Eme S Ufomba

Preliminary Matters

Service

1. The Panel has seen an email dated 23 July 2025 which was sent to the Registrant’s registered email address. The Panel has also seen a document which confirms that the email was delivered to the Registrant’s registered email address. The email set out the date of today’s hearing and informed the Registrant that the hearing will be conducted virtually. The Registrant was invited to attend, and she was informed that she could make any submissions in relation to the review of the Substantive Order.

2. The Registrant has also acknowledged receipt of the Notice of Hearing and confirmed she is aware the hearing is taking place today in her email dated 11 August 2025. The Registrant was present when the matter was adjourned on 18 July 2025 to enable her to receive printed documentation. During that hearing the Registrant confirmed she would waive the requirement for 28 days’ notice of any adjourned hearing.

3. Having seen these documents, the Panel is satisfied that the Registrant has been served with reasonable notice of this hearing.

Proceeding in the absence of the Registrant

4. Ms Sampson on behalf of the HCPC submitted that this hearing should proceed in the absence of the Registrant. Ms Sampson submitted that the Registrant had voluntarily waived her right to attend and that this review, which is mandatory should proceed in her absence. Ms Sampson submitted that if the review did not take place today, a hearing could not be re-listed in the remaining time and so the Order would expire. In these circumstances she submitted that the public would not be protected.

5. Ms Sampson submitted that the Registrant had provided documentation for the Panel to consider and had not requested an adjournment. Ms Sampson drew the Panel’s attention to the email of the Registrant to the HCPC dated 11 August 2025 which stated:

“I am unable to attend the review meeting scheduled for 13 August 2025 as I have been feeling unwell.

I have provided the necessary documents and supporting information in advance, and I trust these will assist you in proceeding with the review and making any decisions in my absence.

Thank you very much for understanding. I appreciate your consideration and look forward to the outcome.”

6. Ms Sampson submitted that the Registrant was clearly aware of the hearing and had provided documentation for the Panel to consider in her absence. She submitted that this would mitigate any unfairness in proceeding. In these circumstances she submitted that it was fair and proportionate to proceed in the absence of the Registrant.

7. The Panel considered the submissions of Ms Sampson and accepted the advice of the legal assessor. The Panel also had regard to the HCPTS Practice Notes relating to Postponement and Adjournment of Proceedings and Proceeding in the Absence of the Registrant.

8. The Panel has decided to proceed in the absence of the Registrant. Its reasons are as follows:

a. Notice of this hearing has been served with a reasonable period of notice and the Registrant is aware that the hearing is taking place today;

b. The Panel noted that the order is due to expire on 18 August 2025 and there is insufficient time to list a further review before the order expires. In these circumstances the Panel considered that there was a strong public interest in proceeding today;

c. The Registrant has not applied for an adjournment and has supplied documents for the Panel to consider in her absence;

d. The Registrant’s email does not set out the nature of any illness or how long it is expected to last;

e. The Panel considered that adjourning the hearing would serve no useful purpose. There is no reason to think that the Registrant would attend the hearing if it were to be adjourned;

f. The Panel determined that the Registrant has voluntarily waived her right to attend.

Background

9. The Registrant is an Occupational Therapist (“OT”) who was employed as a Band 6 OT within the rapid response team at Virgin Care between 23 March and 4 December 2020.

10. On 29 July 2020, the Registrant attended Service User 1’s home address. Social Services had requested that the Registrant undertake a functional assessment of Service User 1. Upon arrival, Service User 1 was unwell and was bleeding heavily from her lower body. The Registrant cleaned Service User 1, changed the blood-soaked bed mats and then left the property. The Registrant informed Social Services of Service User 1’s condition but did not contact emergency services. Later that morning, carers from Austen Allen Agency arrived at Service User 1’s home. The carers found Service User 1 in a very poor condition and proceeded to call the emergency services. Service User 1’s daughter made a formal complaint to Virgin Care regarding the care that was provided by the Registrant to Service User 1. As a result of the complaint, an internal investigation was conducted.

11. On 5 August 2020, Virgin Care made a fitness to practise referral to the HCPC.

12. On 19 October 2021, a panel of the HCPC’s Investigating Committee found that there was a case for the Registrant to answer and referred the matter to the Conduct and Competence Committee.

The Substantive Hearing

13. A panel of the Conduct and Competence Committee heard the case between 17 and 21 July 2023. It found all the particulars of the Allegation and the ground of misconduct proved. The panel found the Registrant’s fitness to practise to be impaired and imposed a 12-month Suspension Order.

14. The final hearing panel was satisfied that the Registrant had failed to deal with the situation presented to her and failed to undertake a risk assessment. It concluded that the Registrant’s actions and omissions fell short of what would be proper in the circumstances. In relation to impairment and the personal component, the panel found that the misconduct was remediable. It considered that as there was only extremely limited evidence of insight or remediation by the Registrant, that there was a high risk of her repeating the misconduct.

15. The final hearing panel was concerned that the Registrant had continued to advance a case which was not supported by the evidence and was unable to acknowledge the findings of the panel in her representations to them regarding impairment. The panel noted that the Registrant continued to apportion blame in relation to the situation upon others and that she was unable to take responsibility for her own acts/omissions. It concluded that until the Registrant was able to acknowledge and address the actions which led to the misconduct there was an increased risk of repetition.

16. The final hearing panel acknowledged that the incident on 29 July 2020 was a one-off incident and that it had not been intentional, but it indicated its concern that the Registrant’s reflections related primarily to the impact of the situation upon herself rather than the safety of service users. The panel noted that the Registrant had completed some online learning in relation to first aid, safeguarding vulnerable adults and emergency resuscitation. However, the panel was satisfied that despite this, the Registrant had yet to acknowledge that there was a delay in Service User 1 receiving medical assessment and/or treatment, or that her conduct fell below professional standards. The Registrant had shown no understanding of the potential consequences of her actions on Service User 1 and had failed to acknowledge the impact on the wider reputation of the profession. The panel therefore found that there was a risk of harm to service users due to the reckless disregard of risk demonstrated by the Registrant on 29 July 2020 and that the Registrant’s fitness to practise was impaired on the personal component.

17. In relation to the public component, the final hearing panel concluded that the public would be dismayed if there was no finding of impairment following misconduct of the type proved. It found the Registrant’s fitness to practise impaired on the public component, having decided that such a finding was required in order to ensure that the public has confidence in the profession and its regulator.

18. The final hearing panel decided that the appropriate and proportionate sanction was a 12-month Suspension Order. The panel considered that the incident had been a one-off incident which had been reckless rather than deliberate at a time when the Registrant had been clearly distressed by the situation she was presented with. The panel decided that the Registrant should be afforded the opportunity to develop appropriate insight.

19. The final hearing panel considered that a reviewing panel might be assisted by the following:

a. Details of how the knowledge gained by the Registrant from courses; such as first aid, safeguarding vulnerable adults and emergency resuscitation has been transferred to her clinical practice;

b. A reflective piece regarding the Panel’s findings, what went wrong in this case with regards to harm/potential harm caused to Service User 1, the impact of her acts/omissions on the profession and its regulation, and how the Registrant will change her future practices as a result;

c. Evidence of understanding the requirement for and practice of keeping robust records which clearly outline the clinical rationale for any decisions made by the Registrant;

d. Evidence of understanding the requirement for and practice of undertaking robust risk assessments;

e. A case study of how the Registrant has effectively worked in partnership with other health professionals;

f. The provision of up to date character references/testimonials about the Registrant.

First Review of Suspension Order

20. The Suspension Order was reviewed on 12 August 2024 by a panel sitting as the Conduct and Competence Committee.

21. The Registrant attended the hearing and gave oral evidence during which she was cross-examined and answered questions from the panel. In summary the Registrant’s evidence was:

a. She told the panel that she accepted the original panel’s finding that as a healthcare professional, she should have acted upon the blood loss she had observed by either calling immediately for an ambulance or by contacting a colleague for advice;

b. The Registrant accepted that she owed a duty of care to Service User 1 and that she had not recognised that there had been a need for medical assessment and/or treatment in the circumstances she had faced on 29 July 2020;

c. The Registrant accepted that she had not provided adequate care and that her actions had caused a delay in Service User 1 receiving the medical treatment which she required. The Registrant also accepted that her clinical notes had been inadequate and incomplete and that she had not recorded any clinical reasoning;

d. The Registrant told the panel that she now accepted that her behaviour had fallen below the standards required of an occupational therapist. The Registrant confirmed that she would now put into practice all that she had learned from these proceedings: she would obtain contact details from colleagues, she would record detailed and accurate case notes, and she would call an ambulance in an emergency;

e. The Registrant considered that she would be able to put into her practice the transferable skills she had acquired;

f. The Registrant confirmed that the reference in her bundle was from her mentor and friend.

22. The first reviewing panel first considered whether the Registrant’s fitness to practise remained impaired on the personal component. The panel agreed with the Registrant’s representative that the misconduct in this case was capable of being remedied. It took the view that the Registrant had begun to make good progress towards developing insight into her misconduct. This was, for example, evidenced by her acceptance in evidence of the original panel’s findings. However, the panel concluded that the Registrant’s level of insight was not yet adequate to conclude that there was only a low risk of repetition.

23. The panel considered that the Registrant had yet to fully understand the impact of her behaviour on Service User 1, Service User 1’s family, on her colleagues, her profession and on the wider public interest. The breaches of the HCPC’s Standards of Conduct, Performance and Ethics related to fundamental tenets of her profession. In reaching this conclusion, the panel was encouraged that the Registrant had engaged with the review hearing despite the late submission of her documentation.

24. The first reviewing panel noted that the training undertaken by the Registrant and referred to in her reflective document appeared to be the same courses she had given evidence of at the substantive hearing. There was no evidence before the panel that she had taken any steps to maintain her skills and knowledge by, for example, undertaking online training in the United Kingdom. The screenshot of an online training course appeared to be from the American Occupational Therapy Association and there were no screenshots of successful completion of the course. The panel took the view that the various matters which the original panel had suggested might assist a reviewing panel in making its decision had not been developed as fully as they should or could have been by the Registrant in her reflections. Her reflections were therefore inadequate to satisfy the panel that she had taken all appropriate steps to remedy her misconduct.

25. The first reviewing panel was satisfied that the Registrant’s fitness to practise remained impaired on the personal component. In relation to the public component, the panel took the view that whilst the Registrant had made good progress towards developing insight into her misconduct, she had not yet made sufficient progress. In particular, it appeared to the panel that the Registrant did not fully understand, the impact of her behaviour on her colleagues, her profession or the wider public interest.

26. The first reviewing panel was satisfied that a reasonable and well-informed member of the public would expect a finding that the Registrant’s fitness to practise remained impaired, where the Registrant had yet to develop sufficiently good insight into her misconduct and had yet to remedy that misconduct such that there was only a low risk of it being repeated. The panel was therefore satisfied that the Registrant’s fitness to practise remains impaired on the public component.

27. The first reviewing panel considered whether to replace the Suspension Order with a Conditions of Practice Order. The panel decided that, in light of the progress being made by the Registrant towards remedying her misconduct, and her developing insight, it was possible to devise appropriate and proportionate conditions of practice which would address the concerns it has identified. The panel was satisfied that the Registrant will comply with conditions of practice.

28. The first reviewing panel suggested that a future reviewing panel, might be assisted by the following:

a. The attendance of the Registrant at the review hearing;

b. Documentary evidence of the completion of any Continuing Professional Development undertaken;

c. A written reflective piece on the impact of the Registrant’s misconduct on Service User 1, Service User 1’s family, her own colleagues, her profession, and the wider public interest;

d. Written, dated and signed testimonials/references regarding any employment undertaken by the Registrant.

29. The first reviewing panel replaced the Suspension Order imposed on 21 July 2023 for a period of 12 months with a Conditions of Practice Order for a period of 12 months. The first reviewing panel imposed the following conditions of practice:

1. You must not undertake employment with any locum agency or work as an independent sole practitioner.

2. You must place yourself and remain under the indirect supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within 14 days of the Operative Date or the commencement of employment whichever is the later date. You must attend upon that supervisor as required and follow their advice and recommendations including, but not limited to, any further progress with your Personal Development Plan.

3. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:

• Record keeping

• Working collaboratively with colleagues and other healthcare professionals

• Recognising risk

• Clinical reasoning and risk assessment

• Understanding the duty of candour.

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

5. You must meet with your supervisor on a fortnightly basis to consider your progress towards achieving the aims of your Personal Development Plan.

6. You must allow your supervisor to provide information to the HCPC every three months from the date that you take up employment as an Occupational Therapist about your progress towards achieving the aims set out in your Personal Development Plan.

7. You must inform the HCPC within seven days if you take up employment as an Occupational Therapist and you must inform the HCPC within seven days if you cease employment as an Occupational Therapist.

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

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

10. 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.

11. 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 prospective employer (at the time of your application).

Submissions by the HCPC at today’s hearing

30. Ms Sampson provided the Panel with detailed submissions relating to the previous history of the proceedings and referred the Panel to the documentation submitted by the Registrant in relation to this review. In summary, Ms Sampson submitted that although the Registrant had undertaken training and had provided evidence of training and reflection her insight and remediation was not sufficient to reassure the panel that she had addressed her past impairment. Ms Samson submitted that as the Registrant had been unable to secure employment in a registered role, she had not been able to provide evidence that she had worked safely under the current conditions of practice. Ms Sampson submitted that although the Registrant had shown some evidence of developing insight and continued to engage with the proceedings there was limited evidence before the Panel to discharge the persuasive burden that the Registrant’s fitness to practise was no longer impaired.

31. Ms Sampson submitted that the reflections provided by the Registrant did not address the impact of her misconduct on the Service User, their family or the wider public. Ms Sampson submitted that the Registrant had not detailed within her reflections how she would act differently in the future. Ms Sampson drew the Panel’s attention to the following statement within the Registrant’s reflection, “I have learned that clear communication and decisive actions are crucial in ensuring patient safety and that compassion to clean her up, based on panel’s finding should have been avoided. I should have left her in that condition and just called the ambulance.” Ms Sampson submitted that this suggested that the Registrant had not appreciated the concerns and had not properly implemented any learning.

32. Ms Sampson submitted that the testimonials provided by the Registrant were of limited weight. She submitted that the testimonial from Ms Thompson did not set out how the Registrant was known to her and did not confirm that she was aware of the findings made against the Registrant. Further, the reference from the Registrant’s current agency did not comment specifically on the matters which led to the previous findings. In these circumstances Ms Sampson submitted that the information submitted by the Registrant was insufficient to reassure the Panel that the Registrant was no longer impaired.

33. Ms Sampson submitted that it was fair and proportionate to extend the current Conditions of Practice Order by a further 12 months. She submitted that this would allow the Registrant an opportunity to further develop her insight and potentially find employment so that she could work safely under the conditions. Ms Sampson submitted that any shorter period would be insufficient to demonstrate full remediation given that the Registrant is not currently employed. Ms Sampson submitted that the current conditions were workable and proportionate and protected the public. She submitted that although they may cause some difficulty for the Registrant in securing employment this was necessary to protect the public.

Decision on Impairment

34. The Panel's remit for this Review is to determine whether the Registrant's fitness to practise remains impaired, and, if so, how to approach any sanction, with reference to its powers under Article 30(1)(a), (b) and (c) of the Consolidated Health Professions Order 2001, as amended (the Order).

35. The Panel considered whether the Registrant's fitness to practise is impaired by reason of her misconduct. It took into account the evidence before it (which included all of the documentation provided by the Registrant) and the submissions of Ms Sampson. It accepted the advice of the Legal Assessor and had particular regard to the HCPTS Practice Note on Finding that Fitness to Practise is Impaired. It recognised that the decision on impairment was a matter for its own independent judgment. The Panel also noted that it was entitled to take into account and give respect to the previous panel's reasons and conclusions, but that this Panel should approach its remit independently, based on the evidence before it today.

36. The Panel determined that the Registrant’s fitness to practise remains impaired by reason of her misconduct. It concluded that both the personal and the public component is engaged for the following reasons.

37. The Panel carefully considered the registrant’s reflections. It considered that the Registrant had made progress since the last hearing and had expressed genuine remorse and regret for her actions. However, the Panel considered that the reflections lacked depth and were basic in nature. The Panel observed that the reflections did not follow a recognised model and as such they lacked focus and detail. In particular, the Registrant did not adequately explain how she would act differently in the future as a result of the reflection and learning she has undertaken. In addition, the Panel considered that it was significant that the Registrant’s reflections did not adequately address the impact of her misconduct on the Service User, her family, her colleagues, the profession or the wider public. The Panel considered that the Registrant’s insight was not yet fully developed. The Panel also noted that the Registrant appeared to suggest that she would not act compassionately in the future in stating, “I should have left her in that condition and just called the ambulance.”

38. The Panel noted the training undertaken by the Registrant and considered that it was encouraging that the Registrant was committed to keeping her knowledge and skills up to date. The Panel noted that the training appeared to be mandatory training and there was no evidence of target specific training to address the Registrant’s previous failings. There was also no evidence of the Registrant having applied any learning from the training in practice. Whilst the Panel noted that the Registrant had not been working in a registered role there was a lack of evidence relating to learning which the Registrant would carry forward into practice.

39. The Panel noted the testimonials provided by the Registrant. It agreed with the submissions of Ms Sampson that these were of limited assistance as they did not provide the Panel with any reassurance that the Registrant would be able to work safely in the future. The Panel was unable to ascertain in what capacity Ms Thompson knows the Registrant and the reference did not comment on her current skills.

40. Taking all of the information into account, the Panel has concluded that there is a risk of repetition of the Registrant’s misconduct and thus a continuing risk to service users.

41. The Panel further concluded that public confidence in the profession of Occupational Therapy and in the HCPC as its regulator would be undermined if a finding of current impairment was not made given the ongoing risk of repetition identified. The Panel concluded that such a finding was necessary to maintain proper standards of conduct within the profession.

Decision on Sanction

42. Having concluded that the Registrant’s fitness to practise remains impaired, the Panel next considered the available sanctions. In reaching its decision on Sanction, the Panel noted its powers under Article 30(1) (a), (b) and (c) of the Order. It accepted the Legal Assessor's advice and took into account the HCPTS' Sanctions Policy. It considered each outcome and sanction available to it, in ascending order of restriction.

43. It considered that to take no action or to impose a caution order would be inappropriate and would provide no protection to the public against the risk of repetition and would not address the public interest.

44. The Panel then considered the current Conditions of Practice Order. The Panel noted that the Registrant had continued to engage with proceedings and had made efforts to secure employment. The Panel considered that there was evidence that the Registrant would comply with a Conditions of Practice Order.

45. The Panel considered that a Conditions of Practice Order was appropriate and proportionate as it would allow the Registrant to return to safe practice and continue to develop her insight and remediation. The Panel considered that the current conditions were workable, appropriate and proportionate. In coming to this conclusion, the Panel adopted the reasons identified by the previous panel.

46. The Panel noted the registrant’s request to relax the conditions to enable her to work via an agency or in a locum placement. The Panel considered that this would not provide the appropriate degree of public protection. The Panel considered that the Registrant’s level of insight was such that she required further supervision and training to ensure her misconduct was not repeated. The Panel considered that there would be insufficient support and oversight in a locum or agency role. The Panel also noted that the current conditions would not prevent the Registrant applying for a return to practice course.

47. The Panel also considered the length of the order and noted that the Registrant had requested a period of 6 months. The Panel considered that this was unrealistic given that the Registrant did not have an offer of employment. The Panel considered that a further period of 12 months would provide the appropriate timescale for the Registrant to develop her insight and remediation. Such an order would protect the public and address the public interest. In coming to this conclusion, the panel had in mind the principle of proportionality; not to impose a more restrictive order than is necessary to protect the public and sustain the public interest.

48. The Panel considered that this period would be sufficient for the Registrant to find suitable employment and demonstrate to a future reviewing panel that she had taken steps to address her previous misconduct. Without in any way seeking to bind a future panel, this Panel suggests that a future reviewing panel, might be assisted by the following:

a. The attendance of the Registrant at the review hearing;

b. Documentary evidence of the completion of any Continuing Professional Development undertaken and evidence of the application of that learning to future practise;

c. A written reflective piece on the impact of the Registrant’s misconduct on Service User 1, Service User 1’s family, her own colleagues, her profession, and the wider public interest;

d. Written, dated and signed testimonials/references regarding any employment undertaken by the Registrant.

49. The Panel considered that to impose a suspension order would be disproportionate to the risk of repetition identified which the Panel had determined could be adequately addressed with conditions.

ORDER: The Panel therefore determined to extend the following Conditions of Practice Order for a further 12 months.

1. You must not undertake employment with any locum agency or work as an independent sole practitioner.

2. You must place yourself and remain under the indirect supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within 14 days of the Operative Date or the commencement of employment whichever is the later date. You must attend upon that supervisor as required and follow their advice and recommendations including, but not limited to, any further progress with your Personal Development Plan.

3. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:

• Record keeping

• Working collaboratively with colleagues and other healthcare professionals

• Recognising risk

• Clinical reasoning and risk assessment

• Understanding the duty of candour.

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

5. You must meet with your supervisor on a fortnightly basis to consider your progress towards achieving the aims of your Personal Development Plan.

6. You must allow your supervisor to provide information to the HCPC every three months from the date that you take up employment as an Occupational Therapist about your progress towards achieving the aims set out in your Personal Development Plan.

7. You must inform the HCPC within seven days if you take up employment as an Occupational Therapist and you must inform the HCPC within seven days if you cease employment as an Occupational Therapist.

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

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

10. 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.

11. 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 prospective employer (at the time of your application).

The Order imposed today will apply from 18 August 2025.

This Order will be reviewed again before its expiry on 18 August 2026.

History of Hearings for Eme S Ufomba