that Dietitians are able to do further training to become a prescriber but the Registrant had not undertaken this. The Registrant had stepped over the boundaries of his job description and the scope of his practice in altering Service User’s medication prescriptions. Certain of the medications that he dealt with lay far outside of his professional range of expertise and he should not have done this. His actions in doing so fell far below the standards expected of a Dietitian. Diabetes nurses are pivotal in this respect. They will suggest doses and discuss with colleagues as appropriate, returning to the patient where necessary. They can in effect take over the management of the patient.

115. For the Registrant to have repeated his actions especially after the management interventions of 2019 and the clear letter to him on 3 October 2019 is even more serious because he knows unequivocally that he cannot intrude into the area of medication changes. Dr Blades said that she felt saddened by the Registrant’s conduct. He appeared to be a personable and valued Dietitian. However, he had stepped outside of his role and he had not focussed on his role in nutrition.

116. In relation to reduced calorie and VLC diets, he should have brought the intentions to proceed to the attention of the team in order to discuss the Service User’s suitability and to have the plans thoroughly discussed. Some persons feel bombarded with adverts for diet shakes and other proprietary products. They can have a serious impact on the Service User. Farmers driving heavy machinery and doing heavy work had been known to collapse and had this occurred while operating heavy machinery, the outcome could be very serious. If the Service User happened to be pregnant, such diets are not a good idea. Where the Service User intends to go on holiday, the diet is not going to be achieved. Other medications can impact differently and unexpectedly in a VLCD regime. Insulin needs to be reduced to guard against hypoglycaemia. This must be discussed with skilled and qualified colleagues. Some service users can become bound to the proprietary products regime and need education and help to resume a more nutritious balanced diet suitable for them. This can be contrary to their best interests.

117. This should all have been obvious to the Registrant. It is covered in Dietitians’ practical placements in hospital where they are very carefully supervised. Dietitians are introduced to common work methods based on experience of eating disorders. It was tremendously important that the Registrant shared information with the team. Communicating with the MDT is ‘…just so basic’. Dr Blades said she found it very difficult to believe that he did not know this. In any event, Dietitians are encouraged to ask the MDT questions. These teams are very welcoming and are open to discussion. Dietitians are also encouraged to share concerns with other Dietitians.

118. Dr Blades observed that in relation to Service User C, who was seen by the Registrant on Friday 17 January 2020, the Service User wanted to take up a VLC diet, but this is not always in the Service User’s best interests. The Service User had a history of hypoglycaemia. The dietary reductions leading to changes in blood sugars should have been discussed and the discussion recorded in the notes. Risks of a sudden collapse should have been discussed but were not according to the notes. Dr Blades believed that the Registrant should have discussed this Service User with other professional colleagues in the diabetes team and screening for eating disorders should have been carried out. Service User’s might ‘…do all sorts of things that you would not advocate. You don’t know what they are doing and hear about it after the event’. The Registrant should have taken this opportunity to educate the Service User regarding making changes in diet without advice.

119. Dr Blades also referred to an entry in Service User E’s notes for 2 February 2021. The Service User should have been invited to wait until a team discussion had taken place before making dietary changes. The Registrant had discussed fibre and fluid intake, which was creditable, but he left it to the Service User to arrange a review. The notes are ‘…scant’ regarding what the Service User was currently consuming each day and other fuller information which is valuable to assist the Service User manage their condition. The Registrant was not meeting the professional Standards. In this respect he fell below, but not far below the standards expected of a Dietitian. He was faced with a Service User who was clear that they wanted to make dietary changes and in such situations, advice from the MDT can be invaluable. It was not clear from the notes, as it ought to have been clear, that a full assessment of possible eating disorders, and other issues were discussed. This is below the standard expected of a Dietitian.

120. Dr Blades said that there are times when an assessment of a Service User’s height and weight will validate a choice to undertake a VLC diet. There are occasions when a patient’s eating disorder will become less problematic. The records available to Dr Blades did not show that the Registrant had assessed why a VLC diet or reduced calorie diet regime was suitable for them. Records are expected to show height and weight as well as current diet as a minimum.

121. Dietitians are expected to shadow professional colleagues when they join a new MDT. They become integrated into the team. Should get the weight and height records and work out service users’ body mass indices. Sometimes food cravings and eating disorders become less for service users placed on an appropriate diet.

122. In relation to Service User C, seen by the Registrant on 17 January 2020, he appears to have given very good advice regarding vegetable intake and snacking. He has fallen below the standards required of him in relation to this consultation, but not very far below.

123. Dr Blades said that the Registrant appeared to be very able as a Dietitian. There was no reason to believe that he could not have successfully undertaken the prescriber qualifications. Looked at overall, the picture suggested a competent Dietitian, and accordingly a lack of professional competence was not a good explanation for the Registrant’s actions. He appeared to be highly knowledgeable and highly able. There had been a repeated disregard for professional boundaries. Dr Blades’ impression of the Registrant was that he regarded his clinical knowledge was greater than other peoples and he felt that he was helping patients. However, he did not seem to want to discuss his decisions with the diabetes team or anyone else. It suggested misconduct, although Dr Blades emphasised that these were matters for the Panel. In Dr Blades’ view there appeared almost to be a sense of professional arrogance, of knowing more than others. Any other Dietitian would be saddened, alarmed, and also censorious of the Registrant’s repeated stepping outside of his role.

Decision on Facts

124. Mr Bellis invited the Panel to find all of the particulars of the allegation true on balance of probabilities. Mr Bellis referred the Panel to the evidence matrix provided by him. Mr Bellis highlighted that in the hearing bundle, there was a chain of emails between the Registrant and his manager, which included the Registrant having been instructed in 2019 not to amend medications as it lay outside his competence. The Registrant had never challenged the contents of the emails and had never disagreed that the limitations on his practice were inappropriate or inaccurate.

125. [Redacted].

126. Mr Bellis invited the Panel to find that the witnesses in this case were clear and straightforward. They could safely be accepted as truthful and reliable witnesses who were moderate in their evidence. Mr Bellis also submitted that the Panel were assisted by the expert, Dr Blades, in her assessment of when the Registrant’s conduct fell far below what was acceptable for a registered Dietitian. The ultimate decision was one for the Panel but there was no reason why the Panel could not rely on the detached professional opinion of Dr Blades in support of this decision.

127. Mr Bellis also submitted that there is no evidence of the Registrant ever having taken professional training as a prescriber. The Registrant had never at any time suggested that in fact he was a prescriber and so able to make medication changes autonomously. Equally, there was no evidence that the Registrant had ever, at the relevant times, sought the input, and support of his fellow professionals in the Service when making decisions regarding medication changes. The Registrant had never disputed that he had not collaborated with his fellow professionals.

128. As an example, Mr Bellis took the Panel to a copy of letter dated 12 January 2018 from the Registrant to Service User J’s general practitioner. The Registrant explained to the General Practitioner the discussion that the Registrant had with the Service User, and the Service User’s enquiry regarding Levemir insulin. The Registrant wrote that he had discussed the NICE guidelines with Service User J, having already discussed dietary recommendations, and the report by Service User J of overnight hypoglycaemic episodes. The letter concluded by requesting medication changes. Mr Bellis said that this was typical of the Registrant’s requests for medication change to medical professionals. They did not include any reference to discussions with the Registrant’s professional colleagues. Importantly, the Registrant did not tell the GP that he was not a prescriber.

129. Mr Bellis also invited the Panel to consider the letter dated 3 October 2019 to the Registrant by the Clinical Service Manager at the Service. In the letter, the Registrant was told:

‘You were reminded on 20 August that Dietitians are unable to remove medications or ask GPs to prescribe new medications (except for nutrition supplements), without liaising with a senior nurse consultant about the proposed change. If the nurse or consultant agrees to the change you are able to write to the GP requesting a change, but you must include the name of the nurse or consultant in your letter to the GP and on the patient record’.
Mr Bellis submitted that in spite of this, the Registrant had continued to act contrary to this instruction and the limitations on the scope of his professional practice.

130. The Panel accepted the advice of the Legal Assessor. He referred the Panel to the principles found in the cases of Suddock v NMC [2015] EWHC 3612 (Admin), Dutta v GMC [2020] EWHC 1974 (Admin), Khan v GMC [2021] EWHC 374 (Admin) and Byrne v GMC [2021] EWHC 2237 (Admin) in relation to its approach to the assessment of witness evidence.

131. The Panel considered each Particular of the allegation in turn. In reaching its decision the Panel considered how the relevant witness evidence fitted with the non-contentious or agreed facts, contemporaneous documents, the inherent probability, or improbability of any account of events, and any consistencies, and inconsistencies.

132. The Panel observed that a common element in particulars 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12 was that 2 sub- particulars featured, at least in part, which were that the Registrant had:

i. no prescription training

ii. had not discussed with or sought or authorisation from a senior nurse or consultant
Accordingly, the Panel considered that it could make a decision on the sub- particulars as a preliminary matter, and if proved, would apply to each Particular were relevant.

133. The Panel noted the evidence of AO who explicitly said that none of the Dietitians at the Service were supplementary prescribers, and that the Registrant did not have this qualification while he was employed at the Service.

134. The Panel also noted that in Dr Blades’ evidence, and in her expert report, she dealt with the issue of no prescription training by the Registrant in relation to Service User B. Dr Blades observed that Dietitians should not change medications unless they are a prescriber or are trained to do so. There was no discussion with consultants or other diabetes team members [in relation to the changes for Service User B]. She noted that in August 2019, the consultant stopped a prescription of gliclazide as requested by the Registrant. This action was not in line with the Registrant’s training as he is not a prescriber and were not within the scope of his practice. Dietitians are not permitted to advise and/or instruct service users’ GPs to change their medication if they do not have any prescription training and do not discuss and/or seek authorisation to do so. The change in medication was outside of the Registrant’s scope of practice. This was well below the practice of a competent Dietitian. The [competent Dietitian] would not alter medications and would focus on dietetic matters.

135. The Panel observed that in relation to other service users, Dr Blades had also come to the view that the Registrant did not have the necessary prescription training and had made changes to service users’ medications without consulting a senior nurse, or consultant. The Panel observed that Dr Blades had been provided with instructions, including copies of necessary correspondence, and service users records. Dr Blades’ evidence had not been contested on these issues. The Panel recognised that, to an extent, the Panel is being asked to find a negative as being factually true. The Panel observed however that the Registrant had been in correspondence with the HCPC and was fully aware of the scope of the allegations against him. The Registrant had never at any time suggested that he did have the necessary prescription training and had completed the necessary discussions with colleagues before making medication recommendations.

136. In the papers available to the Panel, there was a reference to a discussion between AO and the Registrant in 2019, in which he suggested that he had been permitted to make medication changes when employed at a different trust. Importantly, when asked to produce the guidelines which supported this, the Registrant had not done so. The Panel considered that the allegations set out in the sub-particulars required, in effect, an answer from the Registrant if he contested the factual basis for it. The Panel was entitled to rely on the Registrant’s absence of a direct response in this regard.

137. Accordingly, the Panel was satisfied that the negative assertions in the sub- particulars were proved on balance of probability.

138. For those reasons, the Panel found the sub- particulars proved.

139. The Panel found Particular 1 proved. The Panel observed the Registrant’s letter to Service User J’s GP and the relevant patient records in the bundle. They supported that the Registrant had made a request to the GP on 12 January 2018 for a change in the service users’ medication and had done so without having medication training and without having had the necessary discussions with professional colleagues.

140. The Panel found Particular 2 proved. The Panel observed the letter by the Registrant to Service User H’s GP on 13 February 2018 requesting a medication change in the same circumstances as above.

141. The Panel found Particular 3 proved. The Panel observed the letter by the Registrant to Service User G’s GP on 18 January 2019 requesting a medication change in the same circumstances as above.

142. The Panel found Particular 4 proved. The Panel observed the letter by the Registrant to Service User I’s GP on 3 June 2019 requesting a medication change in the same circumstances as above. There was evidence of the discussion with Service User I on 31 May 2019, in which the Registrant advised the Service User to change their medication.

143. The Panel found Particular 5 proved. The Panel observed the letter by the Registrant to Service User B’s GP dated 12 July 2019 prescribing an additional medication, in the same circumstances as above.

144. The Panel found Particular 6 proved. The Panel observed the evidence in the bundle of the dosage instructions provided by the Registrant to Service User a on 26 July 2019 which met the criteria ‘on or around 25 July 2019’. The evidence of AO and Dr Blades supported that the changes in Insulin were not clinically justified in reading the other records for Service User A together. AO considered that a Dietitian should not provide a Service User with instructions on insulin dosage if changing to a new medication. The Service User had been placed at risk of harm in being exposed to the potential for unanticipated hypoglycaemic or hyperglycaemic episodes with consequents risks of falls or loss of consciousness when operating machinery or driving. Dr Blades observed in her evidence that there was little recorded information provided to Service User B on diet other than to eat more carbohydrate and there was no discussion of low Glycaemic Index alternatives. There was no assessment of protein or fat intake discussed. Service User B had not been given ideas on how to supplement meals.

145. The Panel found Particular 7 proved. The Panel observed the Registrant’s letter to Service User B’s GP, dated 2019 containing the instructions to change medication, specifically insulin for diabetes. As above, the Registrant provided the GP with the narrative of the Registrant’s discussions with the Service User, but without telling the GP that the Registrant was not a prescriber and had not discussed these issues with relevant professional colleagues. The content of the letter was also criticised by AO.

146. The Panel found Particular 8 proved. The Panel observed the Registrant’s letter dated 6 January 2022 to Service User C’s GP (which met the criteria of ‘on or around 17 January 2020’) and the Service User’s patient records supporting the medication reduction discussions referred to. Further, as discussed above, the Panel observed the letter to the Registrant from the Clinical Service Manager dated 3 October 2019 advising the Registrant not to make recommendations regarding medication changes without having discussed the matter with appropriate professional colleagues. This was further supported by the records of meetings with the Registrant in August and November 2019 to the same effect, in which the Registrant had acknowledged that he had been mistaken to do so in the past and was sorry for having done so despite the limits on the scope of his practice as a Dietitian.

147. The Panel found Particular 9 proved. The Panel observed the uncontested Service User records for Service User C and also noted the evidence of Dr Blades explaining why the reduced calorie diet proposed was not clinically appropriate. Dr Blades noted the importance of appropriate screening for eating disorders. The factual evidence was also supported by the evidence of AO. The Panel observed that this Particular did not relate to a VLCD proposed, but rather a reduced calorie diet. The Panel considered that in any event, the importance of screening for eating disorders remained. In association with other evidence, Service User C’s patient notes demonstrated that no medical screening by a physician had taken place, nor had any appropriate discussion, or authorisation with a senior nurse consultant taken place. There was no record of the Service User’s GP being updated.

148. The Panel found Particular 10 proved in both sub-particulars a, and b.

149. In respect of sub-particular a, Service User D’s patient records supported the facts that the Registrant had discussed with D their plan to begin a VLC diet in January 2021 supported by proprietary shakes purchased personally. The Registrant discussed some of the issues but supported the Service User by undertaking to assess the nutritional content of the proprietary shakes and that the Service User should weigh themselves weekly.

150. None of the necessary steps that the Registrant ought to have taken in limbs i. to iv. were undertaken as shown by the absence of any recording of them (including an update to the GP) in the patient notes. AO’s evidence and that of the expert, Dr Blades set out the importance of a Dietitian discussing proposed changes with suitably qualified and senior colleagues before alterations are made. Patients and members of the public are at risk from the unintended consequences of Insulin changes, including loss of consciousness, or coma.

151. Service User D’s patient notes includes the entry dated 13 January 2021 ‘…and to stop sitagliptin/reduce metformin when blood glucose regularly 4-4 mmol/l’. As before, heads i. and ii. were already proved and the instruction to the Service User was in defiance of the Registrant’s limits on the scope of his practice (per the Registrant’s job description and the evidence of Dr Blades) and the letter referred to in dealing with Particular 8 above instructing him precisely not to make such medication decisions. The letter to the Registrant from the Clinical Service Manager dated 3 October 2019 advised the Registrant not to make recommendations regarding medication changes without having discussed the matter with appropriate professional colleagues.

152. The Panel found Particular 11 proved which referred to Service User F’s patient records. As before, heads i. and ii. were already proved. The letter to the Registrant from the Clinical Service Manager dated 3 October 2019 advised the Registrant not to make recommendations regarding medication changes without having discussed the matter with appropriate professional colleagues. The patient records showed conclusively that no relevant discussions or authorisations had been sought. The records included the Registrant’s letter to Service User F’s general practitioner dated 14 January 2021 which stated in bold type, perhaps to ensure the prominence of the change asked for by the Registrant:

‘Therefore please can you change her prescription from Novo rapid Pen fill cartridges to Fiasp Pen fill cartridges 100 units/ml via 3ml cartridges x 5?’.

153. The Panel found Particular 12 proved in both sub-particulars a, and b. In respect of sub-particular a., Service User E’s patient records for 2 February 2021 recorded by the Registrant stated:

‘I also advised her to ensure adequate fluid intake and increase fibre in her evening meal.’

This entry and the other records for that date were wholly unsupported by discussions with colleagues other than noting that a colleague review was scheduled for ‘…next week’. The guidance on VLCDs was available to the Panel (as it was to the Registrant). The expert evidence of Dr Blades, establishing that Service User E was not screened before commencing the VLC diet, supported by the evidence of AO, illustrated why, a VLC diet was not clinically appropriate for Service User E in these circumstances. There were no records to support or even infer any form of screening for eating disorders, medical screening by a physician, or authorisation for the VLC diet from a senior nurse of a consultant. Aiming to add in shakes for replacement meals with support of myself

154. In respect of sub-particular b., Service User E’s patient records for 2 February 2021 recorded by the Registrant stated:

‘I advised her to reduce her NoVo rapid dose to 6 units at breakfast and lunch when she starts her shakes tomorrow.'

This entry and the other records for that date were wholly unsupported by discussions with colleagues other than noting that a colleague review was scheduled for ‘…next week’. As before, heads i. and ii. were already proved. Heads iii. and iv. were established by the uncontested evidence of AO and Dr Blades and by the letter to the Registrant dated 3 October 2019.

155. The Panel found Particular 13 proved. The Panel observed the Registrant’s job description which set out at section 5 the Registrant’s main tasks. These did not include any responsibility for medication management for service users. Section 3 includes:

‘a) The post holder [the Registrant] will regularly communicate with patients, dietetic colleagues, GPs, hospital consultants, specialist nurses, practice nurses, podiatrists, clinical psychologists, and other members of the multidisciplinary team.’

156. It was clear, as set out by the Panel above, that the Registrant had not confined himself to the limits of his professional practice within his job description. Importantly, he had stepped outside of the scope of his professional practice as established by the expert testimony of Dr Blades. She told the Panel explicitly that the Registrants decisions to alter service users medications and act autonomously without consulting colleagues in the MDT was outside of the scope of his practice as a Dietitian.

157. Dr Blades told the Panel that certain GPs like a certain range of medication. Medication doses and delivery is outside of the Registrant’s expertise range and he should not have done it. She explained that doing so in the circumstances carried out by the Registrant fell far below what was acceptable for a registered Dietitian.

158. Dr Blades also told the Panel that diabetes nurses are pivotal in this aspect of patient and Service User healthcare. The diabetes nurses will suggest doses and discuss them with patients and clinical colleagues before making a recommended change to a GP. The nurses can take over from Dietitians at the point that changes in medicines are relevant.

159. Dr Blades said that for the Registrant to repeat this course of conduct was very serious. Following the meetings and the letter to him of 3 October 2019 the Registrant must have known that he could not act in this way within the scope of his practice. Where a patient or Service User brings up the issue of a diet change, including a VLC diet plan the Dietitian must focus any advice on the role of nutrition and not more widely. He should have thoroughly discussed the proposed VLC diet with the Service User and with professional colleagues and have ensured that Service User suitability was assessed by screeners and other colleagues. Had he done so, the Registrant would have remained within the scope of his practice as a Dietitian.

Decision on Grounds

160. The Panel was invited by Mr Bellis to determine the grounds of impairment alleged in Particular 14 which were:

The matters set out in particulars 1-13 above amount to misconduct and/or lack of competence.

161. Mr Bellis explained to the Panel that the primary case adopted by the HCPC was that the Registrants actions amounted to misconduct. However, in fairness to the Registrant who had raised matters relating to his health and private life in the Service’s investigation, Mr Bellis said that it was open to the Panel to find that the Registrant’s actions were the result of a lack of professional competence. This might be the case if the Registrant had satisfied the Panel that an external factor or combination of factors related to his health and private life had the effect of removing the intentional deliberateness of misconduct in the knowledge of risks and breaches of the Code. This was a matter for the Panel’s professional judgement.

162. Lack of competence was conceptually different from misconduct and if the Panel was satisfied that this explained the Registrant’s failings, which would also amount to grounds of impairment. A lack of competence was shown if there was a thread of deficiencies in the Registrant’s professional decision making and conduct to be regarded as a fair sample of his work over a demonstratively lengthy period of time and range of practice.

163. Mr Bellis reminded the Panel that negligence on its own was insufficient to establish the grounds of misconduct unless the negligence was repeated or in any one instance was sufficiently grave negligence as to amount to misconduct.

164. Mr Bellis referred the Panel to cases including Roylance v GMC [2000] 1 AC 311 and Nandi v GMC [2004] EWHC 2317 (Admin) in support of his submissions relating to misconduct. Mr Bellis submitted that the facts found proved by the Panel were serious. He further submitted that the seriousness of the Registrant’s actions was demonstrated by the number of breaches of standards set out in the HCPC’s Standards of Conduct, Performance, and Ethics, and the HCPC’s Standards of Proficiency for Dietitians.

165. The Panel accepted the advice of the Legal Assessor who referred the Panel to the principles in cases such as Roylance v GMC [2000] 1 AC 311, Nandi v GMC [2004] EWHC 2317 (Admin). In considering grounds, the Panel took into account the submissions of Mr Bellis and the Registrant’s written submissions, all relevant evidence, and its prior Findings on Facts.

166. The Panel was aware that in respect of misconduct there was no standard or burden of proof and that it was a matter for the Panel’s own professional judgement. It bore in mind that breaches of the Standards did not automatically result in a finding of impairment.

167. The Panel also took into account the expert opinion of Dr Blades, that a substantial number of the Registrant’s various acts fell far below the standards to be expected of a registered Dietitian. The witness AO had expressed a similar view. The witnesses’ views were helpful but not determinative as this was a matter for the Panel to decide.

168. The Panel further considered that the Registrant’s conduct found proved was serious both each instance individually and taken all together. The risks created for the service users were substantial and would have been obvious to a Dietitian of the Registrant’s experience and professional training, in the Panel’s view. The decisions taken by the Registrant, outside of the scope of his practice and without any, or any adequate, consideration of the need to consult with colleagues were repeated despite a careful review, investigation, meeting, and declaration of understanding by the Registrant in 2019. He had expressed regret in that meeting with AO for his actions and said that it would not happen again. Despite that, there had been reoccurrences of the Registrant’s conduct.

169. The seriousness of the Registrant’s actions were illustrated by AO’s response to that. She explained in her statement that ‘What concerned me the most in respect of Service User F was that it was an unequivocal breach of the very explicit instructions that had been set out in the letter of 3 October 2019, produced at Exhibit 11, Appendix 3. The Registrant had repeated the conduct that he had assured the Trust that he understood was wrong in 2019’.

170. In all of these circumstances, the Panel was satisfied that a lack of professional competence was not the true explanation for the Registrant’s conduct. In any event the Registrant had not provided any supporting evidence to suggest that the stressors linked to his health and private life were materially influential in his actions. [Redacted]. Accordingly, the Panel was satisfied that there was no good evidential basis to distinguish the Registrant’s conduct leading up to the 2019 meeting and the Registrant’s subsequent conduct. The Panel considered that in all of the circumstances, deliberate decisions were made by the Registrant despite his assurances to AO in 2019. There was no hint of exaggeration in AO’s response. She said that the Registrant’s actions had not resulted in harm to Service User F.

171. The Panel determined that both individually and cumulatively, the Registrant’s acts and omissions found proved in Particulars 1 to 13 with the exception of Particular 9 fell seriously short of the standards to be expected of a registered Dietitian and amounted to misconduct. The Panel was satisfied that a fellow Dietitian would regard what had been done by the Registrant as deplorable.

172. The Panel observed that the Registrant regarded himself as not being the final decision maker in the medication changes recommended by him. He stated that he relied on the relevant GP or consultant to review his decisions. The Panel was satisfied that, as was observed by Dr Blades, the pressures of time under which medical practitioners operate meant that they relied heavily on recommendations for changes being made to them having been fully considered and discussed prior to the recommendation being made. The Registrant therefore knowingly exposed his professional colleagues, including medical staff, to professional risks by bypassing the essential stages of discussion and evaluation of any proposed recommendations with his professional colleagues.

173. The evidence supported the view that there were risks for service users of diabetic, and possible secondary (accidental) health risks, including injury associated with changes in insulin medications. The Panel was satisfied that the evidence supported there being a high risk to service users of things going wrong, even though there was no evidence of actual harm to service users. One of the service users had a stoma. Accordingly, the change in medication instructed by the Registrant would necessarily require a change in the insulin injection site for the Service User. This raised an important ‘red flag’ when the Registrant made his decisions. The Registrant appeared to have acted without regard to the cautionary factors engaged. The Registrant had not focussed on the importance of a change in injection site and therefore a variation in the uptake of insulin delivery, leading to consequent risks for over, or under delivery of insulin, compounded by calorie intake changes recommended. The Panel considered that the evidence supported the Registrant having made multiple errors with the more complex service users in his group. The Registrant had acted knowingly, and when challenged, had discreditably attempted to hide behind the prescribing Dr as a final backstop.

174. The Panel considered that the documentation provided showed a very poor standard of documentation for a Dietitian. The records did not appear to have been consistent with well-planned and well documented assessments. Any Dietitian would regard this as deplorable.

175. In respect of Particular 9, the expert witness, Dr Blades, had said that the Registrant’s actions had fallen ‘…below but not far below’ what was expected of a Dietitian in the circumstances. Accordingly, the Panel found that in this Particular alone, the conduct was not sufficiently serious even taking into account the other Particulars so that, in the Panel’s professional judgement, misconduct was not made out. The Panel was satisfied however that misconduct was made out in all over respects.

Decision on Impairment

176. Having found that the statutory ground of misconduct had been made out, the Panel moved on to consider the question of impairment. Mr Bellis referred the Panel to his written submissions and he supplemented them with references to the HCPTS Practice Note on Fitness to Practise Impairment and to the cases of Cohen v GMC [2008] EWHC 581 (Admin), and CHRE v NMC & Grant [2011] EWHC 927. He submitted that the Panel were required to consider both the personal and public components as set out in the HCPTS Practice Note Fitness to Practise Impairment.

177. Mr Bellis submitted that whether the Registrant’s fitness to practise was impaired was a matter for the Panel’s professional judgement. He referred the Panel to the approach formulated by Dame Janet Smith in the Fifth Shipman Report set out in the Grant case in relation to the consideration of impairment of fitness to practise. He submitted that although the Panel was considering the Registrant’s current fitness to practise, the Panel required to take into account the way the Registrant had acted in the past as a way to assess this. The Panel was entitled to take into account any evidence of insight and practical targeted remediation undertaken by the Registrant which might suggest that any past impairment had now been resolved, or otherwise.

178. Mr Bellis invited the Panel to find the Registrant’s fitness to practise was currently impaired.

Decision

179. The Panel accepted the advice of the Legal Assessor. He referred the Panel to the HCPTS Practice Note Fitness to Practise Impairment, and the principles found in the cases already referred to by Mr Bellis.

180. In reaching its decision on current impairment, the Panel took into account the submissions of Mr Bellis and the written material available from the Registrant in the service bundle and in the hearing, bundle relating to the Service’s investigation and management processes. Where these related to the Registrant’s private health and family life, these were considered in private session.

181. The Panel also took into account all other relevant evidence before it and its prior decisions on facts and grounds. The Panel also took into account the HCPTS Practice Note Fitness to Practice Impairment. The Panel was aware that the question of impairment was a matter for it exercising its own professional judgement and that it was considering the Registrant’s current fitness to practise.

182. The Panel had already determined, in relation to misconduct, that the Registrant’s conduct found proved was serious

Personal impairment component

183. The Panel considered that all of the Registrant’s failings were in theory remediable. The expert witness had suggested, and the Panel agreed, that the Registrant’s resumption of his course of misconduct after his meeting with AO pointed to a certain measure of professional arrogance on his part. Such attitudinal failings are more difficult to remediate than clinical issues and require a depth of insight and meaningful appreciation of wrongdoing coupled with practical proposals for ensuring there will be no further repeat. The courses undertaken by the Registrant were set out in his email to the HCPC of 1 December 2024, and extended to online training modules completed in May 2023 from Health Education England in the following:

i. Signposting

ii. Health, safety, and welfare

iii. Safeguarding adults

iv. Safeguarding children

v. Conflict resolution

vi. Equality and diversity and human rights

vii. Preventing radicalisation - basic prevent awareness

viii. Alcohol and smoking brief interventions

The Registrant had also attended webinars in February and March 2024 related to updates in young adults with type 1 and type 2 diabetes.

184. These are all valuable courses in themselves, but the Panel considered that they related more to continuing professional development as a registered Dietitian. They did not evidence practical and targeted remediation aimed at addressing the Registrant’s misconduct and the associated potential for current impairment. There was nothing in relation to any identification of a need to work with colleagues constructively and within professional boundaries in order to secure and promote Service User’s safety.

185. The Registrant had not provided the Panel with any evidence which pointed towards his frank acknowledgement and acceptance of his failings and the impact that they might have had on the safety of service users, professional colleagues, public trust, and confidence in the profession of Dietitian, and on the standards which must be upheld by Dietitians. There was no material to support a sincere apology for the Registrant’s failings and an acceptance that harm might have arisen and might arise again if there was any repetition and the Panel could not be satisfied that there would no repetition.

186. Accordingly, although remediable, the Panel concluded that the Registrant had not remedied his past failings or had begun to accept what had gone wrong and why. His reflections, to the extent that these can be ascertained from the hearing bundle, were somewhat dated, and self-focussed. The Registrant had not explained why the stressors in his personal life had impacted on his professional decision making in deciding on significant and potentially harmful medication and Service User dietary changes without consulting colleagues and outside of his professional scope of practice. This may be for the reason that there is no such explanation. If there is an explanation, the Panel was unable to establish what it was from the papers available. The Panel observed that the position adopted by the Registrant when the matters were first taken up with him in 2019 was to, in part, justify his decision making rather than accept that he was acting improperly and potentially harmfully for service users.

187. In these circumstances, the Panel concluded that there is no assurance that the Registrant’s failings will not be repeated. Indeed, on the material available to the Panel, it seemed that a repetition was more likely than not. Accordingly, the Panel found that the Registrant’s fitness to practise was currently impaired on the personal component of impairment.

Public impairment component

188. The Panel went on to consider the wider public interest and the public component of the Registrant’s current fitness to practise. In relation to the public component, the Panel has considered very carefully whether given the nature, circumstances, and gravity of the Registrant’s misconduct in this case, public confidence in the Dietitian profession, and its regulatory body would be undermined if there was no finding of impairment in this case. The Panel has also considered whether it would be failing in its duty to declare and uphold proper standards of conduct and behaviour in the profession if it did not find impairment in this case.

189. The Panel took into account the test for current impairment identified in the Grant case where Panels are asked to address a series of questions which assumes that the past is a confident guide to the future unless, with insight, and remediation, something fundamental has changed. These questions are:

“Do our findings of fact in respect of the Registrant’s misconduct … show that the respondent’s fitness to practise is impaired in the sense that the respondent:

a. Has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and / or

b. Has in the past brought and / or is liable in the future to bring the medical profession into disrepute and / or

c. Has in the past breached and./ or is likely in the future to breach one of the fundamental tenets of the medical profession; and / or

d. ….”

190. The Panel was satisfied that the Registrant had created the risk of serious harm for the service users in his care by acting outside of the scope of his practice, and by failing to work collaboratively with colleagues. The evidence of JR alone was sufficient to establish this although there was other evidence.

191. The Registrant had brought the profession of Dietitian into disrepute. He had repeated his failings deliberately and in the face of the risks which had been explained to him in 2019 by his colleague and manager. His behaviour was alarming for his colleagues such as JR who had relied on the Registrant to act collaboratively and respect his professional boundaries.

192. The Registrant had breached a fundamental tenet of the profession to always act within the scope of his practice.

193. The Grant case had made it clear that the public interest was an equal and irreducible component of fitness to practise. Public trust and confidence and the declaring and upholding of professional Standards had to be given prominence and depth in the assessment of fitness to practise. At paragraph 116 of the Grant case, the Court said that insight is a critical factor in determining current impairment. The Panel came to the view that the Registrant lacked any real and material insight into the risks that he created for service users and for his professional colleagues.

194. The Panel had not heard directly from the Registrant and so could not be confident that he would act differently in future if the same circumstances arose. In these circumstances, the Panel concluded that the Registrant is liable in future to put service users at unwarranted risk of harm, to again bring the profession of Dietitian into disrepute and to breach fundamental tenets of the profession of Dietitian.

195. Further, he had not shown any grasp of the adverse impact his actions had in the mind of the public who depend on Dietitians to act within the scope of their practice in a MDT. Accordingly, there was a real risk that the necessary trust and confidence in which the public held the profession of Dietitian might be eroded.

196. The Panel concluded that a reasonable and informed member of the public would be very concerned if there was no finding of impairment in this case given the Panel’s conclusion in respect of insight, remediation, and risk of repetition set out above. The Panel is satisfied that public confidence in the profession and in its regulator would be undermined if there was no finding of impairment. The Panel is also satisfied that it would be failing in its duty to uphold and declare proper standards of conduct and behaviour in the Dietitian profession if it did not find that the Registrant’s fitness to practise is currently impaired.

197. Accordingly, the Panel finds the Registrant’s fitness to practise is impaired on both the personal and public component.

Decision on Sanction

Submissions on behalf of the HCPC

198. Mr Bellis, on behalf of the HCPC, invited the Panel to impose a sanction for reasons of protection of the public in the light of the Panel’s earlier findings and in accordance with the wider public interest. He did not suggest any particular sanction but reminded the Panel that any sanction should take account of the Panel’s findings regarding the Registrant’s lack of insight and his lack of expressions of remorse for the potential harm to the Service Users in this case. Mr Bellis also reminded the Panel that the HCPC Sanctions Policy was an important statement of the relevant factors for the Panel to consider.

199. Mr Bellis reminded the Panel that the purpose of sanctions was to protect the public and not to be punitive in any sense, although a sanction may have a punitive effect. He reminded the Panel of the guidance at paragraph 25 of the Sanctions Policy in relation to aggravating and mitigating factors. Mr Bellis said that there was no evidence of a demonstration of insight, remorse, or apology by the Registrant. [Redacted]. There was no evidence available to the Panel explaining how that would have impacted on his conduct. Mr Bellis reminded the Panel that personal mitigation is relevant but attaches less weight than in other jurisdictions since there is no element of punishment in these proceedings. Mr Bellis referred to the case of Bolton v Law Society (referred to by the Panel below).

200. Mr Bellis said that the Panel should consider the Registrant’s repetition of his behaviour following the internal investigation and letter to him of 3 October 2019. The Registrant had undertaken not to repeat his conduct but had done so. There was a failure to work in partnership in this case and an absence of evidence of insight into the concerns which may be repeated more likely than not.

201. Mr Bellis, in answer to Panel questions, said that the Registrant was not subject to an interim order. The Registrant had not positively consented to information relating to his health and private life being shared with the Panel. In any event, the allegations at the investigation stage of this process were quite different from the allegation in the final hearing dealt with by the Panel. Accordingly, Mr Bellis said, any prior correspondence with the Registrant may be of limited value to this Panel.

The Registrant

202. There were no submissions for or on behalf of the Registrant.

The Panel’s approach to Sanction

203. In considering the appropriate and proportionate sanction, the Panel took account of the HCPC’s Sanctions Policy. The Panel accepted the Legal Assessor’s advice. The Panel recognised that the purpose of any sanction it imposes is not to punish the Registrant, although it may be perceived as having that effect by the Registrant. Sanctions are imposed only for the purpose of protecting the public, maintaining the trust and confidence in which the public hold the Dietitian profession, and to declare and uphold its standards of conduct and behaviour. The Panel has also had in mind that any sanction it imposes must be appropriate and proportionate bearing in mind the nature and circumstances of the case.

Mitigating factors

204. The Panel considered the mitigating and aggravating factors. The Panel noted that paragraph 28 of the guidance provides;

205. ‘A key factor in determining what, if any, sanction is appropriate is likely to be the extent to which a Registrant recognises their failings and is willing to address them. Where a Registrant does recognise their failings and is willing to address them, the risk of repetition is reduced’.

206. The Panel considered very carefully all of the information available to it. It concluded that there was no evidence of the Registrant’s insight, remorse, or apology for his past failings. The Panel noted that the Registrant has completed CPD courses, but there were no certificates available to the Panel and no further information to suggest that these courses directly engaged with the failings identified by the Panel. The risks to the public are therefore unaddressed by the Registrant.

207. In these circumstances, the Panel was unable to identify any relevant mitigating factors. So far as the Panel is aware, there are, in common with the great majority of fellow Dietitians, no previous regulatory findings against the Registrant, who has been a Dietitian for a number of years. The Panel was unable to conclude that this was a mitigating factor, since it is expected that all Dietitians will practice safely and effectively in the interests of Service Users, patients, and the general public.

Aggravating factors

The Registrant’s lack of insight, remorse, or apology

208. The Registrant has not provided the Panel with any expression of remorse or any evidence of practical, targeted, and relevant reflections or courses available to him, which would recognise and engage with the Panel’s decisions and the concerns for:

• public and service user safety,

• the adverse impact on the trust and confidence in which the public holds the profession of Dietitian, and

• the need to declare and uphold professional standards for Dietitians.

209. The Registrant has not provided the Panel with any material or information which would suggest that he has remediated his repetition of conduct, which placed service users at risk. He has not expressly recognised the potential for service user harm and the potential for the continuing risk of such harm in the absence of a meaningful and verifiable commitment to there being no repetition. In addition to the potential for service users to experience episodes of hypoglycaemia and hyperglycaemia, they, and other members of the public at risk if there were episodes which coincided with the operation of dangerous machinery or a motor vehicle. The Registrant ought to be intimately aware of these risks but has not meaningfully engaged with them in this process.

210. The Panel also observed that the Registrant has not engaged with the breach of trust with service users who relied on him to advise them properly when they contemplated undertaking sudden and challenging changes of diet, including the VLCDs.

211. The Panel observed that there were a number of breaches of the code as set out in the section on impairment. These extended to breaches of fundamental tenets of the profession and included making prescribing decisions outside of the scope of the Registrant’s professional competence and without discussions with relevant qualified professional colleagues. The potential for service users to experience adverse effects from a reduction of calorie intake was undertaken without such professional discussions. Risks arose from that decision making. The Registrant has not identified this risk and has not engaged with it meaningfully in this process.

212. The Panel identified that the following aggravating factors applied.

• Breach of service user trust.

• Repetition of concerns and the pattern of unacceptable behaviour after 3 October 2019, extending over a period of 2 years, and unaddressed by the Registrant in this final hearing.

• There was no evidence of insight, remorse, or apology.

• There was a lack of meaningful targeted and relevant remediation.

• There remained risks of serious Service User harm, although the Panel recognised that there was no evidence of actual harm to a service user. In this case.

213. The Panel therefore considered the sanctions available to it as set out in paragraph 94 of the sanctions policy, in ascending order, beginning with the least restrictive sanction available and taking into account the requirement to be fair and proportionate while fully protecting the public.

Mediation

214. The Panel considered mediation as an inappropriate sanction in this case. The Panel had no evidence that the Registrant had shown any willingness to participate effectively in mediation. They would in any event, be a difficult sanction to manage at this late stage. There was a risk of serious harm to service users and a lack of insight and remediation in this case. There was not, in the Panel’s view, an obvious focus for mediation.

No action

215. The Panel considered the option of taking no action. This is an exceptional outcome, and the Panel was of the view that the circumstances of this case were not exceptional. The Panel decided that the option of taking no action was not sufficient to protect the public or uphold the public interest in this case.

Caution Order

216. The Panel next considered the option of a Caution Order. The Panel considered the guidance in the Sanctions Policy that “A Caution Order is an appropriate sanction for cases, where the lapse is isolated, limited, relatively minor in nature or there is a low risk of recurrence, the Registrant has shown insight and taken appropriate remedial action”.

217. The Panel was of the view that such a sanction would not address the risks to Service Users and the wider public. The Registrant had already received what was, in effect, a caution on 3 October 2019. The Registrant had undertaken to ensure that there would be no repetition of his actions. The chronology of events demonstrated that he had departed from this undertaking within a few months. The Panel concluded that the totality of the Registrant’s misconduct made a Caution Order inappropriate and inadequate.

218. Further, a Caution Order would not reflect the seriousness of the findings in this case. It was therefore not an appropriate sanction. The Panel was also of the view that public confidence in the profession, and the HCPC as its Regulator, would be undermined if the Registrant’s behaviour were dealt with by way of a caution.

Conditions of Practice Order

219. The Panel next considered whether to place conditions of practice on the Registrant’s registration. The Panel was of the view that the Registrant’s conduct reflected what had been considered to be a sense of professional arrogance on his part. This suggested a failing which is fundamentally attitudinal in nature, and was therefore conduct that is difficult to remediate by conditions of practice. Further, the Registrant was regarded by his professional colleagues, and by Dr Blades, who reviewed the relevant papers, as a highly competent practitioner. There was accordingly no evidence of any clinical failings which conditions of practice would address meaningfully.

220. The Registrant had already departed from a solemn commitment given by him in the workplace after October 2019 to address the same failings that had been repeated in 2020 and 2021. Accordingly, the Panel had no information available to it, or expression of remorse and reflection which gave it confidence that the Registrant would cooperate with and respect any conditions of practice that might be devised in relation to his conduct. The Panel decided that a Conditions of Practice Order was not workable, proportionate, or appropriate in the Registrant’s case.

Suspension Order

221. The Panel next considered a Suspension Order. The Panel had regard to paragraph 121 of the Sanctions Policy which provides:

“121 A Suspension Order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a Conditions of Practice Order, but which do not require the Registrant to be struck off the Register. 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;

• there is evidence to suggest the Registrant is likely to be able to resolve or remedy their failings”.

222. Having taken account of those factors, the Panel considered that a Suspension Order was the appropriate order in this case. In coming to this view, the Panel recognised one factor relevant in the foregoing list is the gateway factor of serious breach of standards of conduct. The Panel had no evidence to suggest that the other factors set out above were engaged. The Panel however recognised that, taking the totality of the information available to it, together, there was scope for a realistic view that a Suspension Order could provide the Registrant with the platform and the time to productively address the Panel’s determination and the concerns set out in it.

223. The Panel was influenced by what was said in relation to the Registrant’s clinical abilities by AO and Dr Blades. The Panel recognised that service users and the public can always be protected from the failings of Dietitians by removing them completely from the Register. The Panel recognised however that this is a sanction of last resort where the Registrant’s conduct was wholly incompatible with continued registration. In this case, there was scope for the view that the Registrant was acting in the best interests of the service users, although his professional arrogance may have blinded him to the clear risks to service users of his decisions which were made outside the scope of his practice and without appropriate discussions with the MDT.

224. The Panel recalled that the High Court set out in the case of Giele v General Medical Council [2005] EWHC 2143 (Admin) that where possible, protective sanctions can, in appropriate cases, fully protect the public by acting in a way that can restore an otherwise safe and effective practitioner to serve the needs of the public. The Registrant was highly regarded professionally despite his failings and the appearance of professional arrogance. The Panel considered that a period of suspension could provide him with the opportunity to engage with the Panel’s findings and to begin the process of reflection and remediation necessary to allow him to return to practise.

225. One of the factors in support of a Suspension Order is the Registrant’s insight. In this case, the Registrant has demonstrated no insight of any meaningful kind, nor has he provided an apology or any expression of remorse. The Panel had already determined that the Registrant’s conduct may be repeated with potential risks for service users and for the reputation of the Dietitian profession. However, given the potential for the Registrant to reverse that lack of engagement and insight during a period of suspension with the consequent potential benefits for the public if successful, the Panel came to the view that public confidence in the profession and regulatory process would not be undermined if a Suspension Order was imposed in this case.

226. The Panel therefore decided to impose a Suspension Order for 12 months.

Striking Off Order

227. The Panel also considered a Striking Off Order. The Panel was aware that this was a sanction of last resort, as set out in paragraph 130 of the Sanctions Policy for serious, persistent, deliberate, or reckless acts.

228. Paragraph 131 states:

‘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.
…
is unwilling to resolve matters’.

229. The Panel was aware that this is a case that could merit a striking off order in circumstances where the Registrant’s lack of insight and the nature and gravity of the proved misconduct had implications for public safety and for the reputation of the profession of Dietitian.

230. The Panel had in mind what was said by the High Court in the case of Bolton v Law Society [1994] 2 All ER 486 in relation to the factors which are relevant to sanctions. The Court identified that the deterrent effect of a sanction was important to deter others who might be tempted to behave in the same way. There were, the Court said, two other purposes of sanctions orders.

231. The first purpose was to be sure that the offender did not have the opportunity to repeat the offence. That purpose was achieved for a limited period by an order of suspension or for a longer, or indefinite, period by striking off.

232. The second purpose was the most fundamental: to maintain the reputation of the [relevant profession] profession as one in which every member could be trusted. To maintain the profession's reputation and sustain public confidence it was often necessary that those guilty of serious lapses were not only expelled but denied re-admission.

‘A profession's most valuable asset was its collective reputation and the confidence which that inspired. Since orders were not primarily punitive, mitigation had less effect than in criminal cases. … The reputation of the profession was more important than the fortunes of any individual member. Membership of a profession brought many benefits, but that was part of the price’.

233. The Panel concluded that in this case, a Striking Off Order was not the only means by which the public and Service Users could be fully protected. It was not necessary in order to ensure public confidence in the Dietitian profession is maintained, and in order to uphold proper standards of conduct in the profession. It was not decisively appropriate and proportionate to order that the Registrant’s name be struck off the Register. The case of Bolton expressly allowed for the same purposes being served by a period of suspension in appropriate cases.

Future review

234. The Panel considered that a Panel which later reviewed the Registrant’s suspension would be assisted by;

• The Registrant’s attendance and participation in the review

• Information regarding the Registrant’s current professional or voluntary employment relevant to the profession of Dietitian

• Being provided by the Registrant with a reflective piece of writing which engaged closely with the Panel’s findings in this hearing, and

• Evidence of targeted professional education courses dealing with

a. The importance of acting always within the scope of practice

b. Timely and relevant discussions with professional colleagues in the interests of service users

c. Address the insight gained by the Registrant in regard to the risks for the public and for service users of his failings

 

 

 

 

 

 

 

 

 

ORDER: The Registrar is directed to suspend the registration of Mr Billy Law for a period of 12 months from the date this Order comes into effect.

Interim Order

Interim Order Application

Application by the HCPC

1. Mr Bellis made an application for the imposition of an Interim Order for 18 months. Mr Bellis pointed out that the primary order would not take effect for at least 28 days and the public would not be protected by any order until then. If an appeal were to be made by the Registrant, the primary order would not come into effect until that appeal had been withdrawn of otherwise disposed of.

2. Mr Bellis said that the factors in favour of an interim order being imposed were:

• Notice of the Panel’s powers to impose an interim order had been given to the Registrant at page 2 of the service documents, served on him on 4 November 2024;

• There is a necessity for an order in circumstances where a Suspension Order had been imposed for reasons of public protection;

• Taking into account the Panel’s findings, there was cogent evidence that service users and the public were at continuing risk of harm in the absence of an interim order being imposed, pending the primary order coming into effect. The bar for necessity had been met.

• An interim order was also necessary for reasons of maintaining the public’s trust and confidence in the Dietitian profession.

• It was proportionate to impose an interim order as it related only to the period prior to the primary order coming into effect.

Submissions of the Registrant

3. There were no submissions by or on behalf of the Registrant.

Decision on an Interim Order

4. The Panel accepted the advice of the Legal Assessor and took into account the guidance as set out in the HCPTS Practice Note Interim Orders last updated in September 2024. In particular the Panel had regard to the section relating to interim orders imposed at final hearings after a sanction has been imposed.

5. The Panel was satisfied that the Registrant had been warned in the Notice of Hearing, dated 4 November 2024, that there was a real prospect that an Interim Order application would be made by HCPC, should a substantive finding be made by the Panel.

6. The Panel makes an Interim Suspension Order, for a period of 18 months, under Article 31(2) of the Health Professions Order 2001. The Panel concluded that an interim order was necessary for the protection of the public and was also necessary in the public interest. Substantive findings in relation to the Registrant’s misconduct had been made. A primary order had been made that it was necessary to temporarily suspend the Registrant from the Register in order to protect the public. The public would be placed at an unacceptable risk in these circumstances if no order were to be in place pending the determination of any appeal.

7. For the same reasons given in its determination on sanction, the Panel concluded that an Interim Conditions of Practice Order would not be appropriate. The Panel therefore determined that an 18 month Interim Suspension Order is appropriate and proportionate pending the expiration of an appeal period.

Interim Suspension Order

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

i. (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made;

ii. (if an appeal is made against the Panel’s decision and Order) upon the final determination of that appeal.

The maximum length of this order is 18 months.

 

 

 

 

 

History of Hearings for Billy Law

Date	Panel	Hearing type	Outcomes / Status
04/12/2024	Conduct and Competence Committee	Final Hearing	Suspended