David Brown

Preliminary Matters

1. The Panel has been convened to undertake a review of a Substantive Suspension Order imposed in respect of the HCPC registration of the Registrant, Mr David Brown, a Dietitian. The review is being undertaken under the provisions of Article 30(1) of the Health Professions Order 2001.

Service of the notice of hearing

2. The Panel was shown a copy of an unredacted email dated 15 July 2025 that was sent to the Registrant. The email informed him that the review of the Suspension Order was scheduled to be taken today at 10:00am, and that the hearing would be conducted by Microsoft Teams. The Panel was satisfied that this communication satisfied the requirement that the Registrant should be given notice of the hearing.

Proceeding in the Registrant’s absence

3. The Presenting Officer submitted that if the Panel was satisfied that there had been good service of the notice of hearing, the hearing should proceed in the absence of the Registrant. She drew the attention of the Panel to the many attempts to communicate with the Registrant and also to the fact that jurisdiction to consider whether a further sanction should be made would be lost were the hearing not to proceed at the present time.

4. The Panel received and accepted advice from the Legal Assessor, and heeded the guidance contained in the HCPTS Practice Note entitled, “Proceeding in the Absence of the Registrant”. Having carefully considered the matter, the Panel decided that the hearing should proceed notwithstanding the absence of the Registrant. The reasons for this decision were:

• In addition to the notice of hearing sent on 15 July 2025, the HCPC Case Manager with responsibility for the case sent emails to the Registrant on 21 July 2025, 28 July and 31 July 2025. The Hearings Officer also sent an email to the Registrant on 28 July 2025. On 6 August 2025, the Case Manager spoke to the Registrant by telephone, and the following day sent him an email referring to the voluntary removal process and informing him that if he would like to proceed with an application for voluntary removal he should complete and sign the consent proforma that was sent to him. There was no response to that email. On 11 August 2025, a further email was sent to the Registrant putting him on notice that at the hearing the HCPC would request the Panel to make a striking off order.

• The history of the recent communications set out above, coupled with the fact that there was no engagement on the part of the Registrant in the final hearing, has led the Panel to conclude that he has disengaged from these proceedings. The Panel fully accepts that the Registrant’s service in the Army might result in remote attendance at the hearing difficult. It does not accept that it explains the complete absence of direct communication with the Panel, even by sending a document explaining his current position and explaining his future intentions.

• There are no grounds on which the Panel could conclude that the Registrant would engage in a review hearing in the future if the present hearing were to be adjourned.

• Furthermore, if the hearing did not proceed at the present time, jurisdiction to make a further sanction would be lost. Jurisdiction to undertake an Article 30(1) review is dependent upon it taking place before the expiry of the Order being reviewed. The requirement of a notice period of 28 days would preclude a hearing from taking place before the expiry of the present order on 5 September 2025.

• For all these reasons, the clear public interest demands that the present hearing should continue.

Background

5. The Registrant is a registered Dietitian, having been admitted to the Register on 8 July 2017.

6. The Registrant initially worked in a locum capacity within the Community Team at the East Suffolk and North East Essex Foundation Trust (“the Trust”). The date the Registrant started work as a locum and received his induction is unknown, however, there were no records of any concerns relating to the Registrant’s performance and record-keeping during his time working as a locum.

7. The Registrant joined the Trust’s Oncology Dietetic Team on a fixed term contract to cover a period of secondment whilst Person A undertook a Macmillan Project. When the Registrant joined the Oncology Dietetic Team it was as a Band 6 dietitian. He covered Person A's secondment for a period of one year from May 2019 to April 2020.

8. The Registrant’s role within the Oncology Dietetic Team included covering some Oncology patients and managing the Motor Neurone Disease (MND) caseload of patients for Person A, as well as continuing with some project work. Whilst the Registrant was covering Person A’s role, he had sole responsibility for managing the caseload of MND patients, responsibility for Oncology home visits, and radiotherapy patients.

9. Towards the end of January 2020, Person A prepared for her return to Oncology as it became clear that her project and secondment were coming to an end due to the impending COVID pandemic lock down. Upon her gradual return to Oncology, Person A started to re-familiarise herself with the patients who had been under her care before her secondment, and to identify the needs of new patients.

10. Initially a meeting was arranged for handover on 10 February 2020, but this was postponed to later in the week as the Registrant was not in the office that day. In preparation for that meeting Person A undertook a complete review of patient notes. Person A became concerned about the Registrant’s level of record keeping and this concern increased as she reviewed more patient files and identified that visits had not been arranged nor patients given the clinical attention and care they required.

11. At Person A’s meeting with the Registrant in February 2020, he was unable to provide any explanation for sub-standard record-keeping and patient review.

12. Person A committed to a spreadsheet the number and types of information that she had found were missing within those patient notes, such as lack of clinical records, appointments, or core information such as weight, height, feeding etc. Person A shared with Person D her concerns about the extent of these omissions and lack of essential information relating to care given to these patients.

13. The extent of the poor record keeping and missing information was discussed with the Registrant at a meeting on 17 February 2020. Person D led that meeting and committed to writing an outcome action plan in an email later that day, in which she identified immediate action to be taken in respect of specific service users. In that email Person D identified that this work was to be concluded by 13 April 2020, when there would be a final handover from the Registrant to Person A. On 10 March 2020 a Datix incident investigation report was made. This related to the Registrant making an entry within a patient file on 10 December 2019, recording that he had seen this service user on that date. That service user had died on 21 November 2019 and so the Registrant could not have seen that service user on 10 December 2019 as his recorded entry showed.

14. On Friday 20 March 2020, the Registrant attended a meeting with Persons C and D (his co-line managers) to discuss the issue of his record keeping and the error that had resulted in the raising of the DATIX incident investigation report. Following that meeting an action plan was constructed based on the Trust’s Informal Capability Guidance. The Action Plan was expected to take immediate effect; however, it did not become operative until 10 April 2020, as the Registrant had to self-isolate after falling ill. The first Covid lock down started on 23 March 2020, when the department changed the way it worked.

15. Part of the Action Plan was for the Registrant’s appointment plan, notes and records of visits to be reviewed by his supervisor on a daily basis. The Registrant’s records were checked during the period 10 April 2020 to 17 April 2020 by either Person B, C or D, and were found to be of a suitable standard.

16. The Registrant left the Trust on 17 April 2020, having submitted his resignation some time earlier. His resignation was due to the timing of the project and secondment coming to an end, and that of his proposed Army training.

17. The Trust’s investigation into the concerns about the Registrant’s record keeping were the subject of a referral to the HCPC on the 20 April 2020. The matters referenced in that referral are the subject of the Allegation set out above.

18. The final hearing of the Allegation took place between 1 and 8 August 2024. The Registrant did not attend the hearing. Prior to the final hearing there had been sporadic contact with the Registrant. Between December 2021 and July 2022 he informed the HCPC’s Solicitors that he had joined the Army, and the minimum period of his service would be five years that would not end before May 2026. He stated that during his service with the Army he would not require his HCPC registration. In July 2023 he stated that he was overseas and had limited opportunities to communicate. In March 2024, he asked to be provided with a password for the HCPC’s bundle of documentation. Between March 2024, and the final hearing there was no further communication by the Registrant.

19. The final hearing panel decided that it was appropriate to proceed with the hearing in his absence. The final hearing panel received the evidence of five witnesses, four of them members of the Trust’s Dietetic Team. Included in the witnesses were Person A, C and D to whom reference is made in the summary of the background given above.

20. The final hearing panel found the following facts to be proven against the Registrant:

• Particular 1(a), that he did not record full clinical information from his appointments with all 18 of the service users identified in Schedule 1.

• Particular 1(b), that he did not provide full clinical documentation and/or clinical notes in relation to interventions with all 14 of the service users identified in Schedule 2.

• Particular 1(c), that he did not review in a timely manner, five out of the six service users identified in Schedule 3.

• Particular 2, that on 21 February 2020, he had recorded in Service 6’s patient notes that he had seen them on or around 10 December 2019, whereas he had not as Service User 6 had died o 21 November 2019.

• Particular 3, that he did not complete patient notes in a timely manner in relation to Service User 3, in that he recorded on or around 14 November 2019, a home visit that took place on 6 June 2019.

Other factual elements of the Allegation were not proven.

21. When the final hearing panel considered whether the findings of fact it had made satisfied a statutory ground, it concluded that Standards 6.1 6.2, 9.1, 10.1 and 10.2 of the Standards of conduct, performance and ethics in force at the time had been breached. It was decided that when viewed both individually and collectively, the findings made represented serious misconduct, and were shortcomings that fellow practitioners would regard as deplorable.

22. In relation to the decision on impairment of fitness to practise made at the final hearing, it was accepted that there had been some, but very limited, reflection and insight demonstrated by the Registrant. It was recorded in the final hearing determination that:

• The Registrant accepted that his practice had been below that required and considered that he should have made his recording keeping a higher priority.

• His personal circumstances at that time had put him under pressure.

• The impact of his work and his personal life had adversely affected his wellbeing.

• The Registrant had acknowledged that should he return to practice at the end of his Army service he appreciated that he would be required to undertake further training to bring his professional skills and knowledge up to date.

However, it was noted that there was no evidence that any steps had actually been taken in the four years that had elapsed between the Registrant leaving the employment by the Trust and the final hearing taking place. In these circumstances, the panel found that, when considering the personal component of fitness to practise, there was current impairment at that time

23. In relation to the public component of fitness to practise, the final hearing panel considered how fellow practitioners would view the Registrant’s lack of care for vulnerable and failing service users was relevant. His lack of application to his role would be considered by fellow practitioners to have seriously undermined the collective responsibility of upholding and maintaining the standards of their profession. Similarly, it was decided members of the public that would be concerned if a practitioner who had ignored the wellbeing of those under his care, and had been so neglectful of his responsibilities over such a long period of time, were to be allowed to continue in practice without some form of restriction on his practice. For these reasons, the final hearing panel considered that there was impairment of fitness to practise in relation to the public component at that time.

24. When the final hearing panel addressed the issue of sanction, it concluded that no lesser sanction than suspension would be appropriate. Before confirming that a suspension order should be made, the panel expressed its view on the appropriateness of a striking off order. It said this in paragraph 147 of its determination:

“Before settling upon a period of suspension, the Panel considered whether a Striking Off Order would be proportionate, and came to the conclusion that it would not, given, as stated above, the factors of no finding of dishonesty and stated intention of engagement with the process of returning to the profession as a safe practitioner.”

25. In imposing a suspension order for a period of 12 months, the final hearing panel advised the Registrant that there would be a review before it expired. That panel then went on to state this in the final paragraph of its written determination:

“[…] Whilst this Panel cannot tie the hands of that future reviewing panel, the Panel has taken the opportunity to list below matters which the Registrant may wish to consider and address in the next twelve months. Those are:

• Arrangement for the Registrant to be present facially over zoom at the first review of this Order which will be before its expiration in twelve months and twenty-eight days. Notice of that Review hearing will be given.

• Evidence of his ability to maintain and retain his wellbeing.

• Testimonials from whatever source which attest to the Registrant nature and character.

• Evidence of CPD work completed since April 2020.

• Detailed piece of writing in which the Registrant reflects upon his previous misconduct and considers this in the context of how it impacted on his service users and colleagues at the time and also in relation to how that reflection will influence his future conduct.

• Evidence of his understanding of how to obtain and engage coping strategies that he can deploy in the future to ensure that any personal and professional stressors do not adversely affect his professional conduct.”

26. The Suspension Order was imposed on 8 August 2024 for a period of 12 months. After the expiry during which the Registrant could have commenced an appeal, the Order had effect from 5 September 2024. It follows that the task of the present Panel is to decide what, if any, sanction should be imposed from 5 September 2025.

Submissions to the Panel

27. On behalf of the HCPC, the Presenting Officer outlined the history of the case and took the Panel to passages from the written determination of the final hearing panel, particularly those explaining that panel’s reasons for finding that the proven facts amounted to misconduct, that the misconduct resulted in the Registrant’s fitness to practise being then impaired, and the sanction of suspension being imposed. In relation to the HCPC’s submissions as to the Order to be made by the present Panel, the Presenting Officer reminded the Panel of the relevant Practice Note, and in particular, to the fact that a registrant carries a persuasive burden at a review hearing to satisfy a reviewing panel that the factors that led to the previous finding of impairment of fitness to practise have been addressed. In the present case, she submitted that there has been no information provided by the Registrant that could lead to a conclusion that any, let alone all, of the factors identified have been remedied. Accordingly, the Presenting Officer submitted, the Registrant’s fitness to practise remains impaired in respect of both the personal and public components. In relation to the further sanction that it was submitted is required, the Presenting Officer submitted that the Panel should apply to the guidance contained in the HCPC’s Sanctions Policy, and she took the Panel to elements of that document. In submitting that the Panel should impose a striking off order, she submitted that it would not be appropriate to impose a further period of suspension because to do so would be to hope that the Registrant would engage in the fitness to practise process in the future and that, having done so, he might wish to return to practise and take the necessary steps that would be required of him to do so.

28. No submissions were made to the Panel by, or on behalf of, the Registrant.

Decision

29. The Panel accepted the advice it received and followed the guidance contained in the HCPTS Practice Note entitled, “Review of Article 30 Sanction Orders” issued in August 2025. What a panel undertaking a review of a substantive sanction order is required to do can be summarised as follows:

• The reviewing panel is obliged to accept as settled the finding of facts made by the final hearing panel, and also the decision of that panel in relation to the statutory ground of misconduct that it decided had been established.

• The task of the reviewing panel is to decide whether the Registrant’s fitness to practise remains impaired, and, if it is, whether the existing order or some other order needs to be in place upon the expiry of the existing order.

• Included in the issues to be considered are those listed in paragraph 12 of the Practice Note. The reviewing panel is required to consider whether all the concerns raised in the original finding of impairment have been sufficiently addressed. In reaching its decision, it is appropriate for the reviewing panel to take the view that the Registrant carries the persuasive burden of demonstrating that matters have been satisfactorily addressed.

• If the reviewing panel is of the view that a Registrant’s fitness to practise remains impaired and that a further order is required upon the expiry of the exiting order, then ordinary sanction principles apply. The decision should be made by following the guidance contained in the HCPC’s Sanctions Policy. It is necessary that any further order decided upon should satisfy the requirement that it represents a proportionate response.

The Panel confirms that in reaching its decision it has applied these principles.

30. The present Panel agreed with the reasons expressed by the final hearing panel for finding that the Registrant’s fitness to practise to be impaired. With regards to the personal component, his management of service users who were vulnerable, and in some cases frail, exposed them to the risk of harm. The shortcomings related to a considerable number of service users and extended over a lengthy period of time. Without confidence that he would not repeat those shortcomings, there would be a risk of repetition. Furthermore, both fellow practitioners and members of the public would be aghast were there to be no restriction imposed on the ability of a practitioner against whom such findings had been made.

31. The complete absence of information from the Registrant necessarily has the consequence that his fitness to practise is as impaired as it was in August 2024, and for the same reasons.

32. The decision that the Registrant’s fitness to practise remains impaired meant that the Panel had to consider whether a further sanction is required following the expiry of the current Suspension Order.

33. The Panel reviewed the available sanctions, commencing with the least restrictive. It would not be appropriate to take no further action and a caution order would be inappropriate because either course would afford no protection for service users in the event of the Registrant wishing to return to practise as a Dietitian. A conditions of practice order is not appropriate for two distinct reasons. One is that the Registrant is not practising as a Dietitian. The other is that his lack of engagement in the process would make it inappropriate even if he were still practising.

34. With regards to a further period of suspension, the findings made against the Registrant were clearly of a type that were capable of being remediated. But for them to be remediated, positive efforts would be required, and the steps taken would have to be communicated to a reviewing panel for it to be satisfied that the remediated practitioner could safely be permitted to return to unrestricted practice. In the present case there is not only a complete absence of information that any steps towards remediation have been taken (or attempted) in the period of over five years since the events occurred, but the Registrant has not communicated to this Panel any intention that he wishes to do so. For that reason, the Panel has concluded that a further period of suspension would achieve nothing as the position at the end of it would be exactly as it is at present.

35. The decision that a further period of suspension is not appropriate resulted in the Panel concluding that a Striking Off Order should be made. A Striking Off Order is not imposed as a punitive measure. It is required because the findings made against the Registrant are such that were he to return to practise without addressing the shortcomings identified at the final hearing, he would present an unacceptable risk to future service users. The time has come when there is now no realistic prospect that the Registrant will decide to address the shortcomings. For that reason, the making of a Striking Off Order is a proportionate response.

ORDER: The Registrar is directed to strike the name of David Brown from the Register on the date this Order comes into effect.

The Order imposed today will apply from 5 September 2025.

Right of Appeal

The Registrant may appeal to the High Court in England and Wales against the Panel’s decision and the order it has made.

Under Articles 30(10) and 38 of the Health Professions Order 2001, any appeal must be made to the court not more than 28 days after the date when notice is served.

History of Hearings for David Brown