Asuquo B Asuquo

Preliminary Matters

Application to amend particulars

1. The Panel heard an application made by Mr Slack, representing the HCPC, to amend the numbering of particulars 11c, 13, 15, and 16 and proposed that all numbers should be reduced by 1 (i.e., 12a should read 11a). Mr Slack submitted that these are minor typographical errors and that they should be allowed to ensure clarity in the particulars. Given its typographical nature, it was submitted that the amendment is not a substantive one, would be in the interests of justice, and would not cause any prejudice to the Registrant.

2. Mr Slack also sought to add numbered Particular 17, to clarify the particular 15 (in relation to dishonesty) relates to misconduct alone, and does not relate to lack of competence. It was submitted that this proposed amendment is applied for in order to assist the Registrant and the Committee, and does not alter the substance of the allegation against the Registrant. It was submitted that it is in the interests of justice to allow the amendment and would not cause any prejudice to the Registrant.

3. Mr Slack submitted that an application to amend the particulars was made in December 2024 and the panel at that time directed the proposed amendments be referred to an investigating committee. The investigating committee then made a decision on 3 March 2025 and there was then a delay of approximately three weeks before the investigating committee wrote to the Registrant. He accepted there was no good reason or excuse for the delay of three weeks.

4. The proposed amendments were as follows:

11. On 23 June 2022, in respect of a CT scan on Service User D, you:
…
c. Expressed a wish to Colleague H for her not to report the incident at 12a 11a and/or 12b11b above as it would “look bad” for you, or words to that effect.
...

13. On or around 23 June 2022, you created a DATIX report and/or entered notes onto the CRIS system in which you attributed the incident at particular 12a11a to machine failure when this was not the case.
…

15. Your conduct in relation to any or all of Particulars 12c 11c, 1413 and/or 1514 was dishonest.

16. The matters set out in any or all of Particulars 1 to 1614 above constitute misconduct and/or a lack of competence.

17. The matters set out at Particular 15 above constitute misconduct.
…

5. Mr McDermott, on behalf of the Registrant acknowledged the changes were minor and confirmed the Registrant did not oppose the application.

6. The Panel accepted the advice of the Legal Assessor.

7. The Panel noted that the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (‘the Rules’)were silent on amendments in such circumstances; the key question was one of fairness.

8. The Panel was of the view that the proposed amendments were in the interest of justice and would also assist in making the particulars more accurate. Whilst the delays were unfortunate, the amendments were minor and the changes were proportional to the issues to be considered. The Registrant had also confirmed agreement to the amendments. The Panel was satisfied that there would be no prejudice to the Registrant and no injustice would be caused to either party by the proposed amendments being allowed.

9. The Panel acceded to the application and allowed the amendments.

10. The amended allegations were as follows:

11. On 23 June 2022, in respect of a CT scan on Service User D, you:
…
c. Expressed a wish to Colleague H for her not to report the incident at 11a and/or 11b above as it would “look bad” for you, or words to that effect.
...

13. On or around 23 June 2022, you created a DATIX report and/or entered notes onto the CRIS system in which you attributed the incident at particular 11a to machine failure when this was not the case.
…

15. Your conduct in relation to any or all of Particulars 11c, 13 and/or 14 was dishonest.

16. The matters set out in any or all of Particulars 1 to 14 above constitute misconduct and/or a lack of competence.

17. The matters set out at Particular 15 above constitute misconduct.
…

11. The entirety of the allegation, as amended, is set out at the outset of this determination.

Background

12. Mr Asuquo Bassey Asuquo (‘the Registrant’) is a registered Radiographer. The Registrant began employment with the Hampshire Hospitals NHS Foundation Trust (‘the Trust’) as a Band 6 Senior CT/MRI radiographer on the 26 October 2021.

13. On 21 July 2022, the Trust sent a referral to the HCPC in respect of the Registrant. In its referral, the Trust summarised that over the course of the Registrant’s probationary employment there had been serious concerns as to his competency as a radiographer. The Trust stated that the Registrant had made numerous errors, which had placed patients at risk, and that he had failed his probation, which had been significantly extended.

14. The Trust explained that probation could only be signed off once the Registrant had demonstrated the relevant competencies required of all radiographers, enabling him to practise independently. Moreover, more serious concerns were alleged regarding the Registrant’s attempts to cover up these mistakes because he feared the Trust becoming aware of his errors.

15. Following the Trust’s referral to the HCPC, the Registrant applied for further healthcare work through an Agency; Your World Healthcare. It is alleged that the Registrant failed to inform Your World Health care that he was subject to a HCPC investigation, instead he informed the HCPC that he had told Your World Health care about the investigation.

The Hearing

16. The amended allegation was put to the Registrant. The Registrant accepted the particulars relating to a lack of competence stated in particular 16, but the misconduct element of particular 16was denied. The Registrant was neutral on particulars 1, 4, 5, 6, 9b, 11a and 12. The Registrant denied the remaining particulars.

17. The HCPC had witness statements from the following witnesses:

a) Witness 1: Lead Radiographer (‘RS’);
b) Witness 2: Lead Radiographer (‘RO’);
c) Witness 3: Imaging Services Manager (‘VP’);
d) Witness 4: Radiology Department Assistant (‘BW’);
e) Witness 5: Radiology Department Assistant (‘SL’);
f) Witness 6: Senior Radiographer (‘KF’);
g) Witness 7: Recruitment Agent (Your World agency) (‘HM’);
h) Witness 8: Lead Clinical Advisor (Your World agency) (‘SM’).

18. All these witnesses provided oral evidence and were each cross-examined by Mr McDermott.

19. After the HCPC witnesses completed their evidence, the Panel were provided with a 48-page witness statement from the Registrant and a 3-page witness statement from BE, who was a Band 6 CT Radiographer. The Registrant gave oral evidence, followed by BE. Both were cross examined by Mr Slack.

20. The Panel then heard oral submissions from Mr Slack, followed by Mr McDermott the following day in order to allow him additional time to prepare.

Decision on Facts:

21. Before making any findings on the facts, the Panel heard and accepted the advice of the Legal Assessor. The Panel has read the bundle from the HCPC and the additional papers provided during the hearing.

22. In reaching its decision on the facts, the Panel has borne in mind that the burden of proof rests on the HCPC and it is for the HCPC to prove the Allegations irrespective of any admissions made by the Registrant. The standard of proof is that applicable to civil proceedings, namely the balance of probabilities.

23. The Panel has carefully considered the evidence in the round. It has given appropriate weight to the documentary material, as well as to the written statements and oral testimony of witnesses for both the HCPC and the Registrant.

24. The Panel acknowledged that the Registrant has no previous fitness to practise history.

25. The Panel noted that, in his written and oral evidence, the Registrant made wide-ranging criticisms of the Trust and its management, including assertions that the Radiology Department was not professionally or effectively run. The Panel did not consider these matters relevant to the factual issues it was required to determine. Its task was to decide whether the Registrant carried out the acts alleged in the Particulars, not to evaluate the management of the department. The Panel therefore placed no weight on such criticisms when reaching its findings on the facts.

26. In considering the evidence, the Panel reminded itself that it is entitled to draw inferences from both the presence and absence of evidence, and to place weight on contemporaneous documentation where appropriate. Where accounts differed, the Panel assessed the credibility, reliability and consistency of the witnesses, and whether their evidence was supported by other material in the bundle.

Particular 1 - Proved
1. On 10 December 2021 you performed a CT chest scan without contrast instead of the required CT chest scan with contrast on Service User A.

27. The Panel had sight of RS’s witness statement and oral evidence, supported by contemporaneous emails (Exhibit 9).She was the Lead Radiographer. RS confirmed that the Registrant performed a CT chest scan without contrast on Service User A, which necessitated the patient undergoing a further scan. RO gave evidence that, although he was not present, he was made aware of the incident through departmental emails which confirmed his understanding that the Registrant had not followed the protocol or performed the necessary pre-scan checks.

28. The Registrant admitted Particular 1. In his statement and oral evidence he accepted that the scan had been performed incorrectly, though he suggested this was not reckless but the result of error and inexperience. In oral evidence he said that the incident had occurred, that he admitted it, and that the mistake arose because he did not release the contrast. His representative confirmed the Registrant had accepted Particular 1, and further submitted that there was a lack of contemporaneous records and that the Registrant was operating in effect as a trainee.

29. The Panel did not accept that characterisation. The Registrant was appointed and employed as a Band 6 Radiographer, not as a trainee. His application, interview, and the role offered all made clear that this was not a training position. The Panel accepted the evidence of the Imaging Services Manager, VP, who stated; “The level demonstrated by the Registrant when working on the Department did not appear to tally with the experience indicated by him on his application and at interview” (paragraph 41 of VP’s witness statement). The Panel was satisfied that the Trust had made clear this was not a trainee role, and that the Registrant was expected to practise with the competence of a Band 6 Radiographer.

30. The Panel also placed weight on the direct evidence of the incident by RS, which it found clear and reliable.

31. The Panel accepted that there was uncertainty as to whether the screenshot (page 102 of the bundle) reflected the initial erroneous scan or the subsequent repeat scan, but considered this immaterial in circumstances where the Registrant’s admission and the oral evidence established that two scans were undertaken, the first of which was performed without contrast.

32. In all the circumstances, and on the balance of probabilities, the Panel found Particular 1 proved.

Particular 2 - Proved
2. On 20 December 2021 you performed a CT chest scan instead of the requested CT head scan on Service User B.

33. The Registrant denied this Particular. In his oral evidence he stated that this was his first day at the Andover site on the Canon scanner, and that three radiographers were present: himself, BE (who was a witness on his behalf at this hearing), and another colleague. The Registrant maintained that although a CT head scan had been requested, a CT chest scan was performed in error, but he did not carry out the scan. He stated that he was supernumerary, was not operating the control panel, and that responsibility for the scan lay with the supervising radiographers. He said that RS and RO wrongly attributed responsibility to him. Under cross-examination he accepted that his name appeared on the Clinical Radiology Information System (CRIS) record(page 107) but stated that this reflected his status as the third radiographer present, rather than indicating that he personally initiated the scan.

34. The Panel noted that RS accepted that three radiographers were present at the time of the scan, and the Screenshot of ‘post-processing’ screen on CRIS (page 107) confirmed that the Registrant appeared as one of the operators. RS accepted that she had not witnessed the scan but had been made aware of the error afterwards. The Panel also had regard to the evidence of RO, who confirmed that responsibility for the error was not solely that of the Registrant. On behalf of the Registrant, BE confirmed that the scan had been carried out incorrectly but could not identify precisely who had initiated it.

35. The Panel noted the Registrant’s submission that the use of the word “you” in the Particular should be understood as referring only to the individual who physically pressed the button. The Panel did not accept that interpretation. In its view, “you performed” as capable of encompassing collective responsibility for a scan in which several radiographers were directly involved.

36. The CRIS record (page 107) shows the Registrant listed as one of the radiographers responsible. While the Panel accepted that more senior radiographers were present, it was satisfied that, as a Band 6 Radiographer, the Registrant was expected to function as an autonomous practitioner and exercise independent responsibility for ensuring the accuracy of scans. The Panel did not accept that the Registrant’s role should be equated to that of a trainee.

37. In all the circumstances, the Panel concluded that the Registrant shared responsibility for the incorrect scan of Service User B. Accordingly, on the balance of probabilities, the
Panel found Particular 2 proved.

Particular 3 - Proved
3. On 12 March 2022, you incorrectly assigned a CT scan to locum radiologist for reporting, when it should have been assigned to the Trust’s pool of radiologists.

38. The Registrant, in his witness statement, conceded this Particular. In his oral evidence, he accepted that his name appeared on the CRIS record but stated that he had not been responsible for the post-processing which led to the incorrect assignment. He maintained that two radiographers had been present and that he was working in what he described as a supernumerary capacity. He suggested that the absence of the second radiographer’s name from the CRIS record was unexplained and may have been deliberately removed.

39. RS’s statement (paragraphs 33–39) described the process of scanning and assigning, and at paragraph 40 she set out the training she had provided at induction. RS’s email of 15 March 2022 to the Registrant (page 315) indicated that the Registrant appeared to have both scanned the patient and undertaken the post-processing. RO also gave evidence that the Registrant had carried out the post-processing, although he was not certain who had performed the initial scan. The Panel also noted the contemporaneous email from BS, the Trust’s Radiology IT Systems Manager, dated 14 March 2022 (page 313), which recorded that the incorrect assignment had been made to a locum radiologist and confirmed that she had corrected the error.

40. The Panel accepted that ordinarily one radiographer would undertake the scan and the other would complete the post-processing. However, in this instance the CRIS record showed only the Registrant’s name as operator. The Panel considered the Registrant’s suggestion that another radiographer’s name had been removed, but found no evidential support for that assertion. The Panel further noted that in his reflective statement (page-317), the Registrant apologised for this error, and accepted that he bore some responsibility.

41. The Panel was satisfied that the incorrect assignment was made by the Registrant in the course of post-processing, and that this constituted the error alleged. The Panel considered that the question of who had physically performed the scan was immaterial, as the Particular concerned only the incorrect assignment.

42. Accordingly, on the balance of probabilities, the Panel found Particular 3 proved.

Particular 4 - Proved
4. On 21 March 2022, you informed Colleague F, with whom you were working, that the contrast bottle had sufficient fluid for the scan of a patient with contrast, when this was not the case.

43. The Registrant denied this Particular. In his oral evidence he stated that there was no Datix report or contemporaneous record and that the matter had only been raised retrospectively. He accepted that he had looked at the contrast bottle at the request of RS and had told her that there was sufficient volume, which he estimated to be around 120ml, but maintained that the scan produced a diagnostic image and therefore the allegation was unfounded. He further stated that if a radiologist had considered the images inadequate, the scan would have been repeated, which did not occur. He also argued that, even if the event occurred, it was part of a learning process rather than a matter warranting criticism.

44. In her statement (paragraph 46), RS described the incident and explained that the contrast had run out, resulting in a suboptimal scan. She stated that this issue was raised during the probationary review meeting when the Registrant’s probation was extended. The Panel accepted her account as that of a first-hand witness. RO’s evidence supported this by confirming that the Registrant had been signed off as competent to use the equipment and was not practising in a trainee capacity. The Panel considered this consistent with the Trust’s position that the Registrant had been appointed as a Band 6 Radiographer and not in a training role.

45. The Panel considered the Registrant’s submission that the images were nonetheless diagnostic. It accepted that the scan was not repeated and did enable the radiologist to answer the clinical question. However, it was satisfied that the image quality was not optimal and had been compromised by the lack of contrast. The Panel did not accept the Registrant’s submission that this was merely a learning process, noting that RS raised the matter at the time and her account was consistent with the probationary review records. The Panel also rejected the Registrant’s criticism of RS’s evidence, noting that she had observed the incident directly, raised it promptly, and given an account consistent with the probationary review records. Her evidence was therefore preferred to that of the Registrant.

46. The Panel was satisfied that the Registrant had incorrectly assured RS that there was sufficient contrast when this was not the case. As a Band 6 Radiographer, the Registrant was expected to ensure the adequacy of contrast before proceeding with a scan, and to recognise that inadequate contrast could compromise the diagnostic quality of the examination.

47. Accordingly, on the balance of probabilities, the Panel found Particular 4 proved.

Particular 5 - Proved
5. On 31 March 2022 you performed a scan under an incorrect name on Service User C.

48. The Registrant conceded this Particular in his witness statement and accepted it in his oral evidence. He explained that the error occurred when an image was sent to the wrong PACS folder, which he described as a common phenomenon. He stated that he had subsequently received further PACS training, and accepted under cross-examination that the incident had happened.

49. In relation to this Particular, the Panel considered the evidence of the HCPC from RO together with the Registrant’s admissions. RO gave evidence about the administrative aspects of the Registrant’s role and the Panel noted that the use of the CRIS and PACS systems was covered as part of the induction training. The Panel accepted the HCPC’s submission that the Registrant should have been familiar with these systems at the time of the incident and that the error carried a risk of detriment to the Service User.

50. On the basis of the Registrant’s admissions and the supporting evidence, the Panel found Particular 5 proved.

Particular 6–Not Proved
6. On 8 April 2022, you initiated a scan without ensuring the timed delay feature had been reset, despite Colleague A being in the proximity of the CT scanner, which caused Colleague A to be exposed to radiation.

51. The Registrant accepted in his statement and oral evidence that this incident had occurred. He admitted that he initiated a scan without ensuring the timed delay feature was reset, and that a colleague was still in the scanning room. In cross-examination he accepted that this was the only time during his employment when a colleague had been put at risk of exposure. He expressed regret and stated that he had apologised at the time.

52. The Panel considered the evidence of RS, who was informed of the incident shortly afterwards by a colleague. RS’s statement (paragraph 54) recorded that she had been told that the Registrant had started the scan without resetting the delay, at a time when Colleague Awas still in the scanning room. RS stated that in her view the incident created a risk of placing a colleague at risk of radiation. RO, in his statement, confirmed that in his 12 years of experience he had never encountered an incident of this kind (paragraph 34). The Panel considered the Registrant’s reflective account of the incident in his email of 15 April 2022 to VP, where he apologised and said that he intended to make some changes in his practice.

53. The Panel noted that the Registrant did not dispute initiating the scan without the necessary delay, or that a colleague was in the room at the time. His representative submitted, however, that there was no direct evidence that the colleague had in fact been exposed to radiation, as no dose reports confirmed this, and no statement had been obtained from Colleague A.

54. The Panel accepted the evidence that the Registrant initiated the scan without ensuring the timed delay was reset. It also accepted that a colleague was still present in the room. However, it was not satisfied on the balance of probabilities that the consequence alleged, namely actual radiation exposure, was proved. There was no contemporaneous record of exposure, no dose monitoring evidence, and no statement from the colleague involved.

55. Accordingly, the Panel found that the HCPC had proved that the Registrant initiated a scan without resetting the timed delay when a colleague was in the scanning room. However, it did not find proved that this resulted in the colleague to be exposed to radiation, as alleged.

56. On that basis, Particular 6 was found not proved.

Particular 7 - Proved
7. On 12 May 2022, despite the fact at least 4 attempts had already been made to cannulate a patient and a radiologist had been called to carry out any further attempts, you:

a. Wanted to attempt to cannulate the patient yourself, contrary to workplace procedure.
b. Only desisted with your proposed course of action when Colleague B insisted that you did not do this.

57. The Registrant denied these Particulars. In his oral evidence, the Registrant stated that he had not attempted to cannulate the patient, did not go close to the patent and that he had merely asked BE why there was a delay, as part of his responsibility for workflow. It was common ground that BW (Colleague B) and BE were present at the time with the patient. The Registrant said that BW had wrongly interpreted his actions as indicating an intention to cannulate and that she had overstepped her role by intervening instead of allowing BE to respond to his query on the reasoning for the delay. He described himself as a respectful person by nature and denied ever dismissing or undermining junior colleagues. BE, giving evidence on behalf of the Registrant, also stated that he had not witnessed the Registrant behaving in a disrespectful manner.

58. The Panel considered the evidence of BW, who gave both a written statement and oral testimony. She described how the patient had already undergone multiple unsuccessful cannulation attempts and a radiologist had been called. She stated that the Registrant approached the patient and began looking for a vein with the apparent intention of cannulating, and that she had to intervene to stop him. She said the incident made her feel undermined and redundant in front of the patient. BW had raised her concerns promptly by email on the same day (page 155 of the bundle).

59. RS and RO both referred to the incident in their statements (RS at paragraphs 65 and 67; RO at paragraph 35). RS confirmed receipt of BW’s email and she gave evidence on why further cannulation was inappropriate in the circumstances and the harm that results from further attempts. VP also made reference to it in her statement (paragraph 35) and exhibited the email correspondence from BW on the day. The accounts of RS, RO and VP were based on being informed of the incident at the time and supported the account given by BW.

60. The Panel found BW to be a credible and reliable witness. She gave her evidence in a straightforward manner, was consistent in cross-examination, and her account was corroborated by contemporaneous email and by the accounts of RS, RO, and VP. The Panel attached significant weight to the fact that her email was written during the same shift and at a time when the incident was fresh in her mind.

61. By contrast, the Panel found the Registrant’s denials less persuasive. His suggestion that BW had misinterpreted his actions was inconsistent with the contemporaneous email and her clear oral evidence. The Panel also noted that BE’s supporting evidence was given a significant time later and was less reliable than BW’s contemporaneous account.

62. The Panel was satisfied on the balance of probabilities that the Registrant had given the impression of intending to attempt to cannulate the patient contrary to workplace procedure, and that he only stopped when BW intervened.

63. Accordingly, the Panel found Particulars 7(a) and 7(b) proved.

Particular 8 - Proved
8. On 12 May 2022, you did not communicate professionally with Colleagues B and/or C while cannulating a patient in that you:

a. Dismissed and/or undermined Colleague B’s clinical judgment about the suitability of the arm for cannulation in front of the patient; and/or
b. Dismissed and/or undermined Colleague C as she was identifying a suitable cannulation site by saying “I’ll do this because I want it done quickly”, or words to that effect, in front of the patient.

64. The Registrant denied both Particulars. He accepted that he had suggested an alternative vein to BW but maintained that this was not intended in a dismissive manner. He denied making the comment alleged in Particular 8(b), and said that if SL had been dissatisfied with his behaviour she could have raised a complaint herself at the time. He maintained that he had been seeking to maintain workflow in a busy department, and that his comments and actions had been misunderstood.

65. The Panel considered the evidence of BW (colleague B), who stated in her witness statement and oral evidence that she had been about to cannulate when the Registrant intervened, contradicted her judgment, and took over in front of the patient. She felt this made her feel undermined and redundant. The Panel also heard from SL, who described a similar incident with her on the same day. She said that as she was identifying a vein, the Registrant interjected with the words “I’ll do this because I want it done quickly”, or words to that effect, in the presence of the patient. She perceived this as dismissive and undermining.

66. Both BW and SL gave clear and consistent accounts. BW had raised the issue promptly on the same day by email (page 155 of the bundle), which the Panel accepted as a contemporaneous record. Their evidence was also supported by references in the statements of RS, RO (paragraph 37) and VP (paragraph 35), all of whom had been informed of the concerns at the time. RS, the Lead CT Radiographer & Radiation Protection Supervisor, emailed the Registrant on the same day advising that, although well-intentioned, his involvement in assisting RDAs with cannulation could be perceived as undermining their abilities.

67. The Panel did not accept the Registrant’s evidence. His suggestion that BW and SL had misinterpreted his intentions was inconsistent with the clear wording of their accounts and the contemporaneous email.

68. The Panel was satisfied that both BW and SL were credible witnesses with no motive to fabricate their accounts. Their evidence was mutually supportive, straightforward, and consistent with contemporaneous records and with the broader concerns raised by senior staff about the Registrant’s manner of communication.

69. The Panel concluded that the Registrant had acted in a manner that was reasonably perceived as dismissive and undermining towards BW and SL in front of patients, as alleged.

70. Accordingly, on the balance of probabilities, the Panel found Particulars 8(a) and 8(b) proved.

Particular 9– Proved

9. On an unknown date shortly before 25 May 2022, whilst preparing for a scan with contrast:

a. You failed to recognise and/or respond to an alarm indicating the presence of an air bolus in the injector tubing; and/or,
b. Colleague F had to intervene to prevent you from connecting the patient to the injector.

71. The Panel had sight of contemporaneous documentation. RS’s email of 27 May 2022 (page 130) referred directly to this incident, only two days after the meeting in which it was discussed. The Panel also had sight of RS’s witness statement and oral evidence. RS was the Lead Radiographer present. She described how, while she was setting up the scan, the Registrant was connecting the patient to the injector machine. The injector machine automatically detects the presence of an air bolus and raises a loud, continuous alarm. RS stated that she could hear the alarm from outside the scan room. When she entered, the Registrant had not responded to the alarm and continued connecting the patient to the injector tubing. RS explained that the injector should have been primed first, as it is impossible to flush saline into the patient once connected. She intervened to prevent the Registrant from proceeding further. RS emphasised that flushing an air bolus into a patient can be extremely dangerous and potentially fatal.

72. In his oral evidence, the Registrant accepted that an alarm had sounded but maintained that he did not hear it at the time. He stated that the CT scanner itself was inherently loud, that the control room was a shared space with MRI with constant background noise and colleagues walking in and out, and that he was engaged with the patient. He explained that alarms occurred routinely every few hours when the system detected a problem such as air or a cannula issue, and he would always respond if he heard one. He maintained that RS may have assumed, from her vantage point outside the scan room, that he was not responding. He emphasised that injector systems will not permit unsafe injection until any alarm condition is cleared, and therefore patient harm could not have resulted. He denied ignoring the alarm.

73. The Panel accepted RS’s evidence as clear, detailed and consistent with her contemporaneous actions. She had raised her concerns at the time, discussed them with the Registrant in a meeting on 25 May 2022, and followed this up with a contemporaneous email dated 27 May 2022. The Panel found her account to be credible and reliable, particularly as she directly intervened to stop the Registrant. The Panel also noted that, when the Registrant stated he had not heard the alarm, this amounted in effect to an admission that he had not responded to it.

74. The Panel noted that in his own evidence the Registrant accepted that RS had drawn his attention to the alarm, which amounted to an acknowledgement that it had sounded and that he had not responded to it promptly. It considered his explanation that the alarm was masked by noise, that such alarms occurred routinely, and that machine safeguards would have prevented harm. However, it noted RS’s evidence that the alarm was designed to be impossible to miss, was audible outside the scan room, and was continuing when she entered. The Panel was not persuaded that the Registrant’s explanation adequately explained his lack of response or with RS’s direct observations.

75. The Panel further noted that in his application form the Registrant had claimed experience in using auto-injectors and smart prep techniques, and therefore should have been familiar with injector pumps and responding appropriately to alarms. RS confirmed in her oral evidence that her intervention was motivated by a need to protect the patient, as the injector continued to beep while the Registrant attempted to connect the patient. This reinforced the Panel’s view that the Registrant’s conduct demonstrated a shortfall against the expected competence of a Band 6 Radiographer.

76. The Panel did not accept the Registrant’s submission that any harm would have been prevented by the machine itself. It considered RS’s intervention a necessary and proportionate action by the Lead Radiographer to protect the patient.

77. In all the circumstances, and on the balance of probabilities, the Panel was satisfied that the Registrant failed to recognise and/or respond to the alarm, and that RS had to intervene to prevent him from connecting the patient to the injector.

78. Accordingly, on the balance of probabilities, the Panel found Particulars 9(a) and 9(b) proved.

Particular 10 - Proved
10. On an unknown date shortly before 25 May 2022 when preparing for a scan with contrast:

a. You did not open the clamp and/or flush saline through the cannula; and/or
b. Colleague F had to intervene to prevent you from scanning the patient without effective contrast.

79. The Registrant denied Particulars 10(a) and 10(b). In his oral evidence he stated that there was no factual basis for the allegation, that he had never been given a date or detail of the incident, and that he had a right to know what was being alleged against him. He suggested that, even if something had occurred, it should be treated as a learning point during his probationary period rather than misconduct, and that the ultimate responsibility for scanning rested with the supervising Lead Radiographer.

80. However, under cross-examination the Registrant accepted that he had written in his reflective statement (page 569 of the bundle) that “while preparing a patient for a contrast-enhanced CT scan, I forgot to unclip the cannula before flushing saline, which led to a minor saline spillage”. He also accepted that RS had corrected him at the time. He attempted to characterise this as a learning point, but the Panel considered it an error in practice.

81. The Panel had sight of contemporaneous documentation. RS’s email of 27 May 2022 (page 130) referred directly to this incident, only two days after the meeting in which it was discussed. This provided a contemporaneous record which supported her oral evidence. In her statement and oral testimony, RS explained that she had observed the Registrant attempt to flush without unclipping the cannula, and that she had intervened to stop him proceeding, as otherwise the scan would not have demonstrated contrast enhancement.

82. The Panel considered the Registrant’s submission that six months into post he was still effectively learning CT, and that errors were to be expected in such a high-risk, fast-paced environment. However, it noted that the Registrant had been appointed to a Band 6 radiographer post, not a training role, and that his application form indicated he was experienced in using auto-injectors and smart prep techniques. The Panel therefore considered that he should have been familiar with priming techniques and the need to flush correctly, and that errors of this nature were not consistent with the expected competence of his role.

83. The Panel accepted RS’s account as credible, detailed and supported by contemporaneous documents. It noted that in the Registrant’s reflective statement, he effectively acknowledged forgetting to unclip the cannula (page 569 of the bundle), which was consistent with RS’s account. On the balance of probabilities, the Panel was satisfied that Particular
10(a) was proved.

84. In relation to Particular 10(b), the Panel noted the conflict of evidence. RS’s oral evidence was that she had to intervene to prevent the scan proceeding without effective contrast. The Registrant disputed this, maintaining that he recognised the problem and corrected it himself. The Panel considered the contemporaneous email from RS, which recorded that the scan “would have required repeating as it wouldn’t have showed any contrast if the Lead Radiographer hadn’t noticed and asked for the scan to be stopped” (page 130). The Panel accepted that RS was acting in her capacity as Lead Radiographer and that her evidence was consistent with her contemporaneous account, which the Panel considered reliable.

85. Having considered the evidence in the round, the Panel preferred RS’s account. It considered her evidence consistent and reliable, supported by contemporaneous documentation, and consistent with her broader concerns about the Registrant’s practice. It found the Registrant’s explanation weaker, particularly given his own reflective admission.

86. Accordingly, on the balance of probabilities, the Panel found Particulars 10(a) and 10(b) proved.

Particular 11(a), 11(b)– Proved, 11(c) Not Proved
11. On 23 June 2022, in respect of a CT scan on Service User D, you:

a. Performed the CT scan without contrast when contrast was required;
b. Initiated the scan without ensuring the timed delay feature was set, despite Colleague H being in the proximity of the CT scanner, which caused Colleague H to be exposed to radiation; and/or
c. Expressed a wish to Colleague H for her not to report the incident at 11a and/or 11b above as it would “look bad” for you, or words to that effect.

Particular 11(a) – Proved

87. The Registrant conceded Particular 11(a). In his oral evidence he accepted that a CT scan had been performed without contrast when contrast was required. In cross-examination, he confirmed that the contrast had not entered the patient.

88. The Panel noted that contemporaneous documentation supported this admission, in particular the Registrant’s own reflective piece of 23 June 2022 (Exhibit RS24, page 139 of the bundle) where he confirmed scanning the patent without contrast, together with the email exchange of 23–27 June 2022 between the Registrant, RS and others (Exhibit RS23, pages 135-137 of the bundle).The contemporaneous email dated 23 June 2022 (pages 132–133) from AL, Radiology Department Manager, also set out her account of the incident. The Panel was satisfied that the Registrant’s concession was consistent with the evidence as a whole.

89. On that basis, the Panel found Particular 11(a) proved.

Particular 11(b) – Proved

90. The Registrant accepted in his oral evidence that the timed delay feature had not been reset, although he sought to share responsibility with two colleagues who were present at the time. He stated that all three radiographers were involved in the scan and that he took only “partial responsibility”. Under cross-examination, he accepted that “we did not reset the timer”, but nonetheless accepted he bore responsibility as one of the radiographers operating the scanner.

91. The Panel considered the evidence of RO, who described in his oral testimony how he had been undertaking administrative work in the control room, but had to lean across the Registrant to pause the scanner. This was consistent with his email of 27 June 2022 (page 135 of the bundle). He gave a detailed description of intervening, which the Panel found compelling. The Panel also considered the Registrant’s own reflective statement (p.139), in which he expressed regret and acknowledged that he “should have stopped the scanner”.

92. The Panel further noted that, although not directly contemporaneous with the 23 June incident, an earlier email from AJ, the Radiology Department Manager, to the Registrant dated 17 June 2022 (pages 132–133), recorded concerns that, without direct supervision, the Registrant risked continuing scans inappropriately. While referring to a separate occasion, this evidence supported the Panel’s overall finding regarding the Registrant’s repeated difficulties in this area.

93. In all the circumstances, the Panel was satisfied that the Registrant had initiated the scan without ensuring the timed delay feature was set, at a time when a colleague was still in the scanning room, and that RO had to intervene to prevent further risk.

94. Accordingly, the Panel found Particular 11(b) proved.

Particular 11(c) – Not Proved

95. The Registrant denied Particular 11(c). He stated that he had not asked Colleague H not to report the incident, and that such a comment would have made no sense in the circumstances as RO was present and supervising the scan. He accepted that he had been under stress and pressure at the time, but maintained that what he had said was misunderstood. In his witness statement (paragraph 66), he explained that a casual comment made under pressure (“still mode”) had later been reframed, and that an emotional reaction (“this might look bad for me”) had been distorted into a claim of dishonesty or concealment.

96. The Panel considered the oral evidence of Colleague H (KF), who gave a clear and straightforward account that the Registrant had said words to the effect that she should not report the incident because it would “look bad” for him. The Panel found her evidence to be honest, consistent, and without any apparent motive to fabricate. She described the Registrant as a pleasant colleague, and there was no suggestion of animosity between them.

97. The Panel also considered the wider context. At this stage the Registrant was under additional probationary measures and was subject to close scrutiny, with concerns already recorded about his level of competence. The Panel accepted that this background gave the Registrant a motive to wish to avoid further incidents being reported. KF’s evidence was consistent with that context.

98. However, the Panel also took into account the Registrant’s previous good character. It reminded itself that evidence of good character is relevant both to his credibility as a witness and to the likelihood of him having acted as alleged. The absence of any prior regulatory or disciplinary findings meant that the Panel approached the allegation of concealment with particular care.

99. The Panel was mindful that the evidence was essentially one person’s word against another. While it found KF to be a credible witness, it also had regard to the Registrant’s consistent denial, his explanation at paragraph 66 of his statement, the absence of any contemporaneous record from KF, and the lack of reference to the alleged comment in RO’s statement, despite his presence at the time. The Panel considered that these factors, taken together, created sufficient doubt.

100. In all the circumstances, and bearing in mind that the burden of proof rests on the HCPC, the Panel was not satisfied on the balance of probabilities that the Registrant had made the remark alleged in Particular 11(c). Accordingly, it did not find this aspect of the allegation proved.

101. Accordingly, the Panel found Particular 11(c) not proved.

Particular 12 - Proved

12. On 24 June 2022 you assigned a scan on Service User E to an incorrect patient.

102. The Registrant conceded this Particular. In his oral evidence he accepted that he had incorrectly assigned a scan to the wrong patient record, explaining that this occurred in the aftermath of the incident on 23 June 2022. He described it as an administrative error of placing the scan into the wrong folder, for which he apologised at the time.

103. In closing submissions, Counsel for the HCPC noted that the Particular had been consistently admitted by the Registrant and submitted that it should therefore be found proved.

104. The Panel accepted the Registrant’s admissions. On the balance of probabilities, the Panel was satisfied that the Registrant had assigned a scan to an incorrect patient.

105. Accordingly, the Panel found Particular 12 proved.

Particular 13–Not Proved

13. On or around 23 June 2022, you created a DATIX report and/or entered notes onto the CRIS system in which you attributed the incident at particular 11a to machine failure when this was not the case.

106. The Registrant denied this Particular. He stated that he did not attribute the incident to “machine failure”, but had described it as a “pump fault”. In his oral evidence, he explained that English was not his first language, and that his intention had been to record that the contrast had not flowed, which could have been due to operator error or a technical issue. He accepted that the scan had been completed without contrast, but maintained that he had not deliberately sought to misrepresent what had happened.

107. The Panel considered the evidence of KF, whose statement at paragraph 33 recorded that the Registrant had written on the CRIS system: “scan was completed without contrast media because pump stopped giving contrast during scan. Scan repeated after pump fault was corrected” (Exhibit KF1, page 149 of bundle). She stated this was incorrect because, in her view, the scan had completed without contrast not due to a pump fault, but because the Registrant had started the scan and failed to stop it. The Panel accepted that this entry demonstrated the Registrant had attributed the issue to a “pump fault”, but not expressly to “machine failure” as alleged in the Particular

108. The Panel accepted that there was a difference in meaning between attributing an incident to “machine failure” and describing it as a “pump fault”. It considered that the Particular as drafted alleged attribution to machine failure, whereas the Registrant’s terminology was different. The Panel also took account of the Registrant’s explanation that his written English was limited, and that his description reflected his understanding at the time rather than an intention to conceal his own error. The Panel considered this explanation credible.

109. The Panel did not accept the HCPC’s submission that the Registrant had deliberately misrepresented the cause of the incident. While it was satisfied that he had sought to avoid personal responsibility, it was not persuaded that his DATIX or CRIS entries went so far as to attribute the incident to machine failure, as alleged. The Panel noted that, had the allegation been framed differently, it may have reached a different conclusion.

110. In all the circumstances, and bearing in mind that the burden of proof rests with the HCPC, the Panel was not satisfied on the balance of probabilities that the Registrant attributed the incident at Particular 11(a) to machine failure. Accordingly, the Panel did not find this Particular proved.

111. Accordingly, the Panel found Particular 13 not proved.

Particular 14–Not Proved
14. On 6 September 2022 you informed the HCPC that you had told Your World Healthcare that you were subject to a fitness to practise investigation when this was not the case.

112. The Registrant denied this Particular. In his oral evidence he explained that, in the early hours of 6 September 2022, he had been replying to multiple emails from the HCPC after discovering three hours prior that a referral had been made against him. He stated that he was tired, anxious, and replying in his second language. He said that in his email to the HCPC he had referred to disclosing an “FTP issue” to his agency, not an “investigation”. He explained that he had told HM at Your World Healthcare about difficulties with his employment and the possibility of a referral, and therefore did not accept that what he had written was untrue.

113. The Panel noted the HCPC’s submission that two witnesses from Your World Healthcare stated that the Registrant had not informed them of any ongoing HCPC investigation, and that telling them a referral might occur was different from saying that it had occurred. The HCPC submitted that the Registrant’s email to the regulator was therefore misleading, and further argued that the Registrant did not correct this position once he became aware of the distinction. The Panel considered this submission but remained mindful that the allegation must be determined strictly as drafted.

114. The Panel considered the Registrant’s contemporaneous email to the HCPC on 6 September 2022 at 02:09 hours (page 396 of the bundle). In that email, the Registrant stated: “I have disclosed my fitness to practice issue to the agency, and my new line manager”. The Panel noted that he used the phrase “fitness to practice issue” rather than “investigation”. The Panel also noted his evidence that he had been corresponding with the HCPC between 11pm and 2am. In his oral evidence, the Registrant explained that on that night he had decided to sit and reply to all emails one after another after discovering the emails as this was an account he did not often use. He said that by 2am he was tired and sleepy but determined to respond, and that this was when he drafted the email. He stated that he did not know that there was an investigation, and maintained that his wording reflected that context. He stated that when his employment was terminated by the Trust he did inform HM at the agency, and also added that he was under no restrictions until 30 September 2022, by which time he was working elsewhere. He further stated that he had no reason not to inform Your World Healthcare, and that he had told them he was expecting a referral and therefore would not have concealed it when it eventually came. The Panel considered that this explanation was consistent with the evidence before it.

115. The Panel considered that there was an important distinction between referring to an “issue” and referring to an “investigation”. It accepted that the Registrant’s choice of words was consistent with his explanation that he had told the agency about problems at work and the possibility of referral. The Panel was not satisfied that his wording in the email amounted to a false claim that he had told the agency about a formal HCPC investigation.

116. The Panel also considered the HCPC’s submission that the Registrant did not subsequently correct this position once he was aware of the distinction between an “issue” and an “investigation”, but it did not regard this as sufficient to prove the Particular as drafted. The Panel noted that, although there might have been scope to allege that the Registrant failed to inform Your World Healthcare once he became aware of the HCPC investigation, that was not the charge before it.

117. The Panel therefore concluded that the Particular, as drafted, had not been made out. It was not satisfied on the balance of probabilities that the Registrant informed the HCPC that he had told Your World Healthcare he was subject to a fitness to practise investigation when this was not the case.

118. Accordingly, the Panel found Particular 14 not proved.

Particular 15 - Not Proved
15. Your conduct in relation to any or all of Particulars 11c, 13 and/or 14 was dishonest.

119. The Registrant denied this Particular. He stated that he had not acted dishonestly in relation to any of the matters alleged. He explained that he had told his agency about problems at work and the possibility of a referral, and that he had never deliberately misrepresented his position. He maintained that any errors in wording, particularly in his 6 September 2022 email to the HCPC, were the product of tiredness, stress, and English not being his first language.

120. The Panel reminded itself of the test for dishonesty set out in Ivey v Genting Casinos [2017] UKSC 67. The Panel was required to first ascertain the Registrant’s actual state of knowledge or belief as to the facts, and then determine whether his conduct was dishonest by the standards of ordinary decent people.

121. The Panel also took account of the wider context in which the Registrant was working. It accepted the evidence that he presented as vulnerable in the workplace at that time, both in his demeanour and in his ability to cope with the pressures of the role. He was relatively new to the United Kingdom having started working for the Trust in October 2021, adjusting to a different professional and cultural environment. The Panel considered that these factors contributed to his vulnerability. It also noted that his application form appeared to have overstated his level of competence, which left him exposed. The Panel regarded these factors as relevant to his state of mind and as diminishing the likelihood that his conduct was deliberately dishonest.

122. In considering the Registrant’s state of knowledge, the Panel took account of his explanation that his words in Particular 11(c) were a panicked emotional reaction, his description of a “pump fault” in Particular 13 reflected his understanding at the time, and that in Particular 14 he had written of a “fitness to practise issue” rather than an “investigation”. The Panel accepted that these explanations were credible in light of his evidence, the surrounding context, and the evidence of stress he was under at the time.

123. The Panel also gave weight to the Registrant’s previous good character. It accepted that he had no prior regulatory or disciplinary history, and considered that this made it less likely that he would deliberately seek to conceal or misrepresent matters.

124. The Panel acknowledged the HCPC’s submission that, had Particulars 11(c), 13, or 14 been found proved, this would have supported a finding of dishonesty. However, Particulars 11(c), 13, and 14 had not been proved.

125. The Panel concluded that the Registrant’s conduct could properly be described as naive, panicked, and reflective of cultural and communication difficulties, but that it was not dishonest.

126. Accordingly, the Panel found Particular 15 not proved.

Reconvened Hearing

127. The hearing resumed on 26 August 2025. On the morning of the first day, the Panel handed down its written decision on the facts. The Panel allowed the parties, in particular the Registrant and his representative to have the remainder of the day to read and consider the determination in order to prepare for the next stage of proceedings. It was agreed by both parties that the issues of grounds and impairment should be considered together.

128. The Panel received additional documentation, including a supplementary bundle from the Registrant and a detailed witness statement addressing grounds and misconduct. The Registrant also gave oral evidence. The Panel took into account the written submissions of the HCPC, and Ms Bass, appearing on behalf of the HCPC, confirmed that she had no further submissions to add. The Panel then granted Mr McDermott, on behalf of the Registrant, his requested three hours to prepare oral submissions. When the hearing resumed, those submissions were heard and thereafter the Panel received and accepted the advice of the Legal Assessor.

Registrant’s evidence

129. In his witness statement and oral evidence, the Registrant accepted the Panel’s findings of fact and took responsibility for the errors identified. He explained that the incidents occurred during his probationary and supernumerary period, when he was still adapting to NHS systems, protocols, and workflow expectations which were very different from those in his previous practice overseas. He emphasised that, in his view, the errors were not deliberate or reckless but arose in the context of training, unfamiliarity, and cultural adjustment.

130. The Registrant gave detailed evidence of the steps he has since taken to remediate his practice. He highlighted over three years of safe and effective work in the NHS, completion of extensive CPD, and his role in mentoring junior staff and students. He stated that he had insight into the impact of his actions on colleagues, patients, and public confidence, and expressed regret for the anxiety and disruption caused. He described how he now approaches his work with structured “pause and check” procedures, greater communication with clinical teams, and meticulous documentation.

Submissions

 

131. Ms Bass, on behalf of the HCPC, submitted that the proven facts amounted to both misconduct and lack of competence. She argued that the misconduct in this case arose from a series of clinical errors, including omitting contrast during a CT scan (Particular 1), performing the wrong type of scan (Particular 2) and failing to respond to an injector alarm signalling the presence of air (Particular 9). In addition, the Registrant committed basic administrative errors such as assigning a scan for reporting incorrectly (Particular 3), placing images in the wrong patient record (Particular 5) and allocating a scan to the wrong patient (Particular 12). The HCPC also relied on failures of professional communication, including indicating an intention to cannulate after four failed attempts (Particular 7) and undermining colleagues in the presence of a patient (Particular 8). These incidents, it was said, could not be explained simply as training lapses because of their number, breadth, and recurrence despite suppo

 

132. Ms Bass submitted that the errors created real risks to patient safety and clinical care. Incorrect or misallocated scans (Particulars 2, 3 and 12) could have delayed reporting and led to missed diagnoses; repeating scans unnecessarily exposed patients to higher radiation doses (Particular 2); failing to respond to the injector alarm (Particular 9) carried a recognised risk of fatality; and repeated cannulation attempts (Particular 7) risked unnecessary pain and distress. She argued that undermining colleagues in front of patients (Particular 8) further breached core professional standards of respect and teamwork. The HCPC therefore invited the Panel to conclude that the proven facts, taken individually and cumulatively, demonstrated the Registrant’s work evidencing lack of competence, and instances of behaviour so serious as to amount to misconduct.

 

133. Ms Bass submitted that a finding of current impairment was required to protect the public and to uphold confidence in the profession. She argued that the Registrant’s errors were wide-ranging, went to the heart of safe CT practice in particular and occurred over a period of months despite supervision. In her submission, the Registrant’s insight, while developing, was not yet sufficient to mitigate the risk of repetition. Even if the risk were now low, the public component required a finding of impairment to mark the seriousness of the failings and to maintain proper standards.

 

134. Mr McDermott, on behalf of the Registrant, submitted that neither misconduct nor lack of competence had been made out. He emphasised that all the incidents occurred during the Registrant’s probationary and supernumerary period, when he was still in training and unfamiliar with NHS systems. The errors were isolated, arose in a learning context and were promptly corrected without patient harm. He argued that they were reflective of adaptation difficulties rather than an inability to practise safely. In respect of Allegations 7 and 8, he submitted that the Registrant’s words may have been poorly phrased but did not amount to serious misconduct, as there was no dishonesty, malice, or risk to patient safety. He invited the Panel to conclude that the matters did not cross the threshold of misconduct or lack of competence.

 

135. Mr McDermott submitted that the Registrant is not currently impaired. He highlighted the Registrant’s acceptance of the facts as now found by the Panel, his extensive reflection, and his clear evidence of insight. He referred to over three years of subsequent safe and effective NHS practice and completion of substantial CPD, and positive feedback from colleagues and patients. He argued that the risk of repetition is very low and that the Registrant has demonstrated remediation in both technical and professional domains. In respect of the public component, he submitted that public confidence is best maintained by recognising meaningful remediation and not by imposing further regulatory findings for historic, training-stage errors.

Decision on grounds:

136. The Panel reminded itself that there is no formal burden or standard of proof at this stage and that the question of whether the facts amount to misconduct or lack of competence is a matter of judgment. Misconduct requires conduct that falls seriously short of the standards expected of a registered radiographer. A finding of lack of competence requires the Panel to be satisfied that the failings represent the Registrant’s work and demonstrate an inability to practise safely and effectively. Not every error will cross these thresholds. The Panel’s task was therefore to exercise its own professional judgment in deciding whether the threshold was met.

137. In reaching its decision, the Panel had regard to its earlier findings of fact. At paragraph 25 the Panel noted that the Registrant had sought to deflect responsibility by making wide ranging criticisms of the Trust and its management, but that these matters were irrelevant to the factual issues and the Panel placed no weight on them. At paragraph 29 the Panel rejected the Registrant’s characterisation of himself as effectively a trainee. The Panel was clear that the Registrant was appointed and employed as a Band 6 Radiographer, not as a trainee, and was expected to practise with the competence of that role. The evidence of the Imaging Services Manager, cited in paragraph 29, was that “The level demonstrated by the Registrant when working in the Department did not appear to tally with the experience indicated by him on his application and at interview.” These findings provided important context for the Panel’s assessment of whether the failings found proved amounted to misconduct and/or lack of compete

138. The Panel considered the facts proved in three categories: (i) clinical and procedural errors in imaging and contrast use; (ii) patient identification and reporting errors; and (iii) technical judgment and professional conduct issues.

Clinical and Procedural Errors in Imaging and Contrast Use

139. The Panel determined that Particulars 1 (CT chest without contrast), 2 (CT chest instead of CT head), 9(a) and 9(b) (failure to respond to injector alarm and colleague intervention), 10(a) and 10(b) (failure to flush cannula and colleague intervention), and 11(a) and 11(b) (CT scan without contrast and failure to set timed delay, causing colleague exposure) represented serious failings. These incidents involved fundamental errors in CT practice, some carrying risks of unnecessary radiation, repeated exposure, and in the case of the air bolus, a potentially fatal risk.

140. In respect of Particular 2, the Panel noted its earlier finding at paragraph 35 that there was collective responsibility. Three radiographers were present in the room, the

Registrant was one of the operators, and it was the shared responsibility of the three to identify and correct the error. RS accepted that three were present and the Registrant’s name appeared on the CRIS record. The Panel was satisfied that he shared responsibility for this serious error.

141. In relation to Particulars 9(a) and 9(b), the Panel concluded that the Registrant should have been familiar with injectors, as indicated in his application form, and responded appropriately to alarms. The Panel did not accept his submission that harm was prevented by the machine itself. RS’s intervention was both necessary and proportionate to protect the patient, and this placed the incident at the high end of seriousness. The Panel emphasised that the fact that colleagues or systems were present to intervene does not lessen the seriousness of the Registrant’s failings.

142. The Panel found that each of these Particulars amounted to serious misconduct. Separately, and in addition, the Panel found that they also demonstrated a lack of competence when judged against the standards expected of a Band 6 Radiographer. Accordingly, the Panel was satisfied that the incidents under this category amounted to both serious misconduct and lack of competence.

Patient Identification and Reporting Errors

143. The Panel considered Particular 3 (incorrect reporting assignment) to amount to misconduct but not serious as the error was promptly corrected. Nevertheless, the Panel was satisfied that this error also demonstrated a lack of competence in relation to essential patient identification and reporting safeguards.

144. Particular 5 (scan under wrong name) was regarded as very serious, amounting to gross misconduct at the top end of seriousness, given the significant risk to patient safety and care. Particular 12 (assignment of a scan to the wrong patient) was also considered serious misconduct due to its potential for direct adverse impact on the patient. Both errors further demonstrated a lack of competence in relation to the safe and accurate management of patient imaging records.

145. The Panel therefore concluded that within this category Particular 3 did not amount to serious misconduct, but did amount to a lack of competence, whilst Particulars 5 and 12 amounted to serious misconduct and also lack of competence.

Technical Judgement and Professional Conduct Issues

146. Particular 4 (misjudging contrast volume) was misconduct but not serious as the scan remained diagnostic, albeit suboptimal. However, the Panel noted that the Trust did not make a Datix report of this incident at the time, which limited contemporaneous documentation. The Panel was satisfied that while the error did not result in repeat imaging, it nonetheless demonstrated a lack of competence in relation to contrast administration, which is a fundamental aspect of safe CT practice.

147. Particulars 7(a) and 7(b) (seeking to cannulate after four failed attempts and desisting only when stopped) were misconduct but not serious, as the Registrant did not proceed with cannulation. Particulars 8(a) and 8(b) (undermining colleagues in front of patients) were likewise misconduct but not serious, reflecting unprofessional communication rather than serious attitudinal failings. These matters did not demonstrate a lack of technical competence but did evidence lapses in professional judgment and conduct.

148. The Panel therefore concluded that within this category Particular 4 did not amount to serious misconduct, but did amount to a lack of competence. Particulars 7 and 8 did not amount to serious misconduct, and also did not demonstrate a lack of competence.

Summary

149. Taking the matters cumulatively, the Panel determined that the Registrant’s conduct represented a pattern of failings across core aspects of CT radiographic practice, patient identification, and professional communication. The Panel concluded that a number of the errors, in particular those in groups (i) and (ii) above, crossed the threshold of serious misconduct. In addition, the range and frequency of the errors across a sustained period demonstrated a lack of competence, particularly as the Registrant had been appointed to a Band 6 role and was expected to practise at that level.

150. The Panel concluded that the facts found proved amount to both misconduct and lack of competence. The conduct involved breaches of the following HCPC Standards of conduct, performance and ethics (2016 edition), which are quoted in full below:

Standard 2: Communicate appropriately and effectively

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

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

Standard 6: Manage risk

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

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

Standard 8: Be open when things go wrong

8.1 You must be open and honest when something has gone wrong with the care, treatment or other services that you provide by: informing service users or, where appropriate, their carers, that something has gone wrong; apologising; taking action to put matters right if possible; and making sure that service users or, where appropriate, their carers, receive a full and prompt explanation of what has happened and any likely effects.

Standard 9: Be honest and trustworthy

9.1 You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.

Decision on Impairment

151. The Panel has approached its decision on impairment by looking at the situation as it is today. It has had regard to the HCPTS Practice Note “Fitness to Practise Impairment”. The Panel noted there is no formal burden of proof and that the assessment is a matter of judgment. In reaching its conclusions on impairment the Panel had regard to its findings of fact set out earlier in this decision.

152. The Panel’s primary objective is the protection of the public, the maintenance of public confidence in the profession, and the declaring and upholding of proper standards of conduct and behaviour.

153. In reaching a decision on impairment the Panel has considered all of the evidence and the submissions. The Panel reached its decision on impairment by exercising its independent judgment.

154. Whilst there is no statutory definition of impairment, the Panel was assisted by the guidance provided by Dame Janet Smith in the Fifth Shipman Report, as adopted by the High Court in CHRE v NMC & Grant [2011]. In particular, the Panel considered whether its findings of fact showed that the Registrant’s fitness to practise is impaired in that he:

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 liable in the future to breach one of the fundamental tenets of the medical profession.

The panel concluded that in relation to the Registrant’s fitness to practise these three limbs were engaged.

155. The Panel reminded itself of its duty to protect the public, to maintain public confidence in the profession, and to uphold proper standards. It considered both the personal and public components of impairment.

156. In considering the personal component, the Panel found that the Registrant’s failings were capable of remediation. However, it was not satisfied that they have been fully remedied. The Registrant presented evidence of having undertaken further CPD and claimed to have completed over 20,000 imaging procedures, including 4,000 contrast enhanced examinations, since leaving the employing Trust. The Panel noted that these assertions were not independently corroborated, and that in his current role the Registrant is confined to plain radiography and not practising CT. Accordingly, there was limited evidence of remediation in the specific domains where failings occurred.

157. Notwithstanding this, the Panel nevertheless accepted that the Registrant is a person of previous good character, with no prior regulatory history. It also accepted the evidence that since leaving the Trust in mid-2022 he has worked continuously in NHS practice, including in Cornwall and other Trusts, without further incident. The Panel had regard to positive appraisals, his contribution to mentoring junior staff and students, and references to his supportive approach in team settings. It also accepted that he has undertaken a wide range of CPD courses, including on CRIS/PACS use, human factors, contrast and cannulation, quality assurance, and communication and leadership skills.

158. The Panel noted that while the Registrant accepted the Panel’s factual findings, he continued, at least in part, to minimise the seriousness of the allegation and its particulars, and to attribute many of the errors to deficiencies in Trust systems, training, and supervision. The Panel concluded that his insight remained only partial, as he had not yet fully accepted accountability for his failings.

159. The Panel therefore considered that there remains a risk of repetition, particularly were the Registrant to return to CT scanning. In light of this, the Panel determined that the Registrant’s fitness to practise is impaired on the personal component.

160. In considering the public component, the Panel reminded itself of the three elements set out in CHRE v NMC and Grant: protection of service users, declaring and upholding proper standards of behaviour, and maintaining public confidence in the profession. The proven facts involved multiple serious errors, including errors with patient identification, inappropriate scanning, and failures with contrast use that carried significant risks. Even in the absence of actual patient harm, these errors had the potential to cause very serious consequences.

161. The Panel concluded that members of the public, fully informed of the facts, would expect a finding of impairment in order to maintain trust in the profession and the regulatory process. To find otherwise would risk undermining confidence in the standards of the profession.

162. For these reasons, the Panel determined that the Registrant’s fitness to practise is currently impaired on both the personal and public components.

163. In reaching its conclusions on impairment the Panel also had regard to its earlier findings of fact, which provided the context for its assessment of remediation, insight and risk.

Decision on Sanction:

164. The Panel handed down its decision on impairment early in the afternoon of the third day of the resumed hearing. Both parties were given time to consider the decision and returned the following day for submissions on sanction. The Panel was satisfied that the parties had sufficient time to prepare. The Panel heard submissions from Ms Bass on behalf of the HCPC and from Mr McDermott on behalf of the Registrant.

165. Ms Bass submitted that the concerns in this case were serious and that the Panel had already found that the Registrant demonstrated limited insight. She did not make any specific submission as to the level of sanction and properly left that matter to the judgment of the Panel, reminding the Panel of its duty to apply the HCPC Sanctions Policy. She highlighted aggravating features including the absence of full remediation in CT, the Registrant’s limited insight, and the ongoing risk of repetition if he were to return to CT without further training. She acknowledged, however, that the Registrant had worked in plain film/x-ray radiography without further incident since 2022, and had undertaken CPD.

166. On behalf of the Registrant, Mr McDermott emphasised that the Registrant accepts the seriousness of the Panel’s findings and takes full personal responsibility for the errors identified in CT practice. While acknowledging the challenges of adapting to a new system, he now understands that ultimate responsibility for safe practice is his. He has since worked continuously and safely in NHS practice, undertaken CPD in areas such as CRIS/PACS, human factors, contrast and cannulation, and communication, and has mentored junior staff. He has reflected that he is not currently ready to practise CT independently, and commits that any future return to CT would only be through structured supervised training with employer sign-off. He expressed regret and apology for the anxiety caused to colleagues and patients, and submitted that a Conditions of Practice Order restricting CT practice until supervised competencies are achieved would be the most proportionate sanction, allowing him to continue to serve patients sa

167. Mr McDermott submitted that the Registrant had worked safely in the NHS for over three years since leaving the employing Trust, had undertaken extensive CPD, and had engaged fully with these proceedings. He invited the Panel to recognise the Registrant’s remediation, insight, and continuing contribution as a healthcare professional.

168. The Panel accepted the advice of the Legal Assessor. It has reached its decision on sanction by following the guidance in the HCPC Sanctions Policy (July 2019 edition).

169. The Panel has had regard to all the evidence presented. The Panel reminded itself that a sanction is not intended to be punitive, although it may have a punitive effect. The Panel bore in mind the principles of fairness and proportionality and that a sanction must be reasonable and the least restrictive outcome consistent with protecting the public.

170. The primary function of any sanction is to protect the public. The Panel has had regard to the considerations identified in paragraph 10 of the Sanctions Policy: namely, the risks the Registrant may pose to service users, the deterrent effect on other registrants, the reputation of the profession, and public confidence in the regulatory process.

171. The Panel applied the principle of proportionality, balancing the interests of the Registrant with those of the public, and considered the available sanctions in ascending order.

172. In considering the mitigating factors set out in the Sanctions Policy, the Panel identified the following:

• The Registrant has not previously been subject to fitness to practise proceedings;

• He has worked continuously in NHS practice as an x-ray radiographer at Band 5 level since leaving the employing Trust in 2022 without further incident;

• He provided positive references and evidence of mentoring junior staff and students;

• He has undertaken a CPD, including training on human factors, and communication;

• He has engaged fully with the HCPC process and attended the hearing;

• He expressed some remorse and accepted the factual findings of the Panel.

173. The Panel also identified aggravating factors consistent with the Sanctions Policy:

• The concerns involved multiple serious errors across core areas of CT radiography and patient identification;

• There was a pattern of failings over a sustained period;

• The Panel found that the Registrant demonstrated only partial insight, continuing to deflect responsibility onto Trust systems and in his view poor supervision;

• There remains a risk of repetition, particularly if the Registrant were to return to CT scanning without further training and supervision;

• The errors carried the potential for very serious consequences, including unnecessary radiation exposure and, in the case of the air bolus incident, a potentially fatal risk.

174. The Panel considered the sanctions available under Article 29 of the Health Professions Order 2001 in ascending order of seriousness.

175. The Panel determined that it would not be appropriate to take no action. The proven facts were too serious and there remains a risk of repetition. To take no action would fail to protect the public or uphold public confidence.

176. The Panel next considered a Caution Order. A caution order may be appropriate where the issue is isolated, minor, insight is good and the risk of repetition is low. Those features were not present in this case. The conduct was serious, there remains a risk of repetition and insight is limited. The Panel therefore concluded that a Caution Order would be insufficient.

177. The Panel next considered a Conditions of Practice Order. Paragraph 106 of the Sanctions Policy states that a Conditions of Practice Order is likely to be appropriate where the registrant has insight, the failings are capable of remediation, appropriate and verifiable conditions can be formulated, and the registrant does not pose a risk of harm if practising under restriction. The Panel reminded itself of the HCPC’s submission that remediation of CT competence is only partial and that insight remains limited. It also reminded itself that conditions must be workable, measurable and practicable, consistent with the HCPC Conditions Bank, which require commitment from both the Registrant and the regulator.

178. The Panel considered that these criteria were met. The deficiencies related to competence in CT practice and were capable of being addressed through retraining, supervision, and structured oversight. This was not a case involving dishonesty or attitudinal misconduct that conditions would be inappropriate. The Panel was satisfied that workable and verifiable conditions could be imposed, and that a reviewing Panel would be able to determine whether those conditions were being met. The Panel was also satisfied that the proposed conditions were directly targeted at the identified risks and provided a structured pathway to safe remediation.

179. The Panel concluded, having considered paragraph 110 of the Sanctions Policy, that conditions should include:

• Restriction from working in any modality other than x-ray until completion of approved training;

• Whilst working in any modality other than x-ray, a requirement to work under the supervision of a senior radiographer of the new modality;

• Completion of a Personal Development Plan (PDP) addressing professional communication and teamwork, escalation of concerns, patient identification and patient safety check;

• Maintenance of a reflective practice profile to be reviewed regularly by a workplace supervisor (as referred to below) and submitted to the HCPC on a quarterly basis.

180. The Panel considered whether a Suspension Order was necessary. A Suspension Order is likely to be appropriate where concerns are too serious to be addressed by conditions, but do not justify striking off. The Panel noted that suspension would not assist in remediating the identified deficiencies, which are remediable through training and supervised practice. The Panel was satisfied that public protection and the wider public interest could be achieved by conditions rather than suspension. The Panel considered this to be a proportionate response, balancing the seriousness of the concerns with the opportunity for remediation.

181. The Panel considered that a Striking Off Order would be wholly disproportionate in the circumstances.

182. The Panel therefore concluded that a Conditions of Practice Order was the appropriate and proportionate sanction. The conditions will be set out for a period of 24 months, to allow the Registrant time to complete retraining and demonstrate safe and effective practice. In reaching this decision, the Panel took account of Mr McDermott’s submission that such conditions would provide a structured pathway to remediation while enabling him to continue safe practice in X-ray.

183. In determining the precise form of conditions, the Panel noted that the framework it has imposed is broadly aligned with that proposed on behalf of the Registrant, reflecting his acceptance that proportionate restrictions on CT practice are necessary to ensure patient safety and public confidence.

184. The Order will be reviewed before expiry so that a future Panel can assess compliance and progress. The Registrant may also apply for an early review if he considers that he has complied with all the conditions in advance of the expiry date

 

 

Order: The Registrar is directed to annotate the HCPC Register to show that, for a period of 24 months from the date that this Order comes into effect (“the Operative Date”), you, Mr Asuquo Bassey Asuquo, must comply with the following conditions of practice when working in a role requiring HCPC registration:

 

1. You must not undertake any work in any modality other than x-ray until completion of approved training. Whilst working in any modality other than x-ray, you must work under the direct supervision of a senior radiographer of that modality, and satisfactorily training in all areas before undertaking any unsupervised practice.

2. From the Operative Date you must place yourself and remain under the indirect supervision of a workplace supervisor registered by the HCPC at Band 7 or above or other appropriate statutory regulator and supply details of your supervisor to the HCPC within 14 days of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations. Such supervision may not be carried out online.

3. You must not undertake any out-of-hours work or on-call duties other than X-ray.

4. You must not be involved in the clinical training of students, colleagues, other healthcare professionals, or members of the public in any imaging modality other than X-ray.

5. From the Operative Date you must work with your workplace supervisor to formulate a Personal Development Plan (PDP) designed to address the areas of your practice which have been found to be deficient including but not exclusively:

a. Professional communication and teamwork;

b. Escalation of concerns;

c. Patient identification and safety checks;

d. CT practice.

The requirements in a,b and c above apply in all modalities including x-ray, and d only if working in CT.

6. Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.

7. You must meet with your workplace supervisor on a quarterly basis to review your progress towards achieving the aims set out in your Personal Development Plan.

8. You must allow your workplace supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.

9. You must maintain a reflective practice profile recording your learning and development in the areas identified in your Personal Development Plan. You must provide a copy of this profile to the HCPC every three months, the first profile to be provided within three months of the Operative Date. If there have been no relevant occasions during that period, you must confirm this to the HCPC in writing.

10. Your reflective practice profile must be reviewed and signed off by your workplace supervisor.

11. You must inform the HCPC within seven days if you cease to be employed by your current employer.

12. You must inform the HCPC within seven days if you take up any other or further professional work.

13. You must inform the HCPC within seven days if you take up work requiring registration with a professional body outside the United Kingdom.

14. You must inform the HCPC within seven days of returning to practice in the United Kingdom.

15. You must inform the HCPC within seven days of becoming aware of:

a. any patient safety incident you are involved in;

b. any investigation started against you; and

c. any disciplinary proceedings taken against you.

16. You must inform the following parties that your registration is subject to these conditions:

a. any organisation or person employing or contracting with you to undertake professional work;

b. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);

c. any prospective employer for professional work (at the time of your application).

17. You must allow the HCPC to share, as necessary, details about your performance, compliance with, and/or progress under these conditions with:

a. any organisation or person employing or contracting with you to undertake professional work;

b. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);

c. any prospective employer for professional work (at the time of your application).

 

Application for an Interim Order

1. Following the hand down of the substantive sanction decision, and after providing the Registrant with a copy of the Conditions of Practice Order, the Panel heard further submissions from both parties. The Panel then amended the conditions to tighten and clarify their terms. It was these finalised conditions which the Panel went on to adopt for the purposes of the Interim Conditions of Practice Order.

Application for an Interim Conditions of Practice Order:

2. The Panel heard an application from Ms Bass on behalf of the HCPC to cover the appeal period by imposing an Interim Conditions of Practice Order on the Registrant’s registration.

3. Ms Bass submitted that given the Panel’s findings, the HCPC sought an Interim Order to cover the appeal period for 18 months, and that the terms should mirror the substantive Conditions of Practice Order.

4. The Registrant’s representative was invited to respond and confirmed that the Registrant had no objection to the application for an Interim Conditions of Practice Order.

Panel decision on an Interim Order:

5. The Panel accepted the advice of the Legal Assessor. The Panel had careful regard to Paragraphs 133-135 of the Sanction Policy and to Paragraphs 48-53 of the HCPTS Practice Note on Interim Orders, which offer guidance on interim orders imposed at final hearings after a sanction has been imposed.

6. The Panel recognised that its powers to impose an interim order are discretionary and that imposition of such an order is not an automatic outcome of fitness to practice. The Panel took into consideration the impact of such an order on the Registrant.

7. The Panel decided to impose an Interim Order under Article 31(2) of the Health Professions Order 2001. It had regard to the nature and gravity of the conduct found proved. The Panel was satisfied that an Interim Order was necessary and proportionate for reasons of public protection and the wider public interest. In the judgment of the Panel, the risk of repetition identified in the substantive decision, and the associated risk of harm, meant that an Interim Order was required. The Panel was also satisfied that public confidence in the profession and in the regulatory process would be seriously undermined were the Registrant allowed to practise unrestricted as a Radiographer during the appeal period.

8. The Panel next considered whether the appropriate interim measure should be an Interim Conditions of Practice Order or Interim Suspension. The Panel reminded itself that it had just determined that the concerns in this case can be appropriately and proportionately managed by the imposition of a Conditions of Practice Order, and that workable and verifiable conditions could be formulated.

9. The Panel was satisfied that those same conditions are sufficient to protect the public during the appeal period. An interim suspension would go further than is necessary, and would not be a proportionate response given the Panel’s earlier conclusion that the Registrant can practise safely under conditions.

10. Accordingly, the Panel decided to impose an Interim Conditions of Practice Order, in the same terms as the substantive Conditions of Practice Order.

11. The period of the Interim Conditions of Practice Order is for 18 months, to allow for the possibility of an appeal being made and determined, recognising that delays can occur in the High Court.

12. If no appeal is made, the Interim Order will lapse after 28 days, when the substantive Conditions of Practice Order takes effect. If an appeal is made, the Interim Conditions of Practice Order will continue until the final determination of that appeal, subject to the statutory maximum of 18 months.

Interim Conditions of Practice Order:

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

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

 

 

History of Hearings for Asuquo B Asuquo

Date	Panel	Hearing type	Outcomes / Status
26/08/2025	Conduct and Competence Committee	Final Hearing	Conditions of Practice
01/04/2025	Conduct and Competence Committee	Final Hearing	Adjourned part heard