Jenny Rudston

Preliminary Matters
Application to proceed in Private
1. Mr Bellis made an application that, should any reference be made to the Registrant’s health issues, the hearing should temporarily go into private session in order to protect her private life. The application was supported by Mr Halliday.

2. The Panel had regard to the HCPTS Practice Note on “Conducting Hearings in Private” and accepted the advice of the Legal Assessor. Having considered the information before it regarding the Registrant’s health issues, the Panel determined that the hearing should go into private session if such matters had to be referred to, in order to protect the Registrant’s private life.

Background
3. The Registrant qualified as a physiotherapist in 2006. Following qualification, she worked in a variety of Band 5 Physiotherapist roles at a number of hospitals. The Registrant commenced employment at St Richard’s Hospital (“the Hospital”) which is part of the University Hospital Sussex NHS Foundation Trust, on 8 October 2018 as a Band 5 Physiotherapist. Concerns about the Registrant’s competence were first raised in December 2018 whilst the Registrant was on her first rotation in the Orthopaedics department.

4. The HCPC state that an informal capability process was initiated and ran from December 2018 until April 2019 at which point a formal capability process began. The Registrant was overseen by the two witnesses in this case, LO, at the time Head of Physiotherapy at the Hospital, and JG (Band 7 Physiotherapist), the Registrant’s Team Leader and Line Manager. JG assisted in the formal capability process and supervised the Registrant from April 2019.

5. The Registrant appealed internally against the capability process twice, in September and in December 2019, with the latter appeal being refused. At the final Capability Hearing on 10 March 2020, the Registrant was dismissed from the Hospital. However, she appealed against this decision but her appeal was refused on 17 November 2020. A referral was made to the HCPC the same day by the Hospital.

6. At its meeting on 29 June 2021 a panel of the HCPC’s Investigating Committee determined that there was a case to answer in relation to the allegation of impairment of the Registrant’s fitness to practise.

Decision on Facts
7. In considering this case the Panel has borne in mind that the burden of proving the facts rests upon the HCPC and that the standard of proof is the civil standard of the balance of probabilities. It has taken account of all the evidence presented to it, namely the written and oral evidence of the HCPC witnesses detailed below, together with the written and oral evidence of the Registrant. Furthermore, it has paid heed to the evidence of Mr Tim Edbrooke, the HCPC’s appointed expert in Physiotherapy. It has also considered the submissions of Mr Bellis on behalf of the HCPC and of Mr Halliday on behalf of the Registrant and has accepted the advice of the Legal Assessor.

8. The Panel heard evidence from the following witnesses on behalf of the HCPC:
JG - Team Lead of the Medical Physiotherapy Team in the Physiotherapy Department at the Hospital;
LO - Head of Physiotherapy at the Hospital;
Mr Tim Edbrooke, (“TE”) Chartered Physiotherapist and Director of Tim Edbrooke Physiotherapy Limited, Expert Witness.

9. The Panel also received documentary and oral evidence from the Registrant.

Admissions
10. The Registrant made admissions to the following Particulars of the Allegation, namely:
• Particular 1(c) [Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role. In that…c. You did not demonstrate good clinical reasoning in patient assessments and/or treatment decisions for the patients listed in Schedule A] insofar as it related to Patients A, B, F and G;
• Particular 1(d) [You did not carry out appropriate risk assessments for the patients listed in Schedule B] insofar as it related to Patient A; and
• Particular 1(e) [On or around 8 November 2019 you did not use the emergency bell for an unresponsive patient].

11. Following those admissions, the Panel heard and accepted the advice of the Legal Assessor, who referred the Panel to the HCPTS Practice Note on “Admissions”. Having considered the matter, the Panel found these Particulars proved by way of those admissions.
Particulars 1(c) (insofar as it relates to Patients A, B, F and G); 1(d) (insofar as it relates to Patient A); and 1(e) - Found Proved by way of Admission

12. The remaining matters which therefore needed to be decided by the Panel were Particulars 1(a); 1(b); 1(c) (insofar as it related to Patients C, D and E); and 1(d) (insofar as it related to Patients E, F and G).

Overall background
13. By way of overall background, the Panel noted the evidence of LO. In his written statement dated 5 October 2021, which he confirmed in oral evidence, and which the Panel has set out in detail below as it comprehensively summarises the history of the matter, LO said:
“…4. Any new Physiotherapist who joins the Physiotherapy Department is expected, as part of their training, to rotate through various specialist teams within the department. Jenny Rudston commenced employment at the Hospital in October 2018 and was initially posted to the Orthopaedic team, where she was supervised by MW.
5. Jenny Rudston joined the Hospital as a Band 5 Physiotherapist having qualified in 2006. During each rotation, there is a standard set of competencies and objectives that Band 5 Physiotherapists need to achieve. Jenny Rudston would have discussed these competencies and core rotational objectives for the 4 month rotation when she initially joined the Orthopaedic team and met with her supervisor, MW. During this time, she would have also had the opportunity to identify and agree any personal objectives she may have had. The standard set of competencies/objectives are realistic in what you can achieve in a four month period and they are universal for any Band 5 Physiotherapist on rotation with the team.
6. During a rotation, various day-to-day, on-the-job training is carried out for all Physiotherapists. The in-service training programme may involve the team presenting to each other on different subjects. As a Band 5 Physiotherapist, Jenny Rudston would have had the opportunity of supervision sessions and one-to-one working with a Senior Physiotherapist so she could develop her practical learning. Training in the department also consists of question and answer and problem solving sessions and opportunities to speak with Senior Pliysiotherapists about your patient list and obtain guidance on patient assessment and on-going rnanagement. There were many opportunities for hands on training on the ward and guidance on what we expected from our staff and how they handle their caseload.
7. With any new employee, we are mindful that there.is a natural expectation that they may need a while to get settled, and up to speed with a particular ward environment in order to perform at their best. By December 2018, it seemed Jenny Rudston had still not settled into work and therefore MW raised his concerns with me that Jenny Rudston was having more difficulties than expected in settling in. The concerns MW raised around Jenny Rudston's performance were around the more basic elements of her role such as managing a ward, her clinical reasoning and managing her time effectively. These were the same concerns that continued throughout the capability process…
8. ln February 2019, Jenny Rudston was due to finish her rotation with the Orthopaedic team and move onto her rotation within the Rehabilitation team. MW met with her in the summary meeting which occurs at the end of each rotation and spoke to her about the various objectives she had achieved during that rotation. During this meeting, MW also informed Jenny Rudston that he felt she appeared to be struggling in certain areas…
Capability process
9. The capability process we have at the Hospital consists of both an informal and formal process. The key difference between the formal and informal stage is that the informal stage is not documented on an employee's record. The informal stage of Jenny Rudston's capability process ran from December 2018 until April 2019. I met with Jenny Rudston on î9 December 2018 following the concerns raised by MW and informed her that the informal capability process was now in place. During this meeting, I also provided her with a copy of the Capability Policy…During this initial meeting, l asked her if she had anything going on outside of work which could be impacting her and if we could put in place anything further to support her but she did not raise any concerns.
10. ln April 2019, I met with JG to discuss whether there had been any improvements in Jenny Rudston's work during her first few months within the Rehabilitation team. JG informed me that there had been little improvement and so it was decided that we should move to the formal stages of the capability process…a first stage meeting was conducted and then, following this, the progress of Jenny Rudston was to be reviewed every three months. I met with Jenny Rudston for the First Stage Capability Meeting with JG and CO, Human Resources (HR) Adviser on 29 April 2019…”
11. A key decision arising from the Formal Capability meeting was that, in order to assist Jenny Rudston, we would draft an lndividual Performance lmprovement Plan with specific objectives for her to follow. These plans would be revisited during any further capability meetings to assess progress towards agreed goals and to confirm what objectives Jenny Rudston was to work on over the following few months…ln addition, it was decided that there would be regular supervision sessions conducted by JGd and other members of the Rehabilitation team…
…Other concerns
30. Since concerns were first raised by MW in December 2018, right through the capability process, we continuously checked at each informal and formal meeting whether there was anything impacting on Jenny Rudston's performance at work. There was nothing of note which she ever told us about, aside from a health scare she had in June 2019.
31…. Thankfully this was nothing serious but before that was confirmed it did result in some uncertainty and anxiety which may have impacted Jenny Rudston's work. When we found out about this health scare in August 2019, we were as accommodating as we could be and changed the timescale of meetings to support Jenny Rudston.
32. …Following this being suspected and Jenny Rudston lodging an appeal, Jenny Rudston saw various professionals who made recommendations which were presented to the appeal panel.
33. …To support Jenny Rudston through this time, she was referred to Occupational Health on three occasions…One of the recommendations from Occupational Health was that she completes a stress audit in 2019…”

14. The Registrant commented upon the overall background in her written statement dated 5 March 2025. She stated that:
“…15. The Trust were aware of my background and previous work experience from my application. They were aware that I did not have any significant experience in an acute hospital role. I considered myself a pupil to their experience as senior physiotherapists…As a Band 5 it is understood that there is a lot more to learn and I had anticipated that I would develop under their guidance.
17. I was aware that my rotation would involve me spending approximately 4 months in each area and the skills required in each area of focus placed an emphasis on using a different sets of skills and understanding the risks to patients and how they differ.
18. My first rotation was in Elective Orthopaedics and my supervisor was MW, Clinical Lead Physiotherapist in Trauma and Orthopaedics, in October 2018 which was to run until 26 February 2019…I finished my elective orthopaedic rotation in February 2019, by which time I was working on the weekend rota with elective patients.
20. One of my objectives was to obtain experience working on the weekends – this meant that I was supervised less and working autonomously to be working at a weekend. I recall completing a weekend day shift and Mark, my supervisor who was also on duty told me, ‘Congratulations, you worked as a band 6 today,’ with which I was very pleased.
21. At a later date, MW agreed to act as a referee in my application for other physiotherapy posts…I got on very well with MW and found him to be very supportive.
23. I commenced rotation in Rehabilitation on 26th February 2019…I approached the team lead, MS ahead of the rotation to ask what I needed to do in preparation and I studied the areas she told me, which included Parkinson’s disease and rhabdomyolysis. She left the team one week before I started, and the new Acting Team Lead was JGs.
25. I didn’t receive an induction for this rotation nor resources to consider…I was aware that it was my responsibility to be informed and I wanted to come to the rotation with some knowledge, however there were not any resources for me to access and I felt that I had to figure it out as I went along.
27. At the outset of my rotation, I had a meeting with JGs to discuss and agree my personal objectives. Most are standard, and I added in a personal objective, that I can only best describe now as - that as I developed my practice, I wanted to be delivering this from my authentic self. I chose physiotherapy as I felt it suited me and what I could give and I wanted to develop my practise authentically…I had completed my Junior Passport document of a personal SWOT analysis of strengths, weaknesses, opportunities and threats and of my personal objectives for the Rehabilitation rotation.
29. Unfortunately, JGs didn’t agree with this personal objective I suggested and we were not able to come to any form of resolution and so all of my objectives just got left. The conversation and meeting simply came to a stop and was never revisited.
30. When working with JGs I soon came to realise that if I had questions, I didn’t feel as though there was any room for questions, and she didn’t value the questions I asked.
31. For one month before I came to St Richard’s Hospital, I had a bank Band 5 role at Southend hospital. They had asked me for longer, but I told them I was coming to work at St Richard’s hospital. They were able to teach me to treat and change the tracheotomy tube on a patient, but at St Richard’s hospital, they were not even able to guide me on their protocols for managing a mobile patient recovering from an oxygen requirement, or their approach to their physiotherapy role with medical patients.
…Capability Process
33. I had been unable to establish agreed rotational objectives with JGs. I asked LO on 3 occasions to meet with me and JGs to resolve this and although he agreed too, I heard no more about this.
34. The Capability process was triggered on 8th March 2019. I had been on the rotation 9 working days. I was told when I started on the rotation that I would be working one:to:one alongside JGs…
…42. On 19th of March, I was working with DL, band 6 physiotherapist. I was in tears and told him how I was struggling. I asked him if he could supervise me instead. He told me he was rotating off this service the next day. DL handed this information over to LO and LO told me he would be introducing the Capability Policy. He waited until JG was in place in April 2019 to commence this process.
43. I felt very uncomfortable, I felt I had not been listened to at any point; my rotational objectives had been thrown out, there had not been proper induction or resources provided and there had not been any room for discussions, questions and direction from my seniors. I had been invalidated at every step. This experience continued throughout my time working for LO.
44. LO reports that he met with me in December 2018. He did. In that meeting he told me that the aim of the meeting was to give me reassurance and confidence to be more confident in my practice. He told me, ‘we are not looking at you any more than any of the other band 5s’. Anything else he relates about that conversation with me is misrecalled.
45. LO states that this was the start of his capability process and that he told me so. This is not true. If anything, he was reassuring and supportive in the meeting, he did not tell me he was implementing this disciplinary process. Also, when LO did introduce the capability process, he referred me for occupational health assessment.
46. Before working with JG, LO pulled me aside and told me that he did not want to hear anything from me about JG. I understood this to imply that he considered that if I came to him regarding JG that I would be making complaints against her, that that would be difficult for him and that he was not willing to provide me with support or a listening ear.
47. In April 2019 LO told me that he was starting the Capability Policy, that he would put together some objectives for me which he would get to me. He told me we were in a snapshot in time and this process was so they could understand me and how to work with me. One of the objectives was risk assessment. He told me that the most important thing was that what I did was safe.
48. Before starting the capability process LO had told me it was important that my practice was safe and that it was important that I was seeing sufficient numbers of patients. From this point on I kept my own notes of how I was spending my time and how many patients I was seeing.
49. Despite reporting daily to JG and meeting with her weekly, it was not until two disciplinary Capability meetings later that I was informed that JG had provided the objectives…You are provided with documented feedback on my practice from seniors. These were always provided in writing after the event. They were never two-way conversations or advice or training given in advance of sessions.
51. The Capability decisions were given by JG. Early on in the process I was in a meeting with LO and JG. LO said to JG words to the effect of, ‘that this process was putting a burden on JG’s time and managing her priorities for the team’. JG’s response was that it was not affecting that at all. She said that she was not helping me. LO shut down this line of discussion with a look at JG.
52. At every capability meeting, JG signed off that I had achieved the risk assessment objective. However, whenever LO completed any paperwork, he always wrote that I had not.
53. When I started working with JG, she asked me to complete a Time and Motion study over a couple of days, which I did. She told me she would come back to me with ideas of how I could improve my time management. She never came back to me from that study.
54. Over time, as I increased the number of patients I was seeing, JG would disagree on my numbers. I point out an example of this on the supervision document from JG for 26th November 2019…On this date I demonstrated seeing 8 patients; JG refused to accept this and documented that I saw ‘5 or 6’. I include my personal record from 26th November where you can see that I approached 9 patients, although I have finally summarised it on that day as seeing 7.
55. I started thinking up strategies to work with colleagues to enable me to increase my numbers in the same way that fellow band 5s used but JG would not allow me to do this.
56. LO referred me to the Occupational Health department three times during the Capability process in 2019 for reports from 18th April, 23rd July and 3rd December. Each time they signed me off for work. On no occasion did LO respond to any recommendations from the Occupational Health department.
57. On 18th April 2019 Occupational Health recommended to LO that he perform a stress risk assessment to understand how my role can cause me to feel stressed. LO did not pick up on this recommendation, It was CO, his Human Resources Advisor, who recommended he should respond to this…He initially provided me the wrong form and then he stated that my results had not triggered his ‘systems’ (I think this is his computer system). He did not have the results to this stress risk assessment until February 2020.
58. I did my best to engage with both LO and JG…I appealed against the Capability process twice, heard first on 23rd September 2019 and then on 10th December 2019. At my first appeal the capability process was delayed, my second appeal was not upheld.
60. [In] [the] notes from the 10 December 2019 appeal hearing …in paragraph 38 it is recorded: Consistency of risk assessment - JG stated that JR (Jenny Rudston) had managed to achieve and maintain an acceptable level of risk assessments….
…62. Towards the end of the process, I was told by LO OweRegistrant’s Human Resources representative, CO, that I would not be eligible for Access to Work Support. I applied to Access to Work and they offered support, a support plan and a budget.
63. My final Capability Hearing was held on Tuesday 10th March 2020 where I was dismissed by SM, Interim Lead for Professions and Lead Pharmacist, from working at the Trust”.

Individual consideration of denied Particulars
15. Having detailed above the background to this matter as perceived by the parties, the Panel moved on to consider each of the denied Particulars.

16. Before doing so, the Panel took account of the advice of the Legal Assessor, which was that it should initially consider the wording of the Allegation and whether a) “effective and efficient time management of a case load”; b) “effective progression of a caseload”; c) “good clinical reasoning in patient assessments and/or treatment decisions” and d) carrying out “appropriate risk assessments” were “skills and/or knowledge expected to be possessed by a Band 5 Physiotherapist”.

17. If it found that they were, the Panel was then to go on and consider whether the Registrant had failed to demonstrate those skills and/or that knowledge during the period 8 October 2018 and 10 March 2020 when it came to consider individually the four sub-particulars a), b), c) and d).

18. The Panel therefore considered, as a preliminary issue, whether the skills and knowledge detailed in sub particulars a), b), c) and d) were skills and/or knowledge expected to be possessed by a Band 5 Physiotherapist.

19. The Panel first noted that LO and JG, both experienced physiotherapists, indicated in their evidence that they considered that these were skills and/or knowledge which were expected to be possessed by Band 5 Physiotherapists.

20. Furthermore, the HCPC expert, TE, confirmed the same in his report dated June 2024. For example, in relation to time management, TE stated that: “it is my experience that the number of patients to be seen in one day suggested by [LO] and [JG] are reasonable, and what would be expected of any Band 5 physiotherapist.” In addition, regarding clinical reasoning, he stated that “Clinical reasoning is taught from the earliest stages of undergraduate study, and competent clinical reasoning would, in my opinion, be considered the minimum standard expected by a reasonable group of physiotherapists, and is covered in Section 4 of the HCPC Standards of Proficiency…for Physiotherapists “to be able to practise as an autonomous professional exercising their own judgement” and Section 14 “to be able to draw on appropriate knowledge and skills to inform practice””. Finally, in relation to risk assessment, TE stated that: “Risk is defined in The Oxford English Dictionary as the possibility of loss, injury, or other adverse or unwelcome circumstance; a chance or situation involving such a possibility. Almost all healthcare comes with risk. Physiotherapists are expected to assess risks and balance them with potential benefits when providing care to patients.”

21. In addition, the Panel noted that the job description for a Band 5 Physiotherapist at the Hospital included working “independently and autonomously as well as working as part of a team…;” carrying out “comprehensive and appropriate assessments of patients;” developing “treatment plans”; managing “a significant clinical caseload”; and taking responsibility for their own learning.

22. Finally, the Panel noted that this was not the first Band 5 role that the Registrant had held and that she confirmed, in answer to the Legal Assessor’s questions, that she accepted in principle that the skills and/or knowledge as detailed in within Allegation 1(a) – 1(d) would be expected of a Band 5 Physiotherapist.

23. Taking into account the evidence of JG, LO, TE, the Hospital job description and the evidence of the Registrant, the Panel concluded that the skills and knowledge detailed in sub particulars a), b), c) and d) were skills and/or knowledge expected to be possessed by a Band 5 Physiotherapist.

Particular 1(a) - Found Proved
“1. Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role. In that:
a. You did not effectively and efficiently time manage your case load;”

24. The Panel first considered a preliminary issue regarding Particular 1(a) and 1(b) raised by Mr Halliwell who argued in his written submissions to the Panel:
“…4. A key issue in relation to allegations 1(a) and 1(b) is articulated in a number of authorities, namely that the Registrant should be assessed on a “fair sample” of their work in the context of competency hearings. For examples, see Calhaem v General Medical Council [2007]
4. There is no definition of what constitutes a “fair sample” of the Registrant’s work, but the panel is invited to consider that it is a body of work which can accurately be described as taking place over a substantial period of time in which the Registrant has been given a fair opportunity to demonstrate their consistent competence or otherwise. EWHC 2606 (Admin) and Vali v General Optical Council [2011] EWHC 310 (Admin).”

25. The Legal Assessor agreed with Mr Halliday’s submissions and confirmed that, when considering Particulars 1(a) and 1(b), given the wording of the allegations (which invited the Panel to decide whether the Registrant time managed or progressed her “case load” and referred to her demonstrating such skills and knowledge, which were issues connected with competence) the Panel should first decide whether a fair sample of the Registrant’s work had been considered.

26. Mr Bellis cautioned the Panel that it should not stray into considerations more associated with the next stages (Grounds and Impairment). The Legal Assessor agreed but confirmed that making a decision about whether a fair sample of the Registrant’s work had been considered would not amount to deciding the next stage.

27. The Panel decided to accept the advice of the Legal Assessor on the basis that it would confine its decision simply to the issue of whether a fair sample of the Registrant’s work had been considered.

28. The Panel noted that the Registrant was employed from October 2018 to March 2020 at the hospital, a period of some 17 months. It took into account that JG had kept a record of review sessions in relation to the Registrant’s work from April 2019 to January 2020, which included details of the number of patients seen by the Registrant. This period of time amounted to at least eight months. In addition, the Registrant had kept details of the number of patients she had seen from August 2019 to December 2019, a period of five months.

29. The Panel considered that the records of both JG and the Registrant covered a significant period of time when compared with the number of months she was employed at the Hospital and therefore it concluded that a fair sample of the Registrant’s work in relation to time management had been presented to it.

30. The Panel therefore went on to consider the evidence regarding this Particular. Once again, the Panel took account of the evidence of LO, since the concerns about the Registrant were ultimately and regularly reported to him and therefore have been summarised by him. In his written statement referred to above, in relation to time management, LO said:
“Failure to effectively and efficiently time manage and progress case load
12. Time managing a case load and progressing a case load could be seen as separate issues, but in the case of Jenny Rudston they became one and the same thing.
13. When a new Physiotherapist joins the team, we would not expect them to manage a ward of 27 patients on their own from day one. However, we do expect that, once an individual has settled into their role, over time they will achieve a certain level of clinical activity in terms of patients per day. For context, on a ward we usually. have around 27 patients and, to attend to those patients, there would ordinarily be [one] Physiotherapist and one support worker on the ward. We would usually expect of those 27 patients, a majority will require active treatment from a Physiotherapist at any one time and these patients would be split between the Physiotherapy team working on the ward that day; Therefore, once a Band 5 Physiotherapist like Jenny Rudston has settled in, there would be an expectation that they would see about 8-10 patients a day. Of course this number fluctuates for various reasons, dependent on patient acuity and dependency, but this is, on average, what is expected.
14. Jenny Rudston would have been aware this was the standard we expect as she had spent much of her time on the wards. It is also something she would have spoken about with her supervisor. You expect those working in a team to absorb that we are working as a team and patient care was a shared responsibility. ln addìtion, when you go to a ward to commence your shift, there is always a handover of all the patients on the ward which allows you to prioritise your caseload. Jenny Rudston would have been informed of the patients referred for or undergoing Physiotherapy treatment so she was aware of the number of patients who required her attention. Furthermore, following our initial concerns, once we had moved to .the formal capability process, this was noted as an area for improvement. ln addition, JG, as her team leader, sat down with Jenny Rudston to note the standards we expected of her when it came to time and caseload management...
15. One concern with Jenny Rudston was that she would often spend an entire morning session attending to one patient and therefore, at the end of the day she would have only seen around 2 or 3 patients. When attending to patients, we expect our Physiotherapists to review the patient notes, get up to speed with what has happened, check a patient's observations to ensure they were well and ready for treatment, make a plan, see the patient and then write up the notes. We expect this to take between 30 minutes and an hour on average for each patient however this would often take Jenny Rudston all morning. Our concern was not only that it would take Jenny Rudston an entire morning to attend to a patient, but she also did not seem to understand that this was a problem or acknowledge that to spend 3 hours with a patient when you have a ward of 27 patients is not efficient. I believe Jenny Rudston was spoken to about this by JG in supervisions sessions on 1 May 2019, 31 May 2019, 14 June 2019 and 19 July 2019,..
16. The result of this poor time management was that other members of the team had to step in to cover those patients Jenny Rudston had failed to see that day. What should have been her workload was falling on to other members of staff. If her colleagues had not stepped in to see those patients, then they would not have been seen that day and therefore their treatment would not have progressed.
17. These issues reoccurred throughout Jenny Ruston's employment and aligned with the initial concerns first raised by MW. Jenny Rudston was spoken to about this throughout the capability process and following each review meeting it was an area of performance to be worked on and noted in her lndividual Performance Plan…effective time management was consistently noted as a target she was unable to achieve.”

31. More specific details were provided by JG. In her written statement dated 30 September 2021, JG stated that: the Registrant’s responsibilities for her patients included taking handover notes for those patients at the start of each day and prioritising patients who needed to be seen in what were called “meaningful” treatment sessions. These were sessions which not only improved a patient’s function but also involved liaising with the Multi-Disciplinary Team (MDT) and planning a patient's discharge or onward referral to a rehabilitation unit. The concerns with the Registrant’s time management centred around the number of patients that she was able to see in a day. It was expected that clinicians could see around 8 patients per day on average and during that time conduct meaningful treatment. However, the Registrant would usually only manage to see one or two patients in the morning and then a further one or two in an afternoon, despite the fact that her caseload was no more complex than any other clinician.

32. JG went on to say that: the Registrant would often get sidetracked because she looked at details of a case which were not necessary or appropriate at that moment in time, rather than looking at the current patient needs and prioritising what needed to be done. JG gave an example that, on one occasion, the Registrant spent a significant amount of time looking at a patient's chest X-ray (when she could have read the radiographer’s report which was provided with the X-ray) and working out if the patient had type 2 diabetes (which was not relevant to the session she was trying to have with the patient). JG confirmed that she discussed this issue during supervision sessions with the Registrant on 8 May 2019 and 31 May 2019. On 8 May 2019, JG spoke to the Registrant about the fact that, by 11:00am on a particular day, she had yet to see any patients which the Registrant “gave no adequate reasoning for.”

33. JG concluded by saying that these were not isolated incidents as the Registrant often struggled to balance being thorough with ensuring that she was being efficient with her time. She “often spoke” to the Registrant in their supervision sessions about this.

34. The Panel noted the expert evidence of TE on the issue of time management. He confirmed in his written report dated June 2024 that:
“TIME MANAGEMENT
4.1 LO states that the expectation of a Band 5 physiotherapist working on the ward on which the Registrant was working was that they would be able have a meaningful engagement with 8 – 10 patients a day. This would allow for the time taken for handover at the start of the day, planning to prioritise the caseload, and for writing up notes after each treatment.
4.2 LO states that the Registrant would, at times, only see 2- 3 patients in a day, sometimes spending a whole morning seeing one patient.
4.3 JG similarly states that there was an expectation that a Band 5 physiotherapist should see an average of 8 patients per day, and that the Registrant usually only managed to see 1 – 2 patients in the morning, and a similar number in the afternoon. JG notes that there was no clear reason for this as the Registrant’s caseload wad no more complex than any other clinician.
4.4 The diary excerpts in Appendix H appear to show that the Registrant had, on some days, 8 – 9 patients to be seen. However, the days presented are not sequential, nor is it clear how many meaningful interactions resulted, and it is therefore not possible to make comment beyond noting their presence.
4.5 If the statements of LO and JG are correct, and it is clear from supervision records at Exhibit 1, Appendix 8, and Exhibits 16 and 17 that time management was a significant issue, it is my opinion that the Registrant’s time management fell below, but not far below, the standard expected of a reasonably competent Physiotherapist. It is my experience that the number of patients to be seen in one day suggested by LO and JG are reasonable, and what would be expected of any Band 5 physiotherapist. I cannot find any evidence of factors that would significantly change the number of patients the Registrant was able to see.”

35. In her written statement dated 5 March 2025, the Registrant responded that:
“90. When I started on the rotation the team was requiring help from other teams to cover the caseload. This resolved after approximately one to two weeks…JGs and I had cases to see from the Team’s caseload, according to priority. It was not a situation of taking on a patient and following their episode through.
92. JG, when she took over, continued the prioritisation and reporting system. She would work from a list at the end of the day before and with an update after morning handover. She would have four or five patient slots to allocate to each staff member for the morning and again for the afternoon.
93. It was not a case that I missed any patients. If I could not get to something I could ask the team… JG assessed my caseload coverage for the capability process according to how many ‘effective treatment sessions’ I delivered. This meant that if I was allocated four patients, but one was not available or refused, they were not counted in my caseload coverage…JG comments that I needed to be completing meaningful treatment sessions in her supervision records…
96. As my skills improved, I was able to go see other patients for colleagues to increase my numbers, but JG would not agree these numbers… Therefore, I stopped doing this. I was also extremely careful about reviewing all of the patient’s paperwork, tests and handovers before considering a session with a patient as I had been instructed to do by JGs...Not all patients were successful in treatment sessions, but my work was still beneficial
to the patient..
98. I would argue that the caseload responsibility was to cover the ward or wards that the staff member is allocated, ensure that patients were appropriately assessed and treated, walking aids prescribed as appropriate and the patient referred on as appropriate, such that there were no discharge delays and patient and staff safety were maintained, for patient care, transfers and mobility…It was more important to patient care that this was adhered to than that eight therapy sessions were completed and I would be criticised if JG did not think a session had an effective outcome.
100. Alternatively, when I took a male patient with Parkinson’s Disease to the gym for an hour, which was a key turning point in his treatment to restore his ability to be able to roll, in order to get out of bed with his carer and enable him to return home, this is documented in JG’s notes for 6th December as ‘took a patient to the gym for an hour’…
101. A ward would have about 27 beds for example, split between three bays and four to six side rooms. Not all of the patients would be appropriate for or require physiotherapy. We assessed, treated and discharged patients. We did not continue working with them and monitoring them after discharge if they were still on the ward. However, we could accept a rereferral if the ward considered they needed referring back to physiotherapy.
102. Thus, I had responsibility for overall awareness of my ward and for seeing the patients I was allocated each morning and each afternoon by JG, this was usually three or four in each session…
108. At the time I was not aware that they had many problems within that section and were undergoing many changes within it. I was later told by my colleague and my Trade Union Representative that people were refusing to work in this section. I later understood that this is why JGs was brought in to restructure the department…I was on the Rehab rotation for approximately a couple of months and then JGs went on maternity leave in approximately the April 2019.
111. Both JGs, then later JG, were responsible for the whole of the caseload of the team…JGs and JG worked very differently. JGs could come in on a morning, absorb all of the information given to her and make decisions on it. She was very quick, sharp and “on it”…In comparison, I found that JG needed more time and wanted to receive information before to plan ahead. She didn’t seem to seem see the point of teaching. Though I appreciate we have to be current and time focused…JGs would tell me to check scans, observations and what else was going on with a patient, however JG would tell me that we didn’t have time to do that.
115. Another example is that when working with JGs, I went where I was needed that working day. I looked to JGs to learn as to what my role and responsibilities were…With JG – I had the responsibility for an actual ward and I had more consistency in working on a patient’s case. JG appeared more willing to allow me more responsibility and she allocated me with a physiotherapy technician to work with...
118. JG later told me it was not about the numbers, but the meaningfulness, and that what I was doing was not meaningful enough…If I allocated my time to an allocated patient, but then they declined or were not available, my time and work was discounted and that patient was not included in my numbers. However, before I went to see that patient, I had to spend time reading that patient’s notes and researching them first.
120. If I had a good day where I was able to treat more patients, JG would give me a reason to discount my numbers. For example, I recall on one occasion returning from sick leave, I had a productive day and my numbers were really good. However, Jennifer’s response to me was that they didn’t count as I had just returned from sick leave…I cannot explain why, but I found that it was not possible for JG to move out of this mindset…
122. I did pay attention to every patient on my caseload, prioritise my caseload, assess and treat them and if I needed assistance that was communicated within the team for help if needed…I discussed each patient within the multidisciplinary team, prescribed the appropriate walking aids and sent onward referrals as relevant…
139. In paragraph 12, JG explains what is a meaningful treatment session. She comments that ‘this would also to be liaising with the multidisciplinary team and planning a patient’s discharge or forward referral onto a rehabilitation hospital where they would have ongoing therapy. However, it was my experience that this part of the role was not included in her assessments of my time management as this did not meet her criterion of ‘a meaningful treatment session’.
140. JG reports that ‘to assist Jenny Rudston, I attempted to keep her working towards a set of objectives each week and an Individual Performance Plan which were set at various stages of the capability process and reviewed weekly’…What JG means is she assessed me against her criteria each week. We did have meetings to review my understanding of the patients on my ward and she assessed me against her criteria. She refused to allow me to discuss the objectives on the Individual Performance Plan and how I could progress my performance…If possible, we would meet weekly for me to discuss my caseload. Initially I created a proforma to discuss this against but my detailed capability objectives did not translate to the ward overview.
143. Eventually, in one of these meetings, JG commented that my handover discussion was fine and we were not gaining from it. I immediately asked her if we could change the supervision session to something more beneficial and her response was, ‘Absolutely not’. She thought better of documenting this in the supervision document, where she wrote that she would ‘think about it’…I then asked LO if in this situation we should change the role of our supervision session and he agreed that we should. This was not something that was changed.”

36. In her oral evidence, the Registrant reiterated that, before JG arrived at the ward, LO had told her that it was important that she practised safely. She thought that the physiotherapy team was not fully staffed and therefore it struggled to cover the patients that needed to be seen. The Registrant said that she did not want to let the team down and, although numbers were important, she felt that she had to “get it right”.

37. When asked for her perspective about what entailed “seeing” a patient, the Registrant said that this applied if she had spoken to a patient, spent time with, or had done something with them. She also indicated that a point was reached where she was able to see more patients, but some refused to be seen. She also offered to help colleagues if she had finished seeing her allocated patients, even if the patients were on other wards. JG, however, did not count patients who refused nor patients that the Registrant had seen on other wards. The Registrant explained that, even if a patient had refused to be seen, she did not want to attempt to see a patient without looking at their notes, which took time, as she could not treat a patient if she did not know about them.

38. The Registrant referred to her diary records which detailed the Registrant’s account of what the Registrant had done. However, JG only recorded what JG considered had been completed. JG was not happy with how the Registrant had documented her time and they did not agree. Moreover, JG did not approve of the Registrant talking to doctors to obtain clarity about what patients needed.

39. In cross examination, the Registrant stated that 8 to 10 patients a day was achievable but it depended on the complexity of the patients and whether to count occasions when the Registrant spoke to patients, but which did not result in treatment. The Registrant maintained that the job was not about ticking boxes. The Registrant considered that she was certainly involved with 8 patients a day but she did not necessarily treat 8 patients a day. Sometimes she simply needed to find out about patients and feed this information back to the MDT.

40. In relation to reading X-rays, the Registrant indicated that JGs was very keen on thoroughness and encouraged the Registrant to read X-rays and reports if she thought that it needed to be done. The Registrant maintained that she would not read X-rays all day and emphasised that she was always doing something on the ward and did not go off somewhere. She also confirmed that finding out about a patient's medical condition enabled her to make clinical decisions as to whether a treatment was likely to be successful. She described a situation in March 2019 whereby she made a mistake with a patient because she only read the physiotherapy notes and not the patient notes as well. JGs had emphasised that the Registrant was to read everything. JG's approach was different and JG was more into managing time.

Decision
41. Having found (as outlined above) that effective and efficient time management was a skill and/or knowledge expected to be possessed by a Band 5 Physiotherapist, the Panel went on to consider whether the Registrant had “effectively and efficiently” managed her case load during the period 8 October 2018 and 10 March 2020. It noted Mr Bellis’ confirmation that the HCPC put its case as meaning that the Registrant did not “consistently” time manage her case load “effectively and efficiently”.

42. The Panel accepted the evidence of LO, JG and TE that it was reasonable that a Band 5 Physiotherapist would conduct meaningful treatments with 8 patients a day. Indeed, the Panel noted that the Registrant accepted that this was achievable, depending upon the complexity of the treatment needed. Moreover, the Panel also took into account the stipulation in the Registrant’s performance improvement plans dated 29 April 2019, 25 June 2019 and 22 October 2019 which stated that the Registrant had "to carry out 8 appropriate and meaningful treatment sessions a day (average)”.

43. The Panel noted the discrepancies between the number of patients recorded by JG and those recorded by the Registrant in their separate diaries. The Panel noted that the Registrant had stated that she had not been able to check JG’s records for accuracy and therefore the Panel assessed the position by reference to the Registrant’s figures of patients seen rather than JG’s figures.

44. JG told the Panel that she did not count occasions when a patient refused to see the Registrant. The Panel accepted that if a patient refused then this is unlikely to take up the anticipated 30 to 60 minutes. However, the Panel accepted that the Registrant would have to spend some time in establishing that the patient had refused. The Panel therefore counted ‘refusals’ within its calculations.

45. Using the Registrant’s figures, the Panel counted 56 entries/working days between 30 August 2019 and 13 December 2019. Of those 56 entries, the Panel noted that, including refusals, the Registrant achieved the target figure of 8 patients a day on 4 October, 7, 8, 11, 19 and 21 November, and 9, 11 and 13 December 2019, total of 9 days. In percentage terms, this meant that the Registrant had achieved her required rate of 8 patients a day on 16% of her working days. The Panel considered that this was significantly low. Accordingly, based upon the Registrant’s records of the number of patients seen, the Panel was led to the conclusion that she had not effectively and efficiently time managed her caseload.

46. Accordingly, the Panel found Particular 1(a) proved.

Particular 1(b) - Found Not Proved
“1. Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role in that…
b. You did not effectively progress your case load;”

47. The Panel first considered the preliminary issue regarding Particular 1(a) and 1(b) raised by Mr Halliwell and commented upon by the Legal Assessor, namely that the Panel should first decide whether a fair sample of the Registrant’s work has been considered.

48. The Panel therefore went on to consider the evidence regarding this Particular. It once again noted the evidence of LO regarding what he described as the linked issues of effective time management and case progression, as set out above.
49. In addition, the Panel noted the evidence of JG. In her written statement dated 8 March 2024, she stated that: failing to progress a caseload makes discharge planning “really difficult” if treatments put in place for a patient were constantly changing. JG indicated that: when planning to discharge a patient, a physiotherapist was required to assess if they were ready for discharge with or without carers; and if they required further therapy, whether that could be provided by an inpatient rehabilitation bed or a care home. If a caseload was not progressed, then discharge becomes difficult to plan for.

50. JG stated that the concerns with the Registrant failing to progress her caseload continued throughout 2019. She gave one example in relation to Patient F whose treatment notes indicated that, during an appointment, the Registrant was unable to make a decision and therefore progress treatment and instead was reliant upon the Occupational Therapist to make a decision. It was also unclear from the notes what the patient’s problems were or how they could be addressed.

51. The Panel noted the expert evidence of TE on the issue of caseload progression. He confirmed in his written report dated June 2024 that:
“5.0 CASE PROGRESSION
5.1 It is my opinion that insufficient evidence has been provided to form a fair opinion on the Registrant’s case progression. Clinical notes covering the duration of a patient’s treatment are required in order to see how treatment was progressed, and the documents provided do not contain this detail.”

Decision
52. The Panel first considered whether a fair sample of the Registrant’s work had been considered. It reminded itself that the Registrant had worked at the Hospital for 17 months. However, the only evidence produced by the HCPC in relation to the Registrant’s progression of cases was a reference to one patient. No patient notes had been produced for this or any other patient which covered the full period of time that such patients were treated by the Registrant which would have allowed the Panel to track what treatments the Registrant had carried out or whether the Registrant had effectively progressed her case load. Indeed, the reference to “case load” in the wording of the allegation indicated that more than one case was intended to be considered; however, the Panel had only been provided with a snapshot of one patient, which the Panel considered was insufficient. The Panel was satisfied that this was not a fair sample of the Registrant’s work and noted that TE shared the Panel's concerns.

53. Accordingly, the Panel found this particular not proved.

Particular 1(c)
1. Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role in that…
c. You did not demonstrate good clinical reasoning in patient assessments and/or treatment decisions for the patients listed in Schedule A.

54. Having found (as outlined above) that good clinical reasoning in patient assessments and/or treatment decisions was a skill and/or knowledge expected to be possessed by a Band 5 Physiotherapist, the Panel went on to consider whether the Registrant had demonstrated such “good clinical reasoning” in respect of each of the Patients C, D and E.

55. By way of overall background, the Panel took into account the evidence of the HCPC witnesses, LO, JG and TE.

56. In his written statement, LO said:
“…Failure to demonstrate good clinical reasoning
18. When initially assessing a patient as a Physiotherapist, you would first read their documentation to establish why they had been admitted into hospital, what other health professionals including doctors had. established in their diagnosis and what medication they are currently taking. Following this initial review, you would then go and talk to the patient to discuss the problems they are experiencing from their perspective and find out about their home situation to enable you to gain further background. Following this, you would then conduct an objective assessment. An objective assessment will vary, depending on what issues the patient is presenting with. For example, if a patient was experiencing issues with muscle strength and walking, you may assess them on the bed initially and then perhaps move them to sit up over the edge of the bed and even request they stand, if it was appropriate, to further assess their balance, stability or mobility. Following your objective assessment, you would then write up your findings, creating a list of problems, developing a treatment plan to address these problems and setting some goals. Clinical reasoning.is partly how you move from the list of problems a patient presents with to achieving the intended goal.
19. It is imperative to demonstrating good clinical reasoning that a Physiotherapist build on the findings of the assessment they have undertaken with the patient to establish the exact problems the patient is experiencing, and identify what to do going forward and develop a treatment plan.
20. Jenny Rudston struggled to demonstrate good clinical reasoning by failing to combine the elements above and put together a suitable treatment plan. Understandably, there might be. situations with a complex patient that require further assistance from a Senior Physiotherapist, however, often Jenny Rudston would not be demonstrating good clinical reasoning for patients with relatively straightforward problems.
21. A further example of Jenny Rudston failing to demonstrate good clinical reasoning is that if she was treating a patient, she would not adapt the treatment plan if the patient, for example, started showing signs of improvement. It was almost as if whenever she went to see a patient there was no link between what she was doing that day and the day before. I recall often once Jenny Rudston had arrived at a treatment plan there was no deviating from it, even if a patient was demonstrating a functional improvement which required an adjustment of approach.
22. As is evidenced in the lndividual Performance lmprovement Plan…demonstrating good clinical reasoning was a constant objective for Jenny Rudston and JG had spent time with her going over the standard expected to demonstrate improved clinical reasoning.
23. JG was directly supervising Jenny Rudston so could speak to specific examples on the ward where Jenny Rudston was failing to demonstrate clinical reasoning.”

57. In addition, the Panel noted the evidence of JG. In her written statement dated 8 March 2024, she stated that, overall: good clinical reasoning was the ability to accurately identify problem lists for a patient and come up with appropriate goals for that patient to achieve. This could involve needing to liaise with the MDT regarding problems outside of physiotherapy or engaging with Occupational Therapists regarding equipment.

58. The Panel noted the expert evidence of TE on the issue of clinical reasoning. He confirmed in his written report dated June 2024 that:
“2.0 CLINICAL REASONING
2.1 Clinical reasoning is the process by which a therapist, having collected all the relevant data regarding a patient, formulates a plan for the patient’s treatment which optimises the outcome for the patient without compromising their wellbeing and safety.
2.2 A therapist gathers information from a variety of sources: from a subjective and an objective examination of the patient; from the patient’s medical history based on the available clinical notes, and from feedback from members of the multidisciplinary team managing the patient, from the patient’s family, and from the patient’s carers.
2.3 Having gathered the information the therapist can then formulate a treatment plan with a specific set of desired outcomes. The treatment plan is based on the patient’s current physical and medical limitations, their previous level of function, and the level of function required for the patient to be progressed to the next level of care (e.g. from an acute ward to a rehabilitation ward, or discharge from hospital into care or to the patient’s home).
2.4 An initial plan is a hypothesis based on known facts and observation. A patient’s condition can change on a daily or hourly basis, so further clinical reasoning is required at the start of every session, based on the same data as the initial assessment, and particularly the handover (HO) meeting at the star of the day, in order to decide whether a patient can be safely treated in line with the progression expected, or whether changes need to be made.
2.5 Evidence of clinical reasoning should be found in the therapist’s clinical notes, which should contain detail of the patient’s current condition, including their current medication and other interventions such as oxygen; the patient’s previous level of function immediately prior to the current episode; an objective assessment of the patient’s ability at the time of examination, and any relevant past medical history. Any changes in any of the recorded parameters should be noted in each daily entry into the clinical notes. I do not have any clinical notes available to me in the preparation of this report, and I therefore base my comments on the statements provided…

Particular 1(c) in relation to Patient C - Found Not Proved
59. The Panel noted the witness statement of JG which referred to an Initial Assessment Pro Forma which the Registrant had completed on 29 May 2019 in respect to Patient C. JG stated that Patient C was a patient on long term oxygen because they had a chronic respiratory disease (COPD) which meant that the aim of the physiotherapists was to reduce their target saturations from greater than 95% of oxygen in blood (the normal level of saturation in blood) to between 88-92%. Her criticism of the Registrant was that she had recorded in the assessment form that the patient had a long-term home oxygen prescription of 2.5 litres which they would ‘wear’ for the majority of the day. However, the Registrant had also recorded in the notes that, at the Hospital, the patient was both on “room air” (i.e. no supplementary oxygen) but was at the same time on one litre of oxygen and that, on arrival at the patient's bedside, he was on 0.5 litres of oxygen. This demonstrated to JG that the Registrant did not have a good level of understanding around oxygen delivery and should have clearly documented what oxygen they were on and what their saturations were.

60. In his report TE stated:
“2.11 Patient C (Exhibit 9)
On an initial assessment pro forma dated 29.05.19 the Registrant has recorded a number of different figures relating to the provision of supplemental oxygen. JG contends that the recording of these figures indicates a lack of understanding of the use for supplemental oxygen. Without a supporting rationale from the Registrant it is not possible to opine as to whether there was a lack of understanding or competence in this case.”

61. In her witness statement, the Registrant responded:
“265. I have made a mistake in documentation of the patient’s NEWS score because I have written it was taken on room air, but not struck it out when I realised the patient had been on one litre of oxygen…This information is taken from the nurses’ NEWS scores.
267. When I went to see the patient, he was on a different dose of 0.5 litres of oxygen. I am saddened and sorry for this mistake and I will make sure not to make this error again.
…The clinical picture, as I understood at the time;
269. This patient had an exacerbation of Chronic Obstructive Pulmonary Disease and a fall where he had collapsed to the floor. It was queried that he may have a pleural effusion on his x-ray, which would also impact his breathing and oxygenation…He was dependant on home oxygen and had a prescription of 2.5 litres…He was moderately frail and had a background of heart failure and a previous heart attack…He was a retired brick layer and had reduced vision and hearing but did not use his glasses or hearing aids. He lived with his wife in a static caravan.
273. On the ward his oxygen prescription had been titrated down from 1 litre on the previous ward NEWS score to 0.5 litres when I saw him with JG. His oxygen saturation reading had been 95% which was too high (hyperoxaemic) for his 88-92% saturation target…For a patient with chronic obstructive pulmonary disease who retains carbon dioxide, it is dangerous to oversaturate the patient’s oxygen level as this can stop the patient’s hypoxic drive to breathe when experiencing low oxygen levels.”

62. Having been provided a copy of the Registrant’s bundle, which contained her comments upon Patient C above, TE produced an Addendum to his report, dated 13 March 2025. In relation to Patient C, TE stated:
“Patient C The Registrant confirms her errors in record keeping. It is my opinion that the Registrant’s statement regarding Patient C does not demonstrate an awareness of her responsibility to ensure that she knew exactly how to proceed before doing so.”

63. However, in his oral evidence, TE stated that any clinician should be 100% aware that what they are noting down is factually accurate. Such a failure of record keeping would be below the standards expected of a Band 5 Physiotherapist but TE went on to say that it did not appear that the patient was put at risk. Moreover, he stated that a typographical error did not amount to a lack of clinical reasoning and, in cross examination, TE agreed that an incorrect note about oxygen did not necessarily mean that the Registrant did not have an understanding of such issues.

64. In her oral evidence, the Registrant reiterated that she had correctly recorded that, at home, the patient was on long term oxygen 2.5 litres as per his prescription. She maintained that she had correctly copied from the nurse’s observation chart that the patient had a NEWS score of 4 and was self-ventilating on room air but had also copied that he was on one litre of oxygen (“4: SV on RA 1L O2”). She then confirmed that when they saw the patient, he was lying in bed and was self-ventilating on 0.5 litres of oxygen via a nasal cannula and that his saturation level was 90%, which was within the safe range of 88 to 92%. She maintained that she had simply made an error in copying exactly what the nurses had recorded regarding his NEWS score and had not realised at the time that it was contradictory. She had essentially made a documentation error.

Decision
65. The Panel considered whether the Registrant had demonstrated “good clinical reasoning” in respect of Patient C. It noted that the Registrant maintained that she had made an error in not noticing the anomaly in the nurse’s observations but had just copied down exactly what had been recorded. The Panel saw no reason not to accept the Registrant’s evidence on this point. Moreover, the Panel considered that, by itself, this did not demonstrate poor clinical reasoning by the Registrant since the only documentation provided to the Panel was the first page of an initial assessment form. No other documentation has been produced by the HCPC to indicate what the Registrant then did to treat the patient nor is there anything on the form which indicated what treatment the Registrant intended to provide to Patient C. Consequently, the Panel concluded that the HCPC had not discharged the burden of proof upon it.

66. Accordingly, the Panel found this particular not proved.

Particular 1(c) in relation to Patient D - Found Not Proved
67. The Panel noted that JG made no mention of Patient D in her written statement dated 8 March 2024.

68. However, the Panel noted the expert evidence of TE regarding Patient D. He confirmed in his written report dated June 2024 that:
“Patient D (Exhibit 18)
Supervision notes dated 26.06.19 detail the Registrant demonstrating a lack of knowledge regarding the rationale for using a collar and cuff (C+C) in the management of a fractured (#) humerus. [It is my opinion that this illustrates a gap in the Registrant’s knowledge below, but not far below, the standard expected of a reasonably competent physiotherapist. There is no evidence presented to suggest that this lack of knowledge resulted in any action on the part of the Registrant.]”

69. The Panel noted that it has not been provided with the supervision notes dated 26 June 2019 upon which TE relies (the relevant part of those notes has been redacted). It has only been provided with a copy of both pages of the initial assessment form dated 26 June 2019 upon which neither JG nor TE comment.

70. In her written statement the Registrant responded as follows:
“The clinical picture, as I understood at the time [was that] [this] patient had fallen and broken the humerus bone in her right arm. She had fallen visiting the toilet in the night and not called for help. She was frail and elderly and had a poor appetite and nutritional intake. During this episode she had had hospital acquired pneumonia and norovirus and was found to carry Clostridium difficile bacteria but not to be ill with it. She had a background of osteoporosis and a large hiatus hernia. She lived in a nursing home and was assisted with her personal activities of daily living, such as washing and dressing. She walked with a zimmer frame until she broke her arm.
[Relevant facts which I knew at the time and are relevant to the assessment of clinical decision or risk assessment were that] the patient was transferring well from bed to chair to commode with assistance from a healthcare assistant and using a wheeled zimmer frame to assist balance. This was a level of assistance that could be managed at the nursing home whilst the patient’s arm healed and a member of the nursing home staff was due to come in and assess the patient. I did not have access to the advice leaflet for fractured humerus and I was unsure whether elbow flexion and extension were advisable at this stage as it would affect the muscles of the upper arm.
[I address, where appropriate, the rationale and reasoning behind the clinical decisions I made for the patient as follows]: My role was to teach the patient exercises to reduce the development of stiffness in her right arm and hand and neck whilst her arm was healing…
…[In] Paragraph 26, JG reports that I repeatedly put pillows under the arms of patients who had a fractured humerus and that she repeatedly told me not to do so. The issue with this statement is that this never happened. I never did put any pillow under the fractured arm of any patient with a fractured humerus at St Richard’s Hospital. JG reported one case at a capability meeting of a patient with a fractured humerus. I had no idea where this accusation came from. I assume she found such a patient on the ward with a pillow under the arm. This was some time after the occurrence and it had not been reported to me. I had not done it nor had I seen it. As JG found it, was concerned about it and had not reported it to me, it was her responsibility to investigate her finding and ensure it did not happen again. I assure you again, I never did put any of these patient’s fractured arms on a pillow.
Every time I saw such a patient, I advised them not to put it on a pillow because the arm needed to hang as part of the healing process (to keep the bone in alignment and prevent the rotator cuff muscles pulling the bone out of alignment). I told the nurses this, I wrote it on the board behind the patient. I wrote it in the patient’s notes and I wrote it on the daily nursing handover on the computer. I do know I found the ward sister one time advising her healthcare assistant to do so and I advised her against it. Also, that I noticed the request on the nursing handover disappeared once or twice. I do not recall any pertinent conversations with JG regarding pillows under patients’ arms.”

71. Having been provided a copy of the Registrant’s bundle, which contained her comments upon Patient D above, TE produced an Addendum to his report, dated 13 March 2025. In relation to Patient D, TE stated:
“Patient D
My opinion remains unchanged. The Registrant states that she had to ask a colleague whether active elbow flexion and extension (bend and straighten) exercises would be appropriate for a frail elderly patient with a fractured humerus demonstrates a lack of clinical knowledge and a lack of clinical reasoning because such movements have the potential to move the fracture and to prevent or to slow the healing process.”

72. In his oral evidence, when asked whether he had any concerns about the Registrant asking a senior colleague whether she could have the patient flex a broken elbow, TE stated that “in her defence she checked and did the right thing and took no action”. In cross examination he confirmed that the Registrant had demonstrated that she had a gap in her knowledge, but she had not tried to do anything but had asked for advice.

73. In her oral evidence, the Registrant was asked whether at the time, she knew that she should not ask a patient to flex a broken elbow and she replied that she did not flex the elbow but came away and asked a colleague if she should do it. She asked because she could not remember what was said about the subject in the leaflet of exercises that she would normally consult. The Registrant commented upon the pro forma assessment form which she had completed and confirmed that this recorded that she had only asked the patient to flex his fingers and form a fist with his hand.

Decision
74. The Panel noted that it had not been provided with all the relevant documentation. TE had based his report on a supervision record that the Panel had not been given. JG had not commented in her witness statement about Patient D and therefore there was no primary evidence before the Panel. It was therefore unclear what the HCPC was alleging. The only document that had been given to the Panel was the pro forma assessment form dated 26 June 2019 which included a second page that detailed a risk and functional assessment, an analysis and a treatment plan. However, the Panel had not been presented with any evidence that this form contained errors in clinical reasoning. The Panel therefore concluded that the HCPC had failed to discharge the burden of proof upon it.

75. Accordingly, the Panel found this particular not proved.

Particular 1(c) in relation to Patient E - Found Proved
76. The Panel noted the evidence of JG, as set out in her written statement dated 8 March 2024, in which she stated, in relation to Patient E, that she was a woman who lived in a house with two handrails to assist her on the stairs. From the notes it seemed that Patient E was independently mobile on the wards and the Registrant taught her some chair exercises. JG considered that the notes should have reflected any muscle weakness that the patient had, so as to justify the exercises that she had been given. The Registrant’s clinical reasoning for the chair exercises was unclear. The patient could possibly have been assessed for higher functioning tasks such as balance.

77. JG also noted that the Registrant decided to conduct a stairs assessment by taking Patient E to stairs with only one handrail, instead of stairs with a second handrail similar to the one the patient had at home. The Registrant had given Patient E handhold support to mimic that second hand rail. On the way down, Patient E “fatigued” on the last two steps, her heart rate became very high and she needed to be wheeled back to bed. Following this, JG considered that the Registrant showed poor clinical reasoning by discharging the patient despite the issues the patient had had on the stairs. The patient notes record that the patient “does not feel ready to go home” but JG comments that these anxieties were not addressed by the Registrant. During this session on 18 July 2019, the Registrant had been supervised by a Band 6 Physiotherapist, AC. AC had suggested that a commode be provided but the patient was not referred to Occupational Therapy by the Registrant.

78. The Panel noted the expert evidence of TE regarding Patient E. He confirmed in his written report dated June 2024 that:
“Patient E (Exhibit 11)
On a MSK Assessment pro forma dated 18.07.19 the Registrant records a session assessing functional activities including climbing stairs. She notes good lower limb strength and the ability to climb one flight after which the patient was fatigued and needed a standing rest before descending. She then notes that Patient E was fatigued on the last 2 steps but that she was able to complete the task safely and then to sit in a wheelchair to return to her bedside. In conclusion the Registrant notes that Patient E was at “baseline” and was ready for discharge.
It appears that this session was a supervised session with AC (Exhibit 1, Appendix 8). The supervision record questions the Registrant’s decision to use a full flight of stairs with only one handrail for assessment rather than a small flight of training stairs with two handrails which is what the patient had at home. The supervision record also suggests that the Registrant failed to notice Patient E’s discomfort on descent. JG contends that the Registrant showed poor clinical reasoning by discharging Patient E despite the issues she had on the stairs, and that she failed to refer the patient to Occupational Therapy for provision of a commode prior to discharge.
It is my opinion that there is no evidence presented that there was a clinical reason why Patient E could not undertake an assessment on stairs. It is likely that there would have been less risk on a smaller set of stairs in a rehabilitation department, and this will be addressed in Section 3 of this report.
It is my opinion that the decision to discharge a patient is a multidisciplinary decision to which the physiotherapist contributes. The assessment carried out by the Registrant was whether Patient E was safe climbing and descending stairs, and, beyond a level of fatigue, clinical notes and the supervision report suggest that she was. It appears that, if a commode was provided, Patient E was unlikely to have to climb and then immediately descend stairs at home, and it was therefore reasonable to say that she was safe to climb stairs.
Section 9 of the HCPC Standards of Proficiency (pre-Sept 2023) for Physiotherapists “to be able to work appropriately with others” outlines the need to work as part of a team. It is my opinion that if the Registrant failed to notify Occupational Therapy colleagues of Patient E’s requirement for a commode at home in order to make her discharge from hospital safe this would represent a failure to meet Standard 9.1 and Standard 9.4, and would fall below, but not far below, the standard expected of a reasonably competent Physiotherapist.”

79. In her written statement the Registrant stated as follows:
“…i. The clinical picture, as I understood at the time;
311. Patient E had heart failure with an ejection fraction of only thirty-five to forty-five per cent; that is the reduced output she was able to produce to pump blood around her body…This impacts the patient by reducing their exercise tolerance and causing breathlessness on exertion.
313. ii. Relevant facts which I knew at the time and are relevant to the assessment of clinical decision or risk assessment;
314. The patient was independent and energetically active around the ward using a wheeled zimmer frame and able to cover the whole length of the ward…The patient had full mental capacity to make her own decisions…The patient had stairs at home and was fearful she would not be able to manage them.
317. iii. I address, where appropriate, the rationale and reasoning behind the clinical decisions I made for the patient;
318. I used the main stairs with one rail, because the patient told me that she was unable to reach to both rails at home. At home, she would manage the stairs using only one rail, despite 2 rails being in place…The main stairs are more comparable to completing a flight of stairs at home, in the physical, visual and emotional experience. This was what I wanted to achieve; to give the patient more confidence for going home.
320. A full flight of stairs is around 14 stairs. The patient had 2 rails on her stairs at home with the aim to hold on with both hands, but she complained that they were too far apart and she could not reach both…The assessment choice was whether to take the patient to the stairs in the physiotherapy gym, where the patient can climb 3 steps to a landing and use two rails or use a single main flight of stairs which need to be completed in one go…In order to compare the task to a flight of stairs on the gym stairs, the patient can complete the task 3 times. Although this is fewer steps than a flight of stairs in a home, the patient also has to descend 3 times. These are great steps to practice on when gaining strength, balance and stamina and requiring frequent rest breaks.
323. We wanted to answer the question: Is the patient able to manage her stairs at home? A full flight all at one time. I reasoned that a flight of hospital stairs, where we also take our patients, would be a reasonable test. The patient’s exercise tolerance around the ward suggested that she would manage it…The ward had decided that a home visit was not required. Which stairs to use is a judgement call. MW had taught me on the elective orthopaedic rotation that it was unreasonable not to provide a proper assessment on the stairs if it was required. (I appreciate he was not considering this patient’s individual case).
325. I considered that using the gym stairs for this patient, would not directly answer the patient’s question, can she manage her flight of stairs at home?...I also had to consider that using the main stairs only provided one handrail, so the patient would either have to hold my hand with her other hand or use 2 hands on the single rail. 327. I considered all of this before taking the patient for this assessment. The assessment was aiming to discharge the patient to go home from the ward. For discharge, I needed to identify if the patient had the exercise tolerance to manage the single flight of stairs; at home she will only be ascending or descending the flight, she will not need to return at the same time.”

80. Having been provided a copy of the Registrant’s bundle, which contained her comments upon Patient E above, TE produced an Addendum to his report, dated 13 March 2025. In relation to Patient E, TE stated:
“Patient E The Registrant states that she was working with a more experienced colleague, and therefore any failure in risk assessment was a joint failure. My opinion regarding the risk assessment remains unchanged. The Registrant states that she offered Patient E a commode for use at home and that patient E refused it. If this was the case there was no need for the Registrant to liaise with colleagues regarding the provision of equipment.”

81. In his oral evidence, TE confirmed that he was not critical of the Registrant regarding the commode because the patient had been offered the commode by the Registrant and had declined. In cross examination, TE confirmed that he had no criticism of the Registrant regarding her attempt to use the stairs. He was also asked about the presence of AC, a senior colleague, who could have intervened If there was an unreasonable risk and replied that this did not absolve the Registrant from responsibility.

82. In her oral evidence, the Registrant confirmed that she was asked to carry out a stair assessment with a view to the patient being discharged. She had never treated the patient before and saw her with AC. She thought that taking the patient to the stairs was appropriate because they were not assessing her strength or stamina but were assessing whether she had the strength to try the stairs. She had seen the patient “motoring around the wards” on her wheeled zimmer frame and she had seemed to be very energetic. The Registrant ultimately did not use the gym stairs because the patient was ready for discharge and the ward felt that she was able to use a full set of stairs. The gym stairs only had three steps and it was not the same as the patient using a full flight of stairs. The Registrant said that she had not been completely sure that using the gym stairs would be sufficient.

83. The Registrant was asked some questions about the pro forma assessment form in relation to the functional assessment she carried out in respect of the patient’s “Power”. She stated that she did not physically push the patient's limbs to assess her strength because she had seen that the patient could stand and walk independently and therefore “I knew that she had sufficient strength to walk up and down stairs”. She confirmed that the patient had a heart condition and that using her wheeled zimmer frame made her breathing easier. In respect of the patient being taught chair exercises by the Registrant, she was asked to comment on JG’s opinion that the Registrant had no reason to teach such exercises. The Registrant stated that this came back to what was meaningful treatment. She maintained that it was part of her assessment of the patient before asking her to climb the stairs. It was to understand the patient's strength. JG had suggested that this had been treatment of the patient but the Registrant meant it as an assessment tool. She clarified that the patient moving her four limbs and being taught the chair exercises took place all at the same time. She reiterated that she had already seen her walking around the ward so that she knew that the patient could walk.

84. During Panel questions, the Registrant was asked whether merely lifting limbs to test resistance against gravity amounted to a functional assessment. The Registrant replied that this was a “good question” and stated that a better question might be whether the patient could go up a step. She confirmed that, from memory, the patient scored 3 out of 5 in the Oxford scale of strength. A score of 1 was a " Flicker”; 2 was “without gravity”; 3 was whether a patient’s limb could “go against gravity”; 4 was whether a patient’s limb was able to withstand “Some resistance”; and 5 was whether the limb was able to withstand “maximum resistance.”

Decision
85. The Panel considered that the notes of the Registrant’s assessment of Patient E demonstrated some muddled thinking. For instance, she recorded that she “taught chair exercises” which was somewhat contradictory to her evidence that she used them in order to assess the patient’s limb strength. The Panel was therefore minded to agree with JG that the Registrant’s clinical reasoning for the chair exercises was unclear.

86. In addition, the Panel noted that, although the Registrant recorded that she had carried out a functional assessment of the patient’s limb strength, she said in her oral evidence that she did not actually physically push the patient's limbs in order to assess her strength, but simply relied upon her observations that the patient could stand and walk. Accordingly, the Panel could not understand how the Registrant had arrived at this conclusion when she did not appear to have carried out the necessary tests of strength (such as the patient's limbs being able to withstand “some resistance” or “maximum resistance”).The Panel considered that this omission was particularly important because the patient had a diagnosis of heart failure and ascending stairs would put additional stress on the cardio vascular system.

87. The Panel noted the evidence of TE who had apparently not been critical of the Registrant’s decision to use the stairs but also noted that he had not been made aware of the Registrant’s subsequent evidence regarding the functional assessment. In any event, the Panel noted that, notwithstanding his lack of criticism of the Registrant’s decision to use the stairs, TE had confirmed in his oral evidence that the Registrant’s clinical reasoning was borderline below/far below but still below the standards expected of a Band 5 Physiotherapist.

88. Taking all these factors together, the Panel therefore concluded that the HCPC had discharged the burden of proof upon it.

89. Accordingly, the Panel found this particular proved.

Particular 1(d)
“1. Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role in that…
d. You did not carry out appropriate risk assessments for the patients listed in Schedule B”.

90. Having found that carrying out appropriate risk assessments was a skill and/or knowledge expected to be possessed by a Band 5 Physiotherapist, the Panel went on to consider whether the Registrant had carried out “appropriate risk assessments” in respect of each of the Patients E, F and G.

91. By way of overall background, the Panel took into account the evidence of the HCPC witnesses, LO, JG and TE.

92. In his written statement, LO said:
“Failure to demonstrate consistent risk assessments for patients
24. The risk assessment of a patient does not always involve a formal document but is rather the spontaneous assessment a Physiotherapist would conduct when attending to a patient. You are risk assessing all aspects of that patient, including their age, medical conditions, previous mobility and level of independent function, to enable you to make judgments on what is safe to do with that particular patient that day. For example, if you have a fragile patient with advanced dementia, you would need to be careful in how you approach that patient, how you speak with that patient and how you move that patient. You would have to make a clear risk assessment in your head regarding what is safe to do with the patient, taking into account all the factors you .are seeing when you arrive at a patient's bedside
25. Jenny Rudston would consistently fail to have a clear grasp in a particular scenario of what the risk factors are and how she should manage those to ensure she had a safe interaction. Specifically, l recall Jenny Rudston failed to demonstrate a constructive risk assessment in her interactions with patients with respiratory problems. These patients would require any Physiotherapist attending to them to check their oxygen saturations before assessing what was appropriate for that patient to do that day. If a Physiotherapist attended to a patient where their oxygen levels were below levels we would deem safe, then this needed to be addressed before they moved forward with any further treatment of the patient.
26. Jenny Rudston would attend to patients with low oxygen levels and, instead of addressing this, she would continue with her treatment plan which would often involve trying to get those patients to exercise by taking them for a walk or getting them to stand up. This sort of safety issue was a common occurrence. The concern with this is that if you get a patient to exercise, they are expending further energy which can cause their oxygen levels to drop significantly which is dangerous if their levels are already low. Therefore, Jenny Rudston was not risk assessing consistently what a patient with low oxygen levels was capable of doing.
27 Jenny Rudston's failure to adequately risk assess was a safety concern for patients. Early on in her rotation, I believe it was around March 2019 when these concerns first arose, it was agreed that Jenny Rudston would not be involved with managing Respiratory patients requiring oxygen without direct supervision. This is unusual for a Band 5 Physiotherapist, as all other Band 5s working for us are able to manage oxygen support patients effectively. Once a Band 5 is inducted on the ward, they need to be able to practice without constant direct supervision. Jenny Rudston knew of this expectation as it is in her job description…We did see some improvement with her risk assessment, as evidenced in the summary of the second stage review meeting conducted on 6 January 2O2O but Jenny Rudston was unable to demonstrate this consistently. Aside from risks to patients, another implication of her failure to demonstrate adequate risk assessments was that Jenny Rudston could not work alone and required on-going supervision. This had a big impact on the overall performance of the Rehabilitation Team and its ability to run efficiently as so much time was put into supporting Jenny Rudston or attending to patients she had not seen that day. This also impacted negatively on the development and supervision of other Band 5 Physiotherapists and other members of the Rehabilitation team. The concerns we had with Jenny Rudston and her lack of risk assessing formed a key part of her supervision. JG supported Jenny Rudston with this aspect of performance during this time and kept clear records of supervision meetings...”

93. In addition, the Panel noted the evidence of JG. In her written statement dated 8 March 2024, she stated that, overall, there were two risk assessments that physiotherapists conducted for patients. First, they expected risk assessments to be made based on the patient's NEWS score and would always expect a physiotherapist to check this when they first attended to a patient. JG observed that from her supervision notes with the Registrant, she did show signs of improvement when it came to risk assessing with NEWS scores, but the improvement was not consistent. Improving her risk assessment formed part of her objectives.

94. The second risk assessment consisted of looking at what a patient could do from their bed which enabled a physiotherapist to make an assessment as to whether they could get a patient to sit on the edge of the bed, stand and potentially then walk. During this risk assessment, a physiotherapist would assess if the patient needed equipment in the meantime to make it safer for them. The concerns with the Registrant were that she would struggle with knowing what was safe to do with a patient. Although risk assessments usually included visual assessment, they would expect notes to be made in a patient's documentation.

95. JG went on to say that, in order to support the Registrant, she would often be accompanied by another member of the team who would supervise her. JG confirmed that she would often be the supervisor. JG observed that the Registrant would often be unable to risk assess if a patient was safe enough to do a transfer from the bed to standing up or taking a step. To do this, one would position the patient so they were standing in front of the bed, so if they needed to quickly sit down they could. JG recalled some sessions where the Registrant was unable to recognise if a patient could then be moved away from the bed.

96. JG stated that the concerns about such safety risks were raised at the formal capability hearing as well as during supervision. However, what often occurred following their conversations was that the Registrant then would overcompensate by risk assessing things that did not need checking, which then resulted in poor time management.

97. JG maintained that the Registrant should have known how to adequately risk assess a patient and, in addition, patient handling formed part of the mandatory health and safety training that physiotherapists had to complete during their induction into a hospital.

98. The Panel noted the expert evidence of TE on the issue of Risk Assessment. He confirmed in his written report dated June 2024 that:
“3.0 RISK ASSESSMENT
3.1 (Previously set out above)
3.2 It is important for a physiotherapist to be aware of, and to prepare for, risks and potential adverse events and have a plan to keep patients safe. To do so it is necessary to consider: What could happen? How likely is it to occur? How severe would the outcome be? How can the chance of occurrence or the impact of the event be reduced? What data should be monitored? Does else need to be involved to lessen the risk?
3.3 Risk assessment when providing physiotherapy treatment is not usually a formal documented process, rather it is an assessment performed automatically by the physiotherapist prior to starting treatment, based upon the state of the patient at that time. In addition to those factors that are already known such as age, past medical history, drug history, the history of their present condition, and their levels of mobility and function prior to hospital admission, those factors which are fluctuant need to be assessed as well.
In the context in which the Registrant was working these factors would include:
Mental state; Level of consciousness; New onset confusion; Co-operation; Physical state; Muscle strength; Bone health; Joint health; Neurological health; Medical state; Temperature; Heart rate; Blood pressure (systolic); Respiratory rate and Oxygen saturation
3.4 The National Early Warning System (NEWS) is a system for scoring the physiological measurements that are routinely recorded at the patient's bedside. Its purpose is to identify acutely ill patients, including those with sepsis, in hospitals in England.
A score of 0, 1, 2 or 3 is allocated to each those parameters highlighted in bold. A higher score means the parameter is further from the normal range. Appropriate clinical responses are given for threshold (trigger) levels, with a recommendation to review and agree these locally:
Low risk (aggregate score 1 to 4) – prompt assessment by ward nurse to decide on change to frequency of monitoring or escalation of clinical care.
Low to medium risk (score of 3 in any single parameter) – urgent review by ward-based doctor to determine cause and to decide on change to frequency of monitoring or escalation of clinical care.
Medium risk (aggregate score 5 to 6) – urgent review by ward-based doctor or acute team nurse to decide on escalation to critical care team.
High risk (aggregate score of 7 or over) – emergency assessment by critical care team, usually leading to patient transfer to higher-dependency care area.
The recommendation for a NEWS2 aggregate score of 0 (that is, no change to any parameter) is a minimum 12-hourly review and to continue routine monitoring.”
99. The Panel then went on and considered whether the Registrant had not carried out “appropriate risk assessments” in respect of each of the Patients E, F and G.

Particular 1(d) in relation to Patient E - Found Proved
100. The Panel noted the evidence of JG, as set out in her written statement dated 8 March 2024, which is set out above in relation to Patient E with regard to her clinical assessment.

101. The Panel once again noted the expert evidence of TE regarding Patient E. He confirmed in his written report dated June 2024 that:
“3.10 Patient E (Exhibit 11) - see para 2.12.
The Registrant took Patient E to a stairway in the hospital which had a single handrail. In order to complete an ascent or descent it would have been necessary to complete the whole flight of stairs as it is inherently too risky to ask a frail, fatigued patient to turn around on a narrow stair. It is my opinion that to fail to foresee the inherent risk in asking a patient with limited physical ability to climb and descend a full set of stairs, with no provision to be able to sit down or rest during the exercise, particularly when a flight of 3- 4 of steps with a double handrail, designed for therapy and assessment, was available, represents a failure to meet Standard 14.15 “ to be able to conduct appropriate diagnostic or monitoring procedures, interventions, therapy, or other actions safely and effectively” and falls far below the standard expected of a reasonably competent Physiotherapist.”

102. In her written statement the Registrant responded as set out above in relation to Patient E with regard to her clinical assessment and added, in respect of risk assessment, the following:
“I address, where appropriate, what risk assessment I undertook and what steps were taken to mitigate that risk.
329. When taking a patient on stairs we always have two staff members. This means we can assist the patient to sit on the stairs or one person can go for help…I was unsure if my decision to take the patient on the main stairs was acceptable so I discussed it with AC before we took the patient to the stairs. AC looked in the notes and said that we could use the main stairs…I took the patient to the stairs in a wheelchair, so as not to fatigue her unnecessarily and this also meant we could sit her in the wheelchair and wheel her straight back onto the ward if she needed it. It also meant she could sit in the wheelchair to rest.
332. To manage fatigue, I offered to place a chair on the landing for a seated rest halfway through the assessment but AC, band 6 physiotherapist told me it was not required…I walked alongside the patient throughout the stair assessment whilst AC remained close, below the patient. This meant we were close if there were any issues with balance or missing a step. We could see any signs of shortness of breath or fatigue. This provided the patient with reassurance on the open hospital staircase…I took an oximeter with us so that we could check her observations…We took her notes with us (this was our normal practice) as we were taking her off the ward, in case she needed any medical attention whilst off the ward.
336. I told the patient our plan before ascending the stairs and how she could stop and return if she did not feel able to complete them…The main stairs are more comparable to completing a flight of stairs at home, in the physical, visual and emotional experience. This was what I wanted to achieve; to give the patient more confidence for going home. I could have reduced the patient’s risk, exertion and fear by repeatedly practising the gym stairs instead.
338. Patient E was considered to have full mental capacity. She was independently mobile on the ward with transfers between bed and chair and walking with a wheeled zimmer frame. She was concerned about managing her flight of stairs at home.
339. The patient ascended the stairs well with one hand holding the rail and the other hand being held. She appeared to cope well and completed all the stairs safely. We waited at the top of the stairs for the patient to rest leaning on the wall. The patient appeared well and we did not take any check observations at the top of the stairs…Descending the stairs, although less effortful, can be more disturbing from a sensory and balance point of view, looking downwards to the drop that the stairs cover. It may also have increased the patient’s anxiety…The patient chose to descend with two hands holding the rail rather than having one handheld. This method is just as good, she can do this at home and she felt safer. She managed well but had only recently completed the exertion of ascending the stairs. This is more than she would need to achieve at home. On the last 3 steps the patient started to appear very uncomfortable, we were able to encourage her to complete these steps and sit in the wheelchair. Once in the wheelchair, we were able to check her observations.
342. I checked her oxygen saturation and pulse (heart rate) with the pulse oximeter. We wheeled her back to her bedside where we monitored her observations for a few minutes as she recovered from her exertion.
343. I asked AC if we needed to perform another assessment before discharging the patient and she said that no we did not need to. However, she concluded that we should not have taken the patient to the main stairs but that we should have taken the patient to the gym stairs. She was angry and upset about it but did not accept her own part in the decision…[In] AC’s write up. AC notes that I advised the patient before ascending, that she could try a few steps and if she was unhappy, she could come back down. This had been AC’s advice to me when planning the assessment.
345. I am upset about this decision. I believe the decision that it was not appropriate to take the patient on the main stairs should have been made before taking the patient on the stairs and not afterwards.”

103. Having been provided with a copy of the Registrant’s bundle, which contained her comments upon Patient E above, TE produced an Addendum to his report, dated 13 March 2025. In relation to Patient E, TE stated:
“Patient E
The Registrant states that she was working with a more experienced colleague, and therefore any failure in risk assessment was a joint failure. My opinion regarding the risk assessment remains unchanged…”

104. In his oral evidence, TE stated, when asked if it was a significant failure not to offer the patient a chair at the top of the stairs, that such should have been in place. Patient E had a diagnosis of heart failure and therefore potentially would need to sit down; it was foreseeable therefore that there should have been something at the top of the stairs. When asked if a chair had been offered and declined and whether that should feature in the notes, TE said that it would not, but the knowledge of the clinician would override the desires of the patient in care and therefore it was good practice to have provided a chair at the top of the stairs.

105. In her oral evidence, the Registrant stated that she had told AC that she would get a chair and put it on the landing, but AC had told her that this was not needed. The Registrant accepted that this had not been recorded in the notes, but this was because the documentation was to advise the ward that the patient could manage the stairs. The Registrant confirmed that when they were at the top of the stairs the patient was not showing any signs of distress or fatigue, but they had a standing rest. She confirmed that they could have had a seated rest because she was a heart patient, and they could have taken observations at the top of the stairs but they did not. This was due to the time factor. However, the patient was alert and her breathing was normal.

106. In cross examination, the Registrant accepted that it was more risky to use the stairs. She confirmed that the patient had been fatigued towards the bottom of the stairs, and was asked what would have been the case if she had been fatigued halfway down. The Registrant answered by saying that they could have sat her down on the stairs but in any event the patient had said that she managed to climb her stairs at home. She did not have limited mobility but had a heart problem which reduced what she could manage to do. The Registrant also accepted that using the stairs was riskier than the patient undertaking the steps in the gym. It was put to her by the HCPC that using the main stairs had not properly been risk assessed, to which the Registrant replied that it was a "fine line” but she maintained that she had thought about it and had reasoned the problem with what she already knew. She had thought that it was a reasonable thing to do although she accepted that using the gym stairs required less exertion and attracted less risk.

Decision
107. The Panel considered that the Registrant did not carry out an appropriate risk assessment in relation to Patient E apart from ensuring that she was wheeled to and from the bottom of the stairs and that two physiotherapists were always on hand. The Panel considered that nothing else was put in place to mitigate the risks involved in a patient, who had a heart condition, climbing up and down stairs. The Panel considered that a chair should have been provided at the landing to enable the patient to rest, irrespective of whether or not the patient declined such an offer. Furthermore, the Panel was particularly concerned by the Registrant’s suggestion that, had the patient felt fatigued earlier on the descent of the stairs, the Registrant could have sat the patient on the stairs. The Panel considered that this, in itself, had a high inherent risk, as to sit on the stairs would require significant effort as would returning to standing, placing additional stress on the patient’s cardiac abilities.

108. Finally, the Panel noted that the Registrant herself indicated that it was a “fine line” making the decision to use the stairs, which suggested to the Panel that, if the Registrant realised this at the time, she should have opted for the safer option of assessing her on the gym steps.

109. In addition, the Panel took account of the opinion of TE who concluded that the Registrant’s actions fell far below what would have been expected of a Band 5 Physiotherapist. It also noted that he was of the opinion that the presence of a Band 6 Physiotherapist did not absolve the Registrant of responsibility, with which the Panel agreed.

110. The Panel therefore concluded that the HCPC has discharged the burden of proof in respect of this allegation.

111. Accordingly, the Panel found this particular proved.

Particular 1(d) in relation to Patient F - Found Proved
112. The Panel noted the evidence of JG, as set out in her written statement dated 8 March 2024, in which she stated, in relation to Patient F, that they were a patient that the Registrant had started to see alongside an Occupational Therapist (“OT”). The Registrant and the OT had made a plan for Patient F to be transferred home with a sling hoist to transfer them in and out of bed, as Patient F was ‘unable to use their legs’ to stand. According to the notes, on 25 November 2019, the Registrant and the OT tried to use a mini lift, which is a piece of equipment that a patient could use at home, to do a standing transfer. However, it appeared that the patient was unable to use the mini lift and therefore it was decided that a sling hoist would be more appropriate in the home. On 26 November 2019, the Registrant asked JG to see Patient F with her and to try to get the patient to use a gutter frame (which in her oral evidence she clarified was like a zimmer frame with extensions so that a patient could rest their forearms onto the frame, hence the description “gutter”). JG considered that this demonstrated a lack of clinical reasoning in addition to poor time management as a gutter frame provided less support than the mini lift and therefore, ‘unsurprisingly’, the Registrant was unsuccessful, and Patient F was unable to use it.

113. In her oral evidence JG added that the risk assessment involved deciding whether it was safe for the patient to participate in physiotherapy, for instance by taking NEWS score readings, but there was no record in the notes relating to Patient F that this had been carried out. In cross examination JG was asked whether it was worth trying to get the patient to use the gutter frame to which she replied that it was, but it also should be logical. The gutter frame was less supportive option than a mini lift. JG agreed that, if the Registrant had noted that the patient was able to stand up, it was possible to try a gutter frame “in isolation” but not where a mini lift had failed before.

114. In addition, JG stated that the gutter frame needed to be safe with the patient’s carers at their home, and if the patient was unable to stand, it would be optimistic to expect Patient F to be able to use the gutter frame and it would not make sense to try. The patient would need to be able to “hold her stand” and the family would also have to be aware of how to assist with the mechanism. JG agreed that, as she was present, she could have assisted/supervised/directed the patient. When asked therefore to confirm that a proper risk assessment had taken place, JG said that she recalled very clearly discussing with the Registrant about the disadvantages of her going back “to try something”. In the past the Registrant had ignored JG's opinion, so JG had agreed to carry on “to prove the point”. She did not consider that the Registrant had done her own risk assessment or if she had, it was not adequate.

115. The Panel noted the expert evidence of TE regarding Patient F. He confirmed in his written report dated June 2024 that:
“Patient F (Exhibit 10) - see para 2.13.
A gutter frame offers a patient less assistance in moving from sitting to standing than does a minilift, and is less stable. It is my opinion that to fail to foresee the inherent risk in asking a patient with limited ability to move from sitting to standing to try to do so using a gutter frame represents a failure to meet Standard 14.15 “ to be able to conduct appropriate diagnostic or monitoring procedures, interventions, therapy, or other actions safely and effectively” and falls far below the standard expected of a reasonably competent Physiotherapist.”

116. In her written statement, the Registrant responded as follows:
“The clinical picture, as I understood at the time;
354. My recollection is that patient F had progressing dementia and was in hospital due to a deterioration in her mobility…At home her grandson was her carer and would assist her to transfer between bed and chair and toilet…She had previously been admitted to hospital with loss of mobility but over time she had regained it.
357. ii. Relevant facts which I knew at the time and are relevant to the assessment of clinical decision or risk assessment;
358. Until this admission the patient had been mobilising at home with her grandson without walking aids…The patient was able to communicate her wishes and follow instructions…
…I address, where appropriate, what risk assessment I undertook and what steps were taken to mitigate that risk.
380. I always did the preassessment checks of reading the patient’s medical notes, getting the ward handover, and reviewing the patient’s recorded NEWS scores…I always treated the patient, assisted by a colleague, as her transfers required two people to assist…Our positioning of the patient and ourselves kept the patient safe at all times.
383. The patient was stable and did not fall, she had independent sitting balance…. I knew about the patient’s dementia and was always mindful to tailor our sessions to the patient’s comfort and capacity, that is give simple, clear instructions, have simple objectives that the patient could engage with, listen and respond to the patient’s needs of when to stop and how to make her comfortable and involve her family in her assessment and treatment as she wanted.
385. Patient F on first assessment was able to stand upright and take shuffling steps (The expert witness, Mr T Edbrooke did not have access to this information). During her admission she was able to maintain bed to chair transfers standing in the ward stand aid machine.
386. Unfortunately, the patient had deteriorated, such that she was no longer walking and her posture was deteriorating. The only transfer aid she was able to use at home was a hoist, assisted by 2 carers, where she is transferred lying in a sling. This meant the patient was not weightbearing or stretching with gravity and will continue to deteriorate physically. The aim of attempting for the patient to engage with a Gutter frame was to assess whether the patient could engage with standing in such a support for personal care in order to slow this deterioration.
388. The Gutter frame is the most supportive standing device and has channels where the client can lean their arms to help support their weight in standing… The risks are that the patient will not engage with it, cannot use it, or maintain upright weightbearing and might tip over.
390. The risks were mitigated because the patient was assessed to use it by two physiotherapists instructing and supporting the patient and evaluating whether the patient is able to use it safely with the appropriate assistance. The patient starts from a sitting position, ideally, they would push up into standing from the bed and then balance with the support of the Gutter frame by placing their forearms in the gutters on the top and holding the handles at the end.
391. The frame can be held steady by one or two physiotherapists, depending on which the patient requires. Alternatively for a patient who cannot manage this, the patient can place their arms in the channels on top and grip the handles, then stand and lean on the frame. In this case the patient requires two people to be holding the frame steady…Unfortunately, the patient had just started leaning to the right and could not stand up, so the Gutter frame was unhelpful. There is sometimes a need for trial and error and this is what I did.
393. She completed her standing stand aid transfer well and confidently and maintained this method of transfer during her time on the ward. However, over time her posture was deteriorating and I was concerned that she would soon lose even this ability.
394. All actions were intended in the best interest of the patient. Not to try could have been considered against the patient’s interests. The family agreed that we had tried everything.
395. If I was dealing with this situation again, I would reflect more and question and discuss the options with colleagues. I hope I would not need to try so many different pieces of equipment.”

117. Having been provided a copy of the Registrant’s bundle, which contained her comments upon Patient F above, TE produced an Addendum to his report, dated 13 March 2025. In relation to Patient F, TE stated:
“My opinion regarding risk remains unchanged: a patient attempting to move from sitting to standing using a gutter frame is more likely to fall than if a mechanical aid is used.”

118. In his oral evidence, TE stated that he had two concerns about the use of the gutter frame. The first was that you could not use a gutter frame to take a patient from sitting to standing - they would need assistance. The second was that a gutter frame is “inherently unstable” because the weight usually goes backwards therefore, if a patient had difficulties standing, they could easily fall.

119. In cross examination, TE was asked whether the support of a colleague in the physical sense changed the risk. TE stated that the patient could not stand without two people being present, but this went against any argument that the patient could be discharged from hospital because they needed two people. It was, he said, an “impractical situation". When asked if the fact that two people were in support reduced the severity to below, from far below the standards expected, TE stated that it lowered the risk, and it would come down, but he did not say how far and referred to giving the Registrant the benefit of the doubt.

120. In answer to Panel questions, TE clarified that the Registrant’s risk assessment for Patient F fell below the standards expected and was close to being far below.

Decision
121. The Panel considered that the Registrant did not carry out an appropriate risk assessment in relation to Patient F. Apart from ensuring that two physiotherapists were always on hand, the Panel considered that nothing else was put in place to mitigate the risks involved in a patient, who could not stand unaided; who the day before had only achieved a “3/4 stand” once and was unable to do more; and who had been unable to use the mini lift.

122. Furthermore, the Panel noted that JG had a supervision meeting with the Registrant the same afternoon as the failed attempt with Patient F during which they discussed this case and in which JG recorded that “Additionally the leaning had prevented safe use with mini lift and therefore will be the same with GFF.” The Panel observes that the Patient notes mention nothing about how the Registrant intended to guard against the patient leaning, although the notes indicate that, on two occasions, the patient was leaning to her left.

123. Finally, the Panel noted that opinion of TE who, although he acknowledged that the presence of two physiotherapists reduced the risk and the seriousness of the lack of competence, nonetheless concluded that the Registrant had remained below the standards expected and was close to being far below. The Panel also had regard to his evidence that the gutter frame was “inherently unstable” which to the Panel's minds increased the risk involved.

124. Taking all these factors together, the Panel therefore concluded that the HCPC has discharged the burden of proof in respect of this allegation.

125. Accordingly, the Panel found this particular proved.

Particular 1(d) in relation to Patient G – Found Proved
126. The Panel noted the evidence of JG, as set out in her written statement dated 8 March 2024, in which she stated, in relation to Patient G, that this was a patient in poor medical condition who needed to be assessed functionally. JG maintained that the Registrant was unable to “pick up on the poor function and persisted with trying to encourage the patient to stand up.” Despite feedback from doctors and other members of the MDT, and joint sessions with JG and the Registrant’s peers, the Registrant was unable to write adequate problem lists or treatment plans for the patient. The Registrant felt that the patient was suitable for further rehabilitation when others were advising that the patient was deteriorating.

127. JG referred to her supervision notes regarding this matter dated 11 September 2019, the day after the event. JG recorded that one of the learning objectives included not seeing Patient G when he had been “sat out in the chair all day”. Nonetheless, the Registrant still wanted to see Patient G. The Registrant was told that he had just been seen by another practitioner who explained that Patient G had been falling asleep and had not been engaging with them. They also told the Registrant that the patient’s nutritional intake had been very poor.

128. On arrival, the Registrant found Patient G slumped in a low chair. His wife explained that he had told her that morning that he had forgotten that she existed. Patient G was on a very low chair and leaning to the side. He engaged in a bit of conversation and the Registrant wanted to try and see if he was able to stand up to change his pad. The Registrant stated that Patient G had managed a 15 second stand when treated before but this apparently had not been very effective. Nonetheless, the Registrant wanted to pursue the stand. JG and the Registrant tried to get Patient G to stand but, after two attempts, JG stated that he needed hoisting back to bed.

129. JG’s supervision notes the following day stated:
“Discussion regarding the session yesterday- Jenny stated that she felt the patient still had potential although on a reflection demonstrated that she had the thoughts “is this patient dying". I explained that the session was badly timed - We had already highlighted that…there is no point in seeing the man when he had been sat out in the chair. I attempted to get from [the Registrant] the suitability of the chair that he is sat on. Talked through the dynamics of standing up and eventually got through the idea that the chair was low. I needed to really feed that trying to stand up from that chair is also setting him up to fail. I needed to suggest that we saw the patient, from the bed after a rest following a wash. I however needed to firmly say that the patient was not appropriate for rehab.
Following this discussion Jenny then proceeded to ask DUS to go with her to see the patient. This was at: 3pm and the patient was sat in the chair. No evidence of listening to and processing anything that had just been discussed.”

130. The Panel noted the expert evidence of TE regarding Patient G. He confirmed in his written report dated June 2024 that:
“Patient G (Exhibit 1, Appendix 8; Exhibit 17) – see para 2.14.
It is my opinion that to fail to foresee the inherent risk in asking a patient who is frail and medically unwell to undertake a strenuous physical task from a mechanically compromised position, in this instance to stand up from a low chair, represents a failure to meet Standard 14.15 “ to be able to conduct appropriate diagnostic or monitoring procedures, interventions, therapy, or other actions safely and effectively” and falls far below the standard expected of a reasonably competent Physiotherapist.”

131. In her written statement, the Registrant responded as follows:
“I ensured that the patient was safe at all times and felt safe and supported. Attempting Patient G to stand, assisted by peer band 5 physiotherapist, MM.
402. i. What was Patient G’s clinical presentation at the time it was decided to ask them to stand/try to get them to stand;
403. In writing this I have access to MM’s reflection HCPC bundle p627-9; JG’s documentation provided in the HCPC bundle on p211 and my very brief notes from the session with MM on 5th September 2019 and the session with JG on 10th September 2019.
404. He was very elderly and slim. He was supporting his own breathing on room air and did not have an identifiable infection. He was confused, not orientated to person, time or place. He did however follow our instructions appropriately…He had independent sitting balance sitting on the edge of the bed. When given the instruction to stand up from the chair, he did initiate this action.
What risks, if any, were identified for this treatment;
410. The risks were:
411. That the patient would be too fatigued to engage with the treatment. 412. That the patient might not be able to follow instructions.
413. That the patient might demonstrate poor balance. The patient might be able to start the activity but not have the strength to lift himself off the chair or achieve a partway stand but then drop back into the chair.
415. That the patient might feel dizzy in standing.
416. That the patient might find physiotherapy assessment stressful.
417. That the session might pose a psychological or manual handling risk to my colleague. My colleague was more experienced than I at working at St Richard’s hospital and so already ahead of me with her risk assessment skills for our role. She was therefore responsible for making her own assessment of these risks as well.
418. Patient G was a vulnerable and deteriorating patient with a delirium of unknown cause.
I followed my risk assessment that it was unsafe for me to assess him on my own, without another member of the physiotherapy team. Which is why I was not able to assess him physically until later in his hospital stay…I did try to push for him to be seen earlier but the overall decision fell to JG and the resources available.
420. iv. What, if any, mitigating steps were taken to reduce this risk.
421. I was up-to-date with the ward handovers from the multidisciplinary team meeting, up to that morning.
422. I had monitored the patient’s NEWS scores.
423. The patient did not have any medical condition that contraindicated the treatment.
424. I took out the patient’s notes and discussed them with my colleague, my band 5 peer, MM, before we went to see the patient.
425. I had two physiotherapists alongside the patient; me and my colleague; in stable standing positions and with hands on the patient. He was sat in the chair which remained behind him throughout the manoeuvre
426. The patient was light and the two physiotherapists were able to support the patient and ensure he lowered safely back into the chair. I was not finding myself lifting or lowering much weight. It was only afterwards, when we met with JG, that my colleague told me that she was lifting significant weight. She did not communicate this at the time we were performing the manoeuvre or ask me if I could take more weight.
427. She did not decide that it was too much to lift at the time and therefore not to proceed. The patient was not harmed by the session nor further exhausted and we hoisted him back into bed to rest.”

132. Having been provided a copy of the Registrant’s bundle, which contained her comments upon Patient E above, TE produced an Addendum to his report, dated 13 March 2025. In relation to Patient G, TE stated:
“Patient G
The Registrant offers no clear rationale for asking Patient G to stand. She states that her objective was to maintain range of movement and to prevent deterioration. This could have been done safely using active, active assisted, and passive movements with the patient lying on his bed. My opinion regarding risk assessment remains unchanged.”

133. In his oral evidence, TE was asked about the significance of the low chair as regards risk assessment and stated that, if the patient was medically unwell, it was unlikely that he would be able to stand from a sitting position and therefore he would need a lot of assistance. This would require a lot of force to his arms and shoulders and therefore it was likely that the patient would sustain further physical injury as well as undertake a high physical exertion.

134. In cross examination, TE was asked whether the presence of a senior physiotherapist lessened the risk, but replied that even though it did, the Registrant’s actions remained far below the standards expected because of the frailty of the patient.

135. In her oral evidence, the Registrant maintained that it was not safe for her to assess Patient G alone because he was confused and had deteriorated. She thought that he was at risk of dying. On that day he was not at his “normal baseline”, and he was normally not confused. As for her encouraging the patient to stand up, she was trying to assess him. He previously could stand up and walk and had independent sitting balance. However, a frail patient, if they had capability could still stand up if they did not lack energy. She stated that he was too weak to stand from the low chair he was sitting in. The Registrant also said that they should have assessed his ability to stand from the bed, set at different heights. They were not trying any treatment. The problem was the patient's confusion.

136. When asked if she would do anything different, the Registrant stated that when she first went on to the ward, she did not assess him, and she should have been more forthright in asking JG to see him. When asked if, in hindsight, she would repeat the request for him to stand up, the Registrant replied that she would not because it was not relevant at that time. He was receiving care, and she could have come back to assess functionality if he was being discharged.

137. When asked about the assessment of risk and mitigation, she commented that TE had identified the patient slipping and falling, but Patient G’s balance was surprisingly good. There were always two physiotherapists present; he was light and slim; and an experienced member of the physiotherapy team was with her. Moreover, she had checked his current observations done by the nurses and the MDT's.

138. In cross examination, the Registrant accepted (as she had done at the beginning of this hearing) that her clinical reasoning was not good on this occasion, but she maintained that the risks itemised in her witness statement (as set out above) had been identified and considered at the time of the incident. When asked to comment upon TE's opinion that undertaking strenuous physical activity could have made the patient's medical condition worse, the Registrant agreed that this was a possibility and accepted that she had not specifically considered this but maintained that she was monitoring the situation. The patient was doing better than expected. She made sure that there were two reasonably experienced physiotherapists present. She accepted that it was not the right thing to do but there was no adverse outcome, and he had been hoisted back into bed.

139. When asked to consider what might have happened, taking the patient's frailty into account, if the patient had fallen and needed physical support, the Registrant responded that this was an issue, but she would never have put him in such a position. When challenged that she did not properly risk assess Patient G, the Registrant stated that there was no moment where the patient could have slipped; he was not heavy, and he seemed to be “doing it by himself”. If he had been unable to stand, he would have remained in his chair. She agreed that he should have been assessed much earlier and they concluded that nothing could be done until his health improved.

Decision
140. The Panel considered that the Registrant did not carry out an appropriate risk assessment in relation to Patient G. Although her witness statement itemised a list of risk factors, none of them appear to have been mentioned in the contemporaneous, albeit subsequent, supervision session with JG. Furthermore, in her oral evidence, the Registrant candidly accepted that she had not specifically considered the risk factor of the effect upon the patient of him being subjected to strenuous physical activity. Moreover, the Panel noted that, despite being aware that the patient should not have been seen when he had been sitting in his chair for any length of time, and therefore that interaction with him was potentially futile, the Registrant nonetheless preceded to attempt to have him stand. Finally, the Panel noted that the Registrant had also said that they should have assessed his ability to stand from the bed, which again suggests an absence of reflection about risk at the time.

141. Finally, the Panel was persuaded by the opinion of TE who maintained his assessment of the Registrant’s falling far below the standards expected of a Band 5 Physiotherapist.

142. Taking all these factors together, the Panel therefore concluded that the HCPC has discharged the burden of proof in respect of this allegation.

143. Accordingly, the Panel found this particular proved.

Decision on Grounds
144. Prior to hearing submissions from the representatives, the HCPC lodged further evidence on behalf of the HCPC. The first was a final decision following a substantive hearing by the HCPC's Conduct and Competence Committee dated 24 May 2012 regarding the Registrant. The allegations were that between 1 January 2007 and 7 February 2011, whilst employed as a rotational Band 5 Physiotherapist, a number of concerns were raised about her competence in relation to patient assessments, clinical reasoning, teamwork, communications with patients and time management. During the relevant period she had demonstrated some improvements but they were not consistently maintained. The Registrant had admitted all the allegations. The panel on that occasion concluded that the Registrant was not able to practise safely and autonomously and imposed a Conditions of Practice Order. That order was reviewed on five occasions.

145. The second piece of evidence lodged by the HCPC was a copy of the decision of the final reviewing panel dated 29 May 2018 which concluded that there were no concerns about patient safety and there was no likelihood of any repetition. That panel accordingly revoked the Conditions of Practice order.

Submissions on Grounds
146. In relation to the statutory ground of lack of competence, the HCPC submitted that the first question for the Panel to decide was whether it had before it a fair sample of the Registrant’s work. The HCPC submitted that the Panel had been presented with ample evidence of the concerns and surrounding context and therefore had clearly been presented with a fair sample of her work.
147. With respect to Particular 1(a) (“Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role. In that: a. You did not effectively and efficiently time manage your case load;”) the HCPC reminded the Panel that it had already found that a fair sample of the Registrant’s work had been presented to it. TE had stated that seeing 8 patients a day would have been expected of a Band 5 Physiotherapist and that the Registrant had fallen “below” the standards expected. The HCPC submitted that the standard of the Registrant’s performance was therefore “unacceptably low”.

148. In relation to Particular 1(c), (“Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role. In that:…c. You did not demonstrate good clinical reasoning in patient assessments and/or treatment decisions for the patients listed in Schedule A.”) Mr Bellis reminded the Panel that it had found this allegation proved in respect of five patients, A, B, E, F and G, with two separate allegations of poor clinical reasoning having been found in respect of Patient A. Therefore, there was a total of six incidents. The incidents took place in March 2019 (two regarding Patient A); May 2019 (Patient B); July 2019 (Patient E); September 2019 (Patient G) and November 2019 (Patient F). Mr Bellis reminded the Panel of TE’s evidence that clinical reasoning was taught from the earliest stages of undergraduate study and that competent clinical reasoning would be considered the minimum standard expected by a reasonable group of physiotherapists. Moreover, TE had stated that the HCPC Standards of Proficiency for Physiotherapists indicated that they were expected “to be able to practise as an autonomous professional exercising their own judgement…[and] to be able to draw on appropriate knowledge and skills to inform practice”.

149. Mr Bellis submitted that a fair sample of the Registrant’s work had been considered. The individual cases relied upon varied in nature and had taken place over an extended period of time. Furthermore, TE had considered that the Registrant’s standards in relation to all these cases fell either “below” or “far below” the standards expected and therefore Mr Bellis maintained that the Registrant’s performance regarding clinical reasoning was “unacceptably low”.

150. In relation to Particular 1(d), (“Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role. In that:… d. You did not carry out appropriate risk assessments for the patients listed in Schedule B..”) the HCPC reminded the Panel that it had found this allegation proved in respect of four patients, A, E, F and G. Mr Bellis accepted that the Registrant had achieved this objective in the Individual Performance Plan dated June 2019 (in that she understood NEWS, medical status and ongoing investigations) and that the outcome letter dated 13 March 2020 again acknowledged that this objective had been met (with the proviso that there was a reduced subset of patients in the area). However, there were specific examples relied on by the HCPC regarding these four patients and again, concerns had been raised across a broad range of issues (including issues out with those specified in the individual performance plan) and therefore the HCPC maintained that a fair sample of the Registrant’s work had been considered.

151. The HCPC reminded the Panel that, during the period covered by these individual cases, March to November 2019, the Registrant was under a heightened level of supervision (more than was usually expected for a Band 5 Physiotherapist). Furthermore, JG had had to intervene on more than one occasion and it had been stipulated that the Registrant would not treat O2 patients without supervision. Finally, TE had considered that the Registrant’s standards in relation to all these cases fell either “below” or “far below” the standards expected and therefore the HCPC maintained that the Registrant’s performance regarding risk assessment was “unacceptably low”.

152. In relation to Particular 1(e), (“Between 8 October 2018 and 10 March 2020, you did not demonstrate the skills and/or knowledge appropriate for your role. In that:…e. On or around 8 November 2019 you did not use the emergency bell for an unresponsive patient..”) the HCPC submitted that, although it was only one single incident, taken together with the other matters, it linked in with similar themes and therefore it was appropriate for it to be regarded as being included in a fair sample of the Registrant’s work.

153. The HCPC reminded the Panel that TE had considered that the Registrant’s standards in relation to this incident fell “far below” the standards expected (he had said that it was a poor assessment, poor risk assessment and a poor response) and therefore the HCPC maintained that the Registrant’s performance regarding risk assessment was “unacceptably low”.

154. In relation to the statutory ground, Mr Halliday made the following submissions regarding whether a fair sample of the Registrants work had been considered.

155. In relation to Particular 1(c) (clinical reasoning) Mr Halliday submitted, once again, that the Panel should be considering the period October 2018 to March 2020. Six specific incidents of poor clinical reasoning had been relied on in this 16/17-month period, which he maintained was not a significant enough number for the Panel confidently to say that a fair sample of the Registrant's work had been considered.

156. Having said that, he submitted that if the Panel did find that a fair sample had been presented of the Registrant’s work, although TE had indicated that the Registrant had fallen “far below” the standards expected in respect of Patients A and G, and “below”, but not “far below”, in respect of patients B, E and F, there was not a sufficiently consistent theme to enable the Panel to conclude that the Registrant's performance was unacceptably low.
157. In relation to Particular 1(d) (risk assessment) Mr Halliday submitted there were insufficient numbers (four patients in 16/17 months) to amount to a fair sample of the Registrant’s work. Furthermore, there was a conflict in the evidence before the Panel in that it had been accepted by LO that, towards the end of the period of her employment, the Registrant had been able to demonstrate consistent risk assessment. Mr Halliday therefore maintained that, notwithstanding TE's opinions, it had not been demonstrated that the standard of the Registrant’s work was unacceptably low.

158. In relation to Particular 1(e), Mr Halliday submitted that it was important that the Registrant went immediately to JG, who was nearby, because the Registrant did not know what to do. The Registrant had addressed this knowledge gap in her reflections and therefore Mr Halliday maintained that her standards had not been unacceptably low notwithstanding TE’s assessment that she had fallen “far below” the standard expected.

Decision on Statutory Ground
159. The Panel accepted the advice of the Legal Assessor. He stated that, when deciding the question of whether the Registrant’s actions amounted to the statutory ground of lack of competence, neither party bore any burden of proof so she did not have the burden of proving her fitness to any standard. It was entirely a matter for the Panel’s professional judgement.

160. Moreover, he reminded the Panel that, in assessing whether the Registrant’s actions amounted to a lack of competence, it was entitled to take account of the various alleged breaches of the standards which were in force at the time, namely the Standards of Proficiency for Physiotherapists (May 2013 version) and the HCPC’s Standards of Conduct, Performance and Ethics (covering the period 2018 to 2020).

161. As to what constituted lack of competence, the Legal Assessor advised that this represented incompetence or work that fell significantly below the standards reasonably expected of membership of a profession. The case of Holton made it clear that a practitioner should be judged by the standards applicable to the post to which they are appointed (in this case a rotational Band 5 Physiotherapist) and the work they are carrying out, rather than a general allegation that they lack competency.

162. The Panel was also to note the case of Calhaem v General Medical Council where Jackson J stated that “deficient professional performance… is conceptually separate both from negligence and from misconduct. It connotes a standard of professional performance which is unacceptably low and which (save in exceptional circumstances) has been demonstrated by reference to a fair sample of the [Registrant]'s work… A single instance of negligent treatment, unless very serious indeed, would be unlikely to constitute deficient professional performance.”

163. The Legal Assessor also referred to the case of McDermott v HCPC (which Mr Halliday had drawn to his attention) which provided (i) that the context in which poor performance is alleged to have taken place may be taken into account and (ii) that lack of competence must be serious, which the Legal Assessor confirmed was synonymous with what was said in Calhaem, that lack of competence connoted a standard of professional performance which was “unacceptably low”.

164. The Legal Assessor advised the Panel to consider, as a prerequisite, whether it had been presented with a fair sample of the Registrant’s work when looking at each of the groups of allegations. He suggested that one way of approaching the task would be for the Panel to ask, for instance in relation to 1(c), whether 6 instances of poor performance in a period of 17 months could be said to be a fair sample of Registrant’s work sufficient for it to say that she lacked competence.

165. If the Panel decided that a fair sample of Registrant’s work had been considered, it was then to go on to assess whether the Registrant’s standards of treatment in each of the sub-particulars, and the cases therein, were “unacceptably low” in relation to the standards expected of a registered Band 5 Physiotherapist. Furthermore, it was entitled to take into account TE’s expert evidence on these matters, although it was not determinative. Where TE’s categorisation of falling “below” or “far below” fitted into the equation was a matter for the Panel.

166. The Panel was to look at each of the allegations and assess whether individually they fell “unacceptably low” in relation to the standards of a registered Band 5 Physiotherapist. It was entitled to take account of any harm which resulted from the Registrant’s actions, or the potential harm which might have ensued, and to take account of the circumstances surrounding each of the incidents. Essentially, it was an objective test.

Fair Sample of Work
167. The Panel therefore first considered the question of whether a fair sample of work had been considered in relation to each of the Particulars 1(c), 1(d), 1(e). It reminded itself that it had already, during the facts stage, decided that a fair sample of Registrant’s work had been considered in relation to Particular 1(a). The Panel had, in reaching this decision, considered schedules of patients seen by the Registrant during each shift, prepared by JG over the period 29 April 2019 to 17 January 2020, and by the Registrant over the period 30 August to 13 December 2019.

168. The Panel did not have such detailed information before it regarding the number of patients that the Registrant actually treated (which would be different to the number of patients she saw during any one day) in connection with the matters raised in Particulars 1(c), 1(d) and 1(e). However, it was aware that the cases referred to in Schedules A and B of the Allegation and 1e were from the period March to November 2019. This amounted to a period of over 8 months, which the Panel noted was almost half of the period of the Registrant’s employment at the Hospital (17 months). The Panel considered that such a period of time was a significant proportion of the Registrant’s employment and, on the face of it, the patients treated by the Registrant during that period were capable of representing a fair sample of her work.

169. The Panel first addressed the question as to whether a fair sample of the Registrant’s work had been considered in relation to Particular 1(c). It noted that six incidents were relied on over a period of eight months, during part of that time the Registrant was subject to a capability process. In addition, the Panel reminded itself that these were 6 examples of poor clinical reasoning in different areas of her practice which extended over a significant period of time. Each incident indicated a lack of understanding and demonstrated that, even towards the end of this 8-month period, the Registrant was still not reaching an acceptable level of performance. The Panel agreed with TE, that clinical reasoning was such a fundamental skill for a physiotherapist and a failure to possess it meant that the Registrant would be unable to practise as an autonomous professional exercising her own judgement.

170. On the basis that clinical reasoning is such a fundamental skill the Panel considered that six examples of poor clinical reasoning over an 8-month period was a high enough proportion to raise concerns and amounted to a fair sample of the Registrant's work.

171. The Panel next addressed the question as to whether a fair sample of the Registrant’s work had been considered in relation to Particular 1(d). It noted that four incidents were relied on over a period of eight months, during part of which the Registrant was subject to a capability process. In addition, as before, the Panel reminded itself that these were four examples of poor risk assessing in different areas of her practice which extended over a significant period of time. Once again, each incident indicated a lack of understanding and demonstrated that, even towards the end of this 8-month period, the Registrant was making basic errors. The Panel agreed with TE, that risk assessment was “performed automatically” so that patients would be kept safe.

172. On the basis that risk assessment is such a fundamental skill the Panel considered that four examples of not carrying out appropriate risk assessments over an 8-month period was a high enough proportion to raise concerns and amounted to a fair sample of the Registrant's work.

173. Finally, the Panel addressed the question as to whether a fair sample of the Registrant’s work had been considered in relation to Particular 1(e). It noted that this related to only one incident in November 2019. The Panel took account of Mr Bellis’ submissions that, although there was one single incident, it did represent a standard that was unacceptably low and which linked in with similar themes. However, as Mr Halliday had not addressed in his submissions the issue of whether a fair sample of work had been considered in relation to this Particular, the Panel interrupted its deliberations to seek the advice of the Legal Assessor and the representatives on the subject. After private discussion between the Legal Assessor and the representatives, the Legal Assessor advised the Panel that their joint agreed position was that Particular 1(e) was not a case of the Panel having to assess that one specific incident individually in order to ascertain whether a fair sample of the Registrant’s work had been considered. The Panel could look at Particular 1(e) as an individual case and could take it into account when assessing whether, overall, a fair sample of the Registrant’s work had been considered.

174. The Panel therefore looked at the final position in relation to Particular 1. It noted that, taken altogether, the Panel had been presented with 11 examples of the Registrant’s work which did not demonstrate the skills and/or knowledge appropriate for her role as a rotational Band 5 Physiotherapist. The Panel concluded that 11 examples, over an eight- month period, was a high enough proportion to raise concerns and amounted overall to a fair sample of the Registrant's work.

Breaches of Standards
175. Having made decisions in respect of whether a fair sample of the Registrant’s work had been considered, the Panel then moved on to make an assessment of what standards had been breached and concluded that the following breaches of standards were relevant in this case:

HCPC standards covering period 2018 to 2020
Standard 6.1 – You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
Standard 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 10.1 – You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

Standards of proficiency – Physiotherapists
Standard 1.2 – recognise the need to manage their own workload and resources effectively and be able to practise accordingly.
Standard 4.1 – be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem
Standard 4.2 – be able to make reasoned decisions to initiate, continue, modify or cease techniques or procedures, and record the decisions and reasoning appropriately
Standard 4.3 – be able to initiate resolution of problems and be able to exercise personal initiative
Standard 12.8 – Evaluate plans be able to evaluate intervention plans to ensure that they meet the physiotherapy needs of service users, informed by changes in circumstances and health status.
Standard 14.4 – be able to select and use appropriate assessment techniques
Standard 14.9 – be able to demonstrate a logical and systematic approach to problem solving
Standard 14.11 – be able to formulate specific and appropriate management plans including the setting of timescales
Standard 14. 12 – be able to apply problem solving and clinical reasoning to assessment findings to plan and prioritise appropriate physiotherapy
Standard 14.14 – be able to set goals and construct specific individual and group physiotherapy programmes
Standard 14.16 – be able to select, plan, implement and manage physiotherapy interventions aimed at the facilitation and restoration of movement and function
Standard 14.18 – be able to select and apply safe and effective physiotherapy specific practice skills including manual therapy, exercise and movement, electrotherapeutic modalities and kindred approaches
Standard 14.19 – be able to change their practice as needed to take account of new developments or changing contexts
Standard 15.4 – be able to work safely, including being able to select appropriate hazard control and risk management, reduction or elimination techniques in a safe manner and in accordance with health and safety legislation
Standard 15.6 – be able to establish safe environments for practice, which minimise risks to service users, those treating them and others, including the use of hazard control and particularly infection control

Particular 1(a)
176. The Panel then went on to consider whether the standard of the Registrant’s time management of her case load fell unacceptably low.

177. In doing so, it took account of TE's evidence as to how he had arrived at the categorisation of “below” and “far below”. TE stated that he had received no guidance as to how to reach his categorisations so had applied the following criteria. A categorisation of “below” was the level that he would expect of a Physiotherapist who had just come “out of school” and was a level that would not put patients at risk. A categorisation of “far below” was a level that would put patients at risk. The Panel considered that, when treating patients, there was always the potential for risk. Accordingly, although the Panel took TE’s conclusions into account, it did not find them determinative and assessed for itself whether the Registrant’s errors were serious enough to connote a standard that was unacceptably low.

178. The Panel took into account all the evidence as set out above in its decision on facts. It noted that time management was a constant issue during supervision sessions and that the Registrant had been given several opportunities to improve but, notwithstanding this, she had not consistently achieved the targets set. The Panel appreciated that she had made some improvements in that, on her figures, she was, on occasion, coming close to achieving the required target, but it agreed with the HCPC that this was not consistent.

179. The Panel took into account the effect that such inefficient time management would have had upon the patients. The Panel considered that there is likely to have been a detrimental impact upon the patients by the Registrant’s failing to attend upon them. It also noted that the Registrant required a lot of supervision, and this impacted upon colleagues’ time and thus their workload. Furthermore, her inability to meet the required target of eight patients a day is likely to have impacted on the efficient running of the Physiotherapy Team (which the Registrant had asserted was understaffed).

180. The Panel acknowledged TE's opinion that the Registrant had fallen “below” the standards expected but noted that he did not specifically address the impact upon patients of the Registrant not effectively and efficiently time managing her caseload.

181. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s time management was “unacceptably low” and therefore represented a lack of competence.

Particular 1(c)
182. The Panel then went on to consider whether the standard of the Registrant’s clinical reasoning fell unacceptably low in relation to each of the matters found proved in Schedule A, beginning with Patient A.

183. In relation to Patient A, the Panel noted that this specific allegation had been admitted by the Registrant and, therefore, that very few details of the allegation had been presented to it during the facts stage.

184. Accordingly, the Panel first took account of JG’s evidence in her witness statement. She stated that, during a treatment on 11 March 2019, Patient A was on two litres of oxygen and the Registrant documented that their oxygen saturation was 83%. This was an unsafe level. JG stated that Physiotherapists should never leave a patient on low oxygen saturations and would want to treat a patient with oxygen saturations which were at least 95%. The concern was that the Registrant did not address the oxygen level and instead continued with trying to get the patient active by attempting to make the patient sit on the hospital bed. The patient oxygen saturations then dropped a little lower to 78% before the Registrant discussed the matter with a doctor and gave the patient a further litre of oxygen to try and assist with their saturation. JG indicated that the Registrant should have immediately addressed the 83% oxygen saturation when she arrived and should not have attempted to get the patient moving as this had the potential to drop saturations even more. The consequences of having a patient with low saturations were that it could lead to respiratory distress including high respiratory rate, high heart rate and the physical inability to continue with the task.

185. The Panel noted the evidence of TE who indicated that proceeding with treatment without addressing the levels of oxygen saturation represented a failure to meet standard 14.15 “to be able to conduct appropriate diagnostic or monitoring procedures, interventions, therapy, or other actions safely and effectively” and fell far below the standard expected of a reasonably competent physiotherapist.

186. In her witness statement, the Registrant stated that she had no experience of titrating oxygen delivery so was unaware that exceeding Patient A’s saturation limit could be harmful. She accepted that this was wrong of her and that she should have discussed the patient with JGs before she went to see him. Moreover, she had first spoken with the doctor who was in charge of his case that day and the doctor was adamant that Patient A no longer had an oxygen requirement and would soon be ready for discharge. The Registrant also said that she did not know that finding a patient with the saturation of 83% entitled her to immediately ask for a medical review, but at the time she thought it was an expected part of his presentation.

187. In the addendum to his report, having considered the Registrant’s statement, TE stated that:
“The Registrant presents some mitigation in so far as she was not presented with consistent information by medical staff on the ward, and that the titration of oxygen might be outside the expected scope of knowledge for a Band 5 physiotherapist.
I agree with both of these points, but my stated opinion remains unchanged, and it is my opinion that the Registrant’s statement regarding Patient A does not demonstrate an awareness of her responsibility to ensure that she knew exactly how to proceed before doing so.”

188. The Panel also noted TE’s oral evidence in which he agreed all physiotherapists should know and understand about patients on oxygen and it should have been dealt with in the Registrant’s training.

189. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s clinical reasoning in relation to Patient A on 11 March 2019 was “unacceptably low” and therefore represented a lack of competence. It considered that taking no action to regulate the patient's oxygen saturation before treating him was serious, particularly since the Registrant had had a number of years’ experience in her previous employments.

190. In relation to the incident regarding Patient A on 13 March 2019, the Panel once again took account of the evidence of JG. She stated that, during an appointment on 13 March 2019, the Registrant again saw Patient A with JGs. On this date, Patient A again had low saturation of 87%, so the Registrant, overlooked by JGs, put Patient A on two litres of oxygen to bring his oxygen saturations up to 94%, which was an improvement. However, the patient treatment notes, initially written up by the Registrant, had an addendum from JGs which added to what the Registrant had written so as to make the entry an accurate reflection of what happened during that treatment session. The Registrant had incorrectly documented the amount of oxygen applied and the subsequent change in the patient's oxygen saturation. This lack of accurate documentation demonstrated, according to JG, that the Registrant did not have a good understanding of what was happening during that appointment.

191. The Panel noted the evidence of TE who indicated that:
“Clinical notes record a treatment session on 13.03.19. The Registrant’s notes record the provision of 2l O2 (2 litres per minute of oxygen) during the treatment session to maintain saturation at 94%, and the gradual reduction of oxygen post-treatment with saturation maintained at 94% but with a drop to 88% on air. A further entry by JGs provides an alternative account whereby treatment was started on a lower oxygen flow on which the patient’s saturation started to drop, so the flow was increased to 2 litres per minute on which saturations were maintained. JGs records that the patient’s saturation remained at 93-94% on air.
It is my opinion that, if the notes of JGs are accurate, the Registrant failed to maintain accurate notes thus failing to meet [the standard] and falls below, but not far below, the standard expected of a reasonably competent Physiotherapist.”

192. In her written statement, the Registrant stated that she was concerned to be concise in her documentation, which is why she documented the two litres of oxygen dosage that was used. She was not at the time aware of the importance of documenting the process of reaching the two-litre dosage. She could now see that it was important to do this and give a more accurate picture of what they did.

193. The Panel again noted TE’s addendum to his report as set out above and that his opinion remained unchanged. TE stated that in his opinion the Registrant’s statement regarding Patient A did not demonstrate an awareness of her responsibility to ensure that she knew exactly how to proceed before doing so.

194. The Panel determined that this lack of understanding, as reflected in her incorrect documentation, demonstrated the Registrant’s inability to demonstrate good clinical reasoning. Moreover, the Panel once again took into account the fact that the Registrant had had a number of years’ experience in her previous employments. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s clinical reasoning in relation to Patient A on 13 March 2019 was “unacceptably low” and therefore represented a lack of competence.

195. The Panel then went on to consider whether the standard of the Registrant’s clinical reasoning fell unacceptably low in relation to Patient B. The Panel noted that this specific allegation had been admitted by the Registrant and therefore that very few details of the allegation had been presented to it during the facts stage.

196. Accordingly, the Panel first took account of JG’s evidence in her witness statement. She stated that the treatment notes from the Registrant’s appointment with Patient B on 22 May 2019 recorded that, when the Registrant first arrived, she checked the blood pressure of Patient B, which was at an acceptable level, although it dropped a little when the Registrant had the patient stand up. The notes document that, later on, Patient B started to “not feel right” when the Registrant asked Patient B to march on the spot. The Registrant had Patient B sit down and raise their legs, which was the appropriate thing to do, but the patient again stated that they did not feel right. A Band 6 Physiotherapist, VN, was walking past and realised that immediate action was required as, although the patient was responsive, an assessment was quickly needed to decide if Patient B should be lowered to the ground or, with the use of a hoist, put back into the bed. VN stepped in and put Patient B onto oxygen using a mask, in accordance with what was perceived to be an emergency situation, and she also took blood pressure readings. A finger probe was needed to find out Patient B's oxygen levels. It looked as if Patient B then recovered and settled. The Registrant then liaised with the MDT and was informed that Patient B needed a cardiology review. JG considered that, from Patient B’s notes, it appeared that there was inadequate clinical reasoning and safety since, had VN not walked past and seen the Registrant with a deteriorating patient, the patient's oxygen levels and blood pressure would not have been addressed.

197. The Panel noted the evidence of TE who indicated that:
“Patient B (Exhibit 8)
Clinical notes record that on 22.5.19 Patient B was performing a sit to stand (STS) exercise and slow marching on the spot (MOTS) for 2 minutes. During the exercise the patient felt “not right” so was sat down (SOOB: sat out of bed) with her legs raised. Patient B was then asked to repeat the same exercise. Again she did not “feel right” and was sat down with her legs raised. The patient’s blood pressure was monitored throughout and demonstrated a steady rise with activity. The Registrant was joined by VN, another physiotherapist, and the patient was provided with a high-rate flow of supplemental oxygen via a rebreathe mask. When oxygen saturation was measured it was 95%.
Supplemental oxygen is usually only given when arterial blood pressure has dropped below 60mmHg or when oxygen saturation has dropped below 89%. There is no indication in the notes that blood pressure had dropped to this level, and oxygen saturation was not being monitored.
It is my opinion that the information available suggests that the Registrant was monitoring Patient B’s condition by means of her blood pressure, and placed her in a safe position each time she felt unwell. It is not possible to opine as to whether the provision of supplemental oxygen was necessary.
It is my opinion that best practice would have been to have had an oxygen saturation monitor available as soon as the patient felt unwell on the first occasion. Having experienced an adverse effect from a set of exercises, good clinical reasoning would have led the Registrant to abandon the second set of exercises, and this failure in clinical reasoning represents a failure to meet Standard 14.5 and falls below, but not far below, the standard expected of a reasonably competent Physiotherapist.”

198. In her witness statement, the Registrant stated that:
“,,,i. The clinical picture, as I understood at the time;
232. It was clear that the patient’s blood pressure readings were very low, but the medical teams had done almost all they could to help. The patient had been moved onto this ward to rehabilitate with the ultimate aim of discharge home…It is usual for such patients to complain of not feeling right and feeling dizzy with changes in blood pressure and activity.
234. ii. Relevant facts which I knew at the time and are relevant to the assessment of clinical decision or risk assessment;
235. On discussion with the doctor, he considered that it was appropriate to exercise the patient…I was not the first physiotherapist to see her…There was nothing documented to identify that the patient required a particular response to her episodes, i.e. oxygen therapy…I should have got a full handover from VN who had seen the patient on a previous ward and had a better understanding of her fatigue and vasovagal episodes.
iii. I address, where appropriate, the rationale and reasoning behind the clinical decisions I made for the patient;
240. I understood that in order to function at home she would need to tolerate standing and walking short distances…There is a vascular response required in an upright posture, to maintain blood circulation in the head and upper body and prevent it from pooling in the lower extremities. It is our regular activity in moving to an upright posture that maintains this response. Should we lie in bed for a long period, we lose this response and have to readapt…To walk to a chair or the toilet requires the patient to exercise gently in an upright position. This is why walking or marching on the spot is used to increase this ability…Ultimately the patient was too fatigued to benefit from the treatment at that time and we had to stop and come back on another day when she was less fatigued and less at risk of an added vasovagal response…
245. I had read what was available of the patient’s medical and physiotherapy notes. There was nothing documented to identify that the patient required a particular response to her episodes, i.e. oxygen therapy…It was clear that the patient had very low blood pressure readings as her current normal. I asked the doctor what the patient could tolerate, before going to see the patient. I suggested I would like the patient to do some marching on the spot…I made sure to monitor the patient’s blood pressure throughout the session…Although the patient was able to follow instructions and stand and step without assistance, I took my very experienced physiotherapy technician with me when I went to assess and treat her.
249. If the patient deteriorated further, we would lie the patient flat, I would pull the emergency bell and my colleagues would come. We would aim to get the patient back to lying on the bed and provide oxygen from the wall as required…It is usual for such patients to complain of not feeling right and feeling dizzy with activity. I have clearly documented the patients shifts in systolic and diastolic readings in the patient’s blood pressure during the session. The systolic reading is the blood pressure reading when the heart is contracting and the diastolic is when the heart relaxes…It is hoped that the patient adapts, as seen in the assessment on 23 May with VN, band 6 physiotherapist present.
252. On 22 May, on initial exertion the patient felt unwell, but recovered after sitting with legs elevated to assist restoration of blood flow to the brain…We attempted again to exercise. However, the patient again felt unwell, but this time it was not resolving. It seems that she may have been too exhausted, after sitting out in the chair for 2 hours. She may also have had some concern as she was working with unfamiliar people, whereas she and VN had built a relationship. It was at this point that we were joined by VN, band 6 physiotherapist…At that point there were no indications of an oxygen requirement, as blood pressure appeared sufficient. If circulation and oxygen were not reaching the brain then sitting or lying down with legs raised is the treatment required. There was nothing previous to the patient feeling unwell to indicate that we should have been monitoring her oxygen saturations during the session.
255. The patient was expected to feel dizzy and unwell as her observations changed during challenge. Although she was unable to tolerate her blood pressure changes, they were improved readings rather than deteriorating values…I understood that I was being directed through supervision to minimise investigations, keep them to essential only to optimise time management and minimise distractions. We could have removed the patient’s nail varnish and checked her oxygen saturation during the first seated rest, although we did not have any indication to do this.
257. I suspect, however, that the patient feeling dizzy and unwell was caused by the patient’s cerebral circulation and vaso-vagal restriction of cerebral blood flow and this did not impact her blood oxygen saturation. She clearly did have a cardiac issue, which is why I made sure to discuss her case with the doctor before going to see her...We have only limited notes, I was not involved with this patient at any earlier date. It appears that VN knew the patient and had been treating her previously so there should be notes from this, I recall that these notes were very limited in amount and scope.
259. I am concerned about having this patient on my list without having any handover from VN and an insight into her exercise tolerance, such as how long she was able to sit out in the chair. I may have read what this was at the time…I am also unhappy at going to treat this patient without a plan to identify and treat her episodes of deterioration over and above our normal safety procedures…This patient had been in the hospital before coming onto our ward and there should have been a better handover in the notes. It was important for me to get a handover from VN, but I did not receive this from her until she was on the ward.”

199. In the addendum to his report, having considered the Registrant’s statement, TE stated that his opinion remained unchanged.

200. In his oral evidence, TE stated that the patient's blood pressure was low, 94/55, and that, if attempts were made to stand the patient up, it would be a concern. He also confirmed that he was not aware that the patient had been wearing nail polish (which had made it difficult to obtain an oxygen saturation reading). In answer to Panel questions, TE stated that, by allowing Patient B's symptoms to settle, a reasonable body of physiotherapists would try to get the patient to exercise again. However, when asked whether SATS should have been done before getting the patient to exercise, TE agreed that he “did not spot that” and that this “moved things up closer to far below, but still below”.

201. In her oral evidence, the Registrant stated that she accepted that her clinical reasoning was “not good”. She stated that, up to the time that VN joined her, there was nothing to indicate a significant deterioration in the patient's health, although she was fatigued by sitting in her chair for two hours. When VN arrived, she took over and they treated the situation as a medical emergency. She said that she would now do things differently, such as convincing the patient to take her nail polish off so that the SATS monitor could be used. She was aware that the patient had nail polish on but it was not a strong colour and it was only when VN arrived that they realised that the SATS monitor was unable to take readings because of the nail varnish.

202. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s clinical reasoning in relation to Patient B was “unacceptably low” and therefore represented a lack of competence. It considered that, having observed that the patient's blood pressure was low, the Registrant should have commenced monitoring the patient’s SATS far earlier than she did. She gave evidence that she was aware that the patient was wearing nail polish and that this hampered the use of the SATS monitor and as stated by her in her oral evidence, she should have had the patient take off the nail polish. The Panel also noted the Registrant’s evidence that, after VN arrived, they treated it as a medical emergency which, in the Panel's view, emphasised the seriousness of the matter.

203. The Panel then went on to consider whether the standard of the Registrant’s clinical reasoning fell unacceptably low in relation to Patient E,

204. The Panel took into account all the evidence as set out above in its decision on facts. It reminded itself of its factual findings. The Panel had found that the Registrant’s thinking was muddled and that her clinical reasoning for carrying out chair exercises was unclear. Furthermore, the Registrant recorded that she had carried out a functional assessment of the patient’s limb strength, contrary to what she then stated in her oral evidence. The Panel considered that this omission was particularly important because the patient had a diagnosis of heart failure and ascending stairs would put additional stress on their cardio-vascular system.

205. The Panel also reminded itself of the evidence of TE. Notwithstanding TE’s lack of criticism of the Registrant’s decision to use the stairs, he confirmed in his oral evidence that the Registrant’s clinical reasoning was borderline as to whether it was below or far below the standards expected of a Band 5 Physiotherapist.

206. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s clinical reasoning in relation to Patient E was “unacceptably low”, and therefore represented a lack of competence, primarily due to the fact that the Registrant had not carried out a proper functional assessment of limb strength when confronted with a patient who had had heart failure.

207. The Panel then went on to consider whether the standard of the Registrant’s clinical reasoning fell unacceptably low in relation to Patient F, which allegation the Registrant had admitted.

208. The Panel noted the evidence of JG and the Registrant, given by them during the facts stage in relation to the Panel's findings under Particular 1(d) (risk assessment). The Panel reminded itself that the Registrant had attempted to get Patient F to use a gutter frame, notwithstanding that an attempt, the day before, to have the patient use a mini lift (a more supportive piece of equipment) had failed.

209. The Panel noted the evidence of TE who indicated that:
“2.14 Patient F (Exhibit 10)
Clinical notes record that on 25.11.19, in a joint session with an Occupational Therapist (OT), the Registrant assessed Patient F’s ability to use a minilift aid to be able to move from sitting to standing (STS). The conclusion to this assessment was “unable to use minilift … to go home with hoist for transfers”.
Clinical notes record that on the 26.11.19 the Registrant proposed and trialled the use of a gutter frame for Patient F to be able to stand for personal care. JG contends that this represented a lack of clinical reasoning.
Patient F had been assessed the previous day as being unable to stand with the aid of a minilift. The minilift is a standard mobile aid providing variable levels of assistance according to the ability of the patient. It offers significantly more assistance than a gutter frame which is only of use once the patient is in a standing position.
It is my opinion that to propose and trial the use of a gutter frame for a patient who is unable to move from sitting to standing with the aid of a minilift represents a lack of understanding of the relative uses of the two pieces of equipment, and of the physical needs of the patient, and would represent a failure to meet Standard 14.9, Standard 14.10, and Standard 4.12. This would fall below, but not far below, the standard expected of a reasonably competent Physiotherapist.”

210. In the addendum to his report, having considered the Registrant’s statement, TE stated that:
“Patient F
My opinion remains unchanged. The Registrant does not appear, in her statement, to appreciate that to move from sitting to standing with a gutter frame takes appreciably more strength and balance from the patient, and more assistance, than doing so with a Stand Aid or a Mini Lift. This demonstrates a lack of clinical knowledge and a lack of clinical reasoning.”

211. In his oral evidence, TE stated that it was sometimes possible to explore all options but this was not a good clinical decision because it was unlikely to work. Mechanical aids for mobility worked on the “ladder principle” in order to find the most convenient aid that was safe. In this case, almost the top intervention had been tried (the mini lift) and had failed, so to “go down the ladder” and try a less supportive aid was not logical.

212. In answer to Panel questions, TE confirmed that the Registrant had demonstrated “very poor clinical reasoning” but he did not change his categorisation that she had fallen simply “below” the standards expected. As two physiotherapists were present, the exercise was “not too high up the scale of risk”, but it was “pointless”.

213. The Panel agreed with TE that the Registrant’s actions demonstrated very poor clinical reasoning, not only being a waste of time but also not taking account of the patient's deteriorating condition. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s clinical reasoning in relation to Patient F was “unacceptably low” and therefore represented a lack of competence.

214. The Panel then went on to consider whether the standard of the Registrant’s clinical reasoning fell unacceptably low in relation to Patient G, which allegation the Registrant had admitted,

215. The Panel noted the evidence of JG and the Registrant given by them during the facts stage in relation to the Panel's findings under Particular 1(d) (risk assessment). The Panel reminded itself that the Registrant had found Patient G slumped in a very low chair and leaning to one side. He engaged in a small amount of conversation and the Registrant wanted to try and see if he was able to stand up, in order to change his pad. The Registrant knew that that the patient had managed a 15 second stand when treated before but this apparently had not been very effective. Nonetheless, the Registrant wanted to pursue the stand. JG and the Registrant tried to get Patient G to stand but, after two attempts, JG stated that he needed hoisting back to bed.

216. The Panel noted the evidence of TE who indicated that;
“Patient G (Exhibit 1, Appendix 8; Exhibit 17)
Notes from two supervised sessions evidence that Patient G was very frail and unwell medically. The opinion of the multidisciplinary team (MDT) was that the patient was deteriorating medically, but the Registrant continued in attempts to get him to stand up from an unsuitably low chair.
It is my opinion that failure to accurately assess a patient’s medical condition, despite medical advice, and to continue ask a patient to attempt activities for which they are not medically or physically fit would represent a failure to meet standards in Sections 4 and 14 of the HCPC Standards of Proficiency (pre-Sept 2023) for Physiotherapists, and would fall far below the standard expected of a reasonably competent Physiotherapist.”

217. In the addendum to his report, having considered the Registrant’s statement, TE stated:
“Patient G
The Registrant offers no clear rationale for asking Patient G to stand. She states that her objective was to maintain range of movement and to prevent deterioration. This could have been done safely using active, active assisted, and passive movements with the patient lying on his bed.”

218. In his oral evidence, TE was asked by Mr Halliday whether his opinion would change if the Registrant was actually carrying out an assessment rather than treatment. TE stated that, if a patient was in a poor medical condition, a physiotherapist could start the assessment in bed and, if they concluded that the patient was capable of doing more, would move on to the next supported position of sitting. Assessment or treatment involved always “working up a ladder”. However, TE could not see that this had been done. He was then asked whether, if it had been an assessment, TE would classify the Registrant’s clinical reasoning to “below” rather than “far below”. TE responded in the negative because this was still putting the patient at risk by doing something which he was not capable of doing.
219. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s clinical reasoning in relation to Patient G was “unacceptably low” and therefore represented a lack of competence. It considered that, the Registrant appeared to be trying something that was likely to be of no assistance to a patient who was in a very poor clinical condition. The Panel particularly took account of TE’s opinion that, against medical advice, to continue to ask a patient to attempt activities for which they were not medically or physically fit would fall far below the standard expected.

Particular 1(d)
220. The Panel then went on to consider whether the standard of the Registrant’s risk assessments fell unacceptably low in relation to each of the matters found proved in Schedule B, beginning with Patient A, which allegations the Registrant had admitted.

221. The Panel noted the evidence of JG and the Registrant recorded above in consideration of the Panel’s findings under Particular 1(c) (clinical reasoning). The Panel reminded itself that the Registrant had, in relation to the incident on 11 March 2019, taken no action to regulate the patient's oxygen saturation before treating him, notwithstanding that she had a number of years’ experience in her previous employments.

222. The Panel noted the evidence of TE who indicated in his report that:
“Patient A (Exhibit 7) – see para 2.9.
It is my opinion that to fail to foresee the inherent risk in asking a patient with reduced oxygen saturation levels of 83% to undertake strenuous exercise, and to proceed with treatment without addressing the levels of oxygen saturation represents a failure to meet Standard 14.15 “ to be able to conduct appropriate diagnostic or monitoring procedures, interventions, therapy, or other actions safely and effectively” and falls far below the standard expected of a reasonably competent Physiotherapist.”

223. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s assessment of risk in relation to Patient A was “unacceptably low” and therefore represented a lack of competence. It agreed with TE that, asking a patient with reduced oxygen saturation levels to undertake strenuous exercise, and to proceed with treatment without addressing the levels of oxygen saturation, was serious.

224. The Panel then went on to consider whether the standard of the Registrant’s risk assessment fell unacceptably low in relation to Patient E.

225. The Panel took into account all the evidence as set out above in its decision on facts. It reminded itself that it had found that the Registrant did not carry out an appropriate risk assessment in relation to Patient E. Apart from ensuring that she was wheeled to and from the bottom of the stairs and that two physiotherapists were always on hand, nothing else was put in place to mitigate the risks involved in a patient, who had a heart condition, climbing up and down stairs. A chair should have been provided at the landing to enable the patient to rest, irrespective of whether or not the patient declined such an offer. Furthermore, the Registrant’s suggestion that, had the patient felt fatigued earlier on the descent of the stairs, she could have sat on the stairs, in itself had a high inherent risk. To sit on the stairs would require significant effort, as would returning to standing, placing additional stress on the patient’s cardiac abilities.

226. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s assessment of risk in relation to Patient E was “unacceptably low” and therefore represented a lack of competence. It particularly agreed with the conclusions of TE, that a failure to foresee the inherent risk in asking a patient with limited physical ability to climb and descend a full set of stairs, with no provision to be able to sit down or rest during the exercise was serious. This was particularly so when a flight of 3-4 of steps with a double handrail, designed for therapy and assessment was available.

227. The Panel then went on to consider whether the standard of the Registrant’s risk assessment fell unacceptably low in relation to Patient F.

228. The Panel took into account all the evidence as set out above in its decision on facts. It reminded itself that it had found that, apart from ensuring that two physiotherapists were always on hand, nothing else was put in place to mitigate the risks involved in asking Patient F to attempt to use a gutter frame. Patient F could not stand unaided and on the previous day had only achieved a “3/4 stand” once and was unable to do more; and who had been unable to use the mini lift.

229. Having considered all the above factors, the Panel concluded that the standard of the Registrant’s assessment of risk in relation to Patient F was “unacceptably low” and therefore represented a lack of competence. It agreed with the opinion of TE that the gutter frame was “inherently unstable” and, therefore, despite the presence of two physiotherapists, the apparent failure of the Registrant to appreciate this, particularly when a more appropriate aid (the mini lift) had been tried and had failed, was serious.

230. The Panel then went on to consider whether the standard of the Registrant’s risk assessment fell unacceptably low in relation to Patient G. Patient G was a frail and deteriorating patient that the Registrant considered should be encouraged to stand up from a very low chair.

231. The Panel took into account all the evidence as set out above in its decision on facts. It reminded itself that it had found that the Registrant had accepted that she had not specifically considered all the risk factors (such as the effect upon the patient of his being subjected to strenuous physical activity). Moreover, despite being aware that the patient was fatigued and therefore interaction with him was potentially futile, the Registrant nonetheless preceded to attempt to have him stand. Finally, the Registrant had also said that they should have assessed his ability to stand from the bed, which demonstrated an absence of assessment of risk at the time.

232. The Panel also reminded itself of TE’s opinion. TE said that to fail to foresee the inherent risk in asking a patient, who was frail and medically unwell, to undertake a strenuous physical task from a mechanically compromised position, in this instance to stand up from a low chair, represented a failure to meet Standard 14.15. It also fell far below the standard expected of a reasonably competent Physiotherapist.

233. Having considered all the above factors, the Panel had little hesitation in concluding that the standard of the Registrant’s assessment of risk in relation to Patient G was “unacceptably low” and therefore represented a lack of competence.

Decision on Impairment
234. In reaching its decision on impairment, the Panel has taken account of the submissions of the representatives and the advice of the Legal Assessor. It has also taken account of the HCPC Practice Note “Fitness to Practise Impairment”.

235. The Panel is aware that, in determining whether fitness to practise is impaired, it must take account of a range of issues which, in essence, comprise two components, namely the ‘personal’ component (the current competence and behaviour of the individual Registrant) and the ‘public’ component (the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession). It appreciates that not every finding of a lack of competence will automatically result in a Panel concluding that fitness to practice is impaired. Moreover, it cannot adopt a simplistic view and conclude that fitness to practise is not impaired simply on the basis that, since the allegation arose, a Registrant has corrected matters or “learned their lesson”. Although the Panel’s task is not to punish past wrongdoings, it does need to take account of past acts or omissions in determining whether a Registrant’s present fitness to practice is impaired. In addition, when assessing the likelihood of a Registrant causing similar harm in the future, the Panel should take account of both the degree of harm, if any, caused by a Registrant and that Registrant’s culpability for that harm. Finally, the Panel is to consider whether a Registrant has demonstrated insight into their failings.

236. The Panel was also aware that:
• The existence of impairment is a matter for the Panel’s own independent judgment or assessment.
• In assessing current impairment, the Panel is looking at the past to assess the present - Sir Anthony Clarke in Meadow v GMC [2007] 1 All ER 1
“In short, the purpose of fitness to practise proceedings is not to punish the practitioner for past misdoings but to protect the public against the acts and omissions of those who are not fit to practise. The FPP thus looks forward not back. However, to form a view as to the fitness of a person to practice today, it is evident that it will have to take account of the way in which the person concerned has acted or failed to act in the past.”
• Cohen v General Medical Council [2008] EWHC 581 (Admin) suggested that at the impairment stage the tribunal should consider whether the conduct (i) is easily remediable, (ii) has been remedied; and (iii) whether it is highly unlikely to be repeated.
• In CHRE v NMC and Grant, the High Court considered that an appropriate approach for panels considering impairment might be that which was formulated by Dame Janet Smith in the report to the Fifth Shipman Inquiry and reminded panels that, in addition to any risk to the public, they should consider whether the need to uphold professional standards and public confidence in the profession would be undermined if a finding of impairment were not made.

237. The Panel began by considering whether the Registrant’s lack of competence is remediable. It determined that in principle it is. However, the Panel also noted the Registrant’s career history, in that she had been subject to fitness to practise proceedings in 2012, which resulted in her being required to adhere to conditions of practice for some six years (from 2012 to 2018). One of the areas of concern for the 2012 panel was time management, which the 2018 panel found to have been remedied. However, the Registrant’s lack of competence regarding time management once again began to be questioned within months and by October 2018. The Panel therefore bore in mind that the Registrant’s improvement in her time management had not been sustained.

238. The Panel reviewed the Registrant’s evidence, both written and oral, to establish the extent to which her lack of competence had been remedied. The Panel determined that she had not demonstrated that it had been, for the following reasons.

239. The Panel noted the Registrant’s written statement, particularly the Section entitled ‘Reflection and Remediation’, in which she stated:
“498.With hindsight, I am remorseful for the potential risks to patients A, B and G and for how I should have worked better for patient F.
499. I believe I have been developing the knowledge and insight, cognitive and communication skills to ensure that this will not happen again.
500. I am remorseful for the pressure that I placed on colleagues at that time and for the potential damage to the confidence of patients, families and the public that my actions could have caused.
501. I am currently still building on this skill development and I will follow this by mapping my next steps, so that I can do what will be right for me.
502. I am more aware of how I am impacted by different work environments and cultures. I explored my personal values and priorities on my DBT course. I know how to access a work coach and what paperwork and discussion to have with a new manager to properly support my mental health.”

240. The Panel accepted that the Registrant is remorseful. It also noted that the Registrant appeared to consider that her remediation is, as yet, incomplete, by her use of the phrase “I am currently still building on this skill development and I will follow this by mapping my next steps…” in paragraph 501 of the Registrant’s witness statement, referred to above.

241. The Panel noted the Registrant’s evidence regarding her lack of an induction into the Rehabilitation Unit and that she has stated that she now recognised that she needs a clear and comprehensive induction into any new role. The Panel noted that the Registrant was apparently complimentary about the induction that she received as part of her previous rotation with the Orthopaedic team. In her witness statement she said:
“69. When I started working at St Richard’s Hospital in October 2018, I was approached by MM, who was one rotation ahead of me. She told me they had a system where the band 5 physiotherapist who was one rotation ahead of the new band 5 would show them around. She did.
70. I got on well with MM and I found her to be a capable and supportive peer and mentor.”

242. However, the Panel noted the evidence of LO, who stated that:
“ln February 2019, Jenny Rudston was due to finish her rotation with the Orthopaedic team and move onto her rotation within the Rehabilitation team. MW met with her in the summary meeting which occurs at the end of each rotation and spoke to her about the various objectives she had achieved during that rotation. During this meeting, MW also informed Jenny Rudston that he felt she appeared to be struggling in certain areas. The notes from this meeting were then handed to the team leader for the next rotation.”

243. The Panel next went on to consider the Registrant’s work placements since January 2020. It noted her witness statement which confirmed that, from August to October 2022, the Registrant was able to shadow a senior colleague in Private Practice covering musculoskeletal physiotherapy, elderly care, balance and sports physiotherapy at the Cirencester Physiotherapy Centre and that she was pleased that he reported that she had demonstrated her physiotherapy competencies.

244. The Panel commends the Registrant’s attempts to keep her skills up to date, which is a positive step. However, the Panel also notes that her CV confirms that the Registrant has had considerable exposure to a wide variety of work environments (some six hospitals prior to the Hospital) yet still there are concerns about her competence. The Panel therefore concluded that work placements, in themselves, do not amount to evidence of remediation.

245. The Panel also took into account the Registrant’s Summary of Continuing Professional Development (2020-2021) and the list of her Continuing Professional Development activities (2024) such as the Physioplus courses in October 2021 on clinical decision-making in clinical practice and a number of certificates regarding courses undertaken. However, the most relevant courses are not current (being from 2020 and 2021) and none of the most recent courses are relevant to the Panel’s findings.

246. The Panel further noted that the Registrant attended the Imperial Enterprise Laboratory (from Imperial College, London) an online workshop with LAK, on ‘Reflecting for peak performance 2025’ but considered that it was not clear how it related to the Panel’s findings. Similarly, it is not clear how the Registrant’s current participation in the three-month Lovebrain cognitive performance programme (which she commenced on 31 January 2025) and which is understood to assist with memory, cognitive processing, creative problem solving and speed reading, relates to the Panel’s findings. The Panel considered that such topics appeared to be too generic and did not demonstrate that the Registrant has remediated the concerns in relation to her time management, clinical reasoning and risk assessment as required within her role as a Physiotherapist.

247. The Panel considered the evidence of JG at the capability appeal hearing on 10 December 2019, where she stated that the Registrant “had managed to achieve and maintain an acceptable level of risk assessments” which Mr Halliday argued meant that the Registrant had, in fact, achieved remediation regarding risk assessments. Although the Panel acknowledges the logic of the submission, it considered that it went contrary to the Panel’s own findings that it had before it a fair sample of the Registrant’s work in relation to risk assessments and that the matters admitted or found proved amounted to a lack of competence.

248. The Panel also considered the Registrant’s reflections during her time at the Hospital. However, they did not appear to bring about any improvement in her performance. For instance, she reflected in July 2019, but went on to make subsequent errors regarding Patients G and F; and similarly reflected on 8 November 2019, but made the subsequent error regarding Patient F. There was, accordingly, no persuasive evidence that her reflections in 2019 led to any sustained improvement in, or remediation of, her practice.

249. Further, the Panel noted that, in her most recent reflections, in 2025, the Registrant displayed a tendency to blame others for her mistakes. For example, she stated, “I did not have the proper conversation about this patient with my supervisor; “I did not get a sufficient handover”; “I did not have the proper conversation with my supervisor about this patient’s case,”; and “not having the proper orientation I made serious mistakes which made it very difficult for me. I found effective communication difficult ...”.

250. In conclusion, the Panel found that the Registrant’s reflections were limited and superficial and were not significantly related to her own failings. She blamed others and did not take responsibility. Accordingly, her reflections did not persuade the Panel that she understood what she had done incorrectly, why she had done what she did, and how she would ensure such failings would not reoccur. In other words, she did not have insight into her lack of competence.

251. The Panel took into account the Registrant’s evidence about her current activities. She stated that she had been unable to find work since 10 March 2020 following her dismissal by the Hospital. The Registrant also stated that:
“Since my father’s passing (Oct 2022), my work was dedicated to resolving his affairs and keeping my mother safe, independent and well. I have been assisting her to take over household and financial duties.”

252. The Panel noted that the Registrant’s current voluntary work does not appear to relate to the role of a Physiotherapist.

253. Accordingly, the Panel noted that the Registrant has not been employed in the role of a Physiotherapist for a period of 5 years. Therefore, the Registrant would be required to complete a return to practice course.

254. The Panel moved on to consider whether there was a risk of repetition and concluded that there was such a risk. It noted that there had been actual repetition of the Registrant’s lack of competence in that the 2012 Panel found that the Registrant lacked competence in a number of areas during a significant period of time and, consequently, made her the subject of a Conditions of Practice Order. This was extended at a number of subsequent reviews until discharged in 2018.

255. During this period, the Registrant failed to successfully complete a four-month probationary period in 2015 with the Basildon and Thurrock NHS Trust. The Registrant did not fulfil the role as expected and failed to demonstrate an ability to significantly improve her level of competency despite a high level of support including one-to-one support.

256. The Conditions of Practice Order was discharged on 29 May 2018. The Registrant commenced her employment at the Hospital on 8 October 2018 and, within months, she again failed to demonstrate an ability to achieve the level of competency required of a Band 5 Physiotherapist.

257. It followed that there was a significant risk of repetition were the Registrant to return to practise.

258. Accordingly, as there was also a lack of meaningful remediation and poor insight, the Panel found that the Registrant is currently impaired in relation to the personal component.

259. The Panel further found that because the Registrant’s lack of competence was unacceptably low and fell significantly short of the competence both professionals and members of the public would expect from a registered Band 5 Physiotherapist, a finding of impairment was also required in the public interest to maintain standards and public confidence in the profession. An informed member of the public and fellow professionals alike would expect the HCPC to mark such lack of competence with a finding of impairment. A failure to do so would undermine public confidence in the regulator and the regulatory process.

Decision on Sanction
260. In reaching its decision on sanction the Panel took account of all the evidence it had received, both oral and documentary (such now including a document entitled “Supplementary reflections from registrant”); the submissions of Mr Bellis and Mr Halliday; the Sanctions Policy (“SP”) document; and the advice of the Legal Assessor, which it accepted. The Panel was mindful that the purpose of sanctions is not to be punitive, although they may have that effect. It appreciated that the primary purpose of any sanction is to address public safety from the perspective of the risk which the registrant concerned may pose to those who use or need their services. It noted, however, that in reaching its decision, panels must also give appropriate weight to the wider public interest, which includes: protection of the public; the deterrent effect to other registrants; the reputation of the profession concerned; public confidence in the regulatory process; and ensuring that professional standards are upheld. In addition, the Panel noted that it must act proportionately, which requires it to strike a balance between the interests of the public and those of the Registrant.

261. The Panel reminded itself that it had found impairment of the Registrant’s fitness to practise on both personal and public interest grounds in relation to findings of inadequate time management, clinical reasoning and risk assessments relating to five patients, A, B, E, F and G.

Submissions
Mr Bellis
262. The Panel first heard from Mr Bellis, who commended the SP to the Panel. He submitted that the Panel had to act proportionately and apply the least restrictive sanction possible which was sufficient to address the concerns about the Registrant. He reminded the Panel that, as this was a lack of competence case, the sanction of Striking Off was not available at this stage.

263. Mr Bellis made various suggestions as to the Mitigating and Aggravating factors in this case.

264. In relation to the Mitigating factors, Mr Bellis stated that, whilst the Registrant had demonstrated remorse, the Panel had found that she did not have insight and had not remediated her failings. In relation to the Registrant’s health concerns identified by the Panel earlier in its determination, Mr Bellis stated that this was a matter for the Panel to decide whether they amounted to a mitigating factor.

265. In relation to the Aggravating factors, Mr Bellis suggested that these included the previous regulatory concerns (as set out in paragraphs 48 to 50 of the SP); a lack of insight (paragraphs 51 to 52); a lack of remediation (paragraph 53); and the risk of harm to patients (paragraphs 54 to 55).

266. As for the appropriate sanction, Mr Bellis confirmed that it was not the HCPC's practice to suggest any particular sanction, which was a matter for the Panel.

Previous Regulatory and Practice history
267. The Panel paused there to remind itself of the previous regulatory concerns and history of the Registrant’s practice as a Physiotherapist as set out in the previous panels’ decisions provided to it at the beginning of the Grounds and Impairment stage.

268. The Registrant qualified in 2006 and was employed as a Rotational Band 5 Physiotherapist by Barnet Primary Care from January 2007, where she worked in different departments and wards on a six-monthly rota.

269. Concerns were expressed about the Registrant’s practice which led to an informal capability process from July 2009, which was followed by a formal capability process in January 2010. In early 2011, as a result of continuing concerns about the Registrant’s competence, she was redeployed from clinical practice to an administrative role. The concerns about her lack of competence were referred to the HCPC (then HPC) and this resulted in allegations of failing to: carry out patient assessments and treatment with sufficient clinical reasoning; work effectively as a team member; communicate effectively with patients; and manage her time efficiently which spanned the period of 1 January 2007 – 7 February 2011. The Panel notes that the concerns about clinical reasoning, risk assessment and time management were duplicated in the current proceedings. It further noted these concerns commenced a year after the Registrant qualified.

270. The final hearing took place before a panel of the Conduct and Competence Committee on the 23 and 24 May 2012. The Particulars of the Allegation were accepted by the Registrant and found proved. She also admitted that her fitness to practise was impaired by reason of lack of competence. The sanction imposed was a Conditions of Practice Order for 12 months.

271. The first review of the Order took place on 7 June 2013. That panel was concerned that only one of the Registrant’s two 3-month placements had worked effectively and added that it was not satisfied that the Registrant had yet demonstrated that all the deficiencies in her practice had been remedied or that she had yet acquired full insight into her failings. A varied Conditions of Practice Order was imposed for a further period of 12 months.

272. The second review hearing took place on 2 May 2014, at which the Registrant requested an extension of the Conditions of Practice Order for a further 12 months. This request was granted.

273. The third review took place on 1 May 2015. To that panel it was apparent from the Registrant’s supervisors’ reports that she was not yet considered safe to practise as a lone worker. That panel was of the view that there would be a risk that the Registrant’s practice would not be adequately supervised outside an NHS hospital setting. Having determined that the Registrant’s fitness to practise remained impaired, that panel decided to impose the same conditions for a further period of 3 years. It also recommended that any reviewing panel would likely be assisted by any record of supervision by the Registrant’s supervisors and by references and testimonials from any employer by whom she was to be employed from May 2015.

274. The fourth review took place on 21 March 2016. This was an early review at the request of the HCPC, as a result of written information from the Basildon and Thurrock University Hospitals NHS Foundation Trust (the Basildon and Thurrock Trust) which confirmed that the Registrant’s employment has been terminated in May 2015 as the Registrant had failed to successfully complete her probationary period with the Basildon and Thurrock Trust. Documentation provided by the Basildon and Thurrock Trust indicated that the Registrant had not fulfilled her role as expected and had failed to demonstrate the ability to improve her level of competence significantly during the four-month probationary period she had been given, despite a high level of support and one-to-one supervision. That panel was told that the Registrant had been working as a Band 5 Physiotherapist intermittently on a zero hours contract, at the Sussex Community NHS Trust (the Sussex Trust) from January 2016. At the time of the early review hearing, the Registrant was working three days a week in elderly rehabilitation wards. At that review hearing, the Registrant accepted her fitness to practise was still impaired and conceded that she had not yet fully remedied the deficiencies in her practice. The reviewing panel reviewed favourable reports from the Registrant’s supervisors at the Sussex Trust but noted that these were based on a very limited period of work. That panel considered there was no evidence to show that the Registrant had fully remedied her lack of competence. It therefore found that the Registrant’s fitness to practise remained impaired and confirmed the existing order. In doing so, that panel considered the Registrant should be given a further opportunity to demonstrate that she could remedy her previous failings. It noted that the Registrant had been making concerted efforts to keep up with her continuing professional development even when not working as a Physiotherapist.

275. The fifth, and final, review, took place on 29 May 2018. The reviewing panel decided that the Registrant had remediated her failings in full and therefore discharged the conditions of practice order.

276. Some six months later, the Registrant commenced employment with the Hospital in October 2018 but was soon made subject to an informal capability process (from December 2018 to April 2019) followed by a formal capability process (from April 2019 to March 2020) following which she was dismissed in April 2020. Her appeal against dismissal was refused on 17 November 2020. Since that time, the Registrant has not been employed as a Physiotherapist.

277. In summary, therefore, the Panel has observed that for the large majority of the 14 years (2006 – 2020) of her career as a registered Physiotherapist, the Registrant has been subject to either: formal or informal capability processes; redeployment to an administrative role; or a conditions of practice order.

278. The Panel has set out the Registrant’s regulatory and practice history in such detail because it has played a significant role in its deliberations regarding sanction, as will become apparent.

Mr Halliday
279. Mr Halliday began his submissions with the candid comment that the Registrant “could have thrown in the towel” having endured a second set of regulatory proceedings following her being made subject to a conditions of practice order for six years. However, she had engaged with these proceedings which, Mr Halliday submitted, showed that the Registrant was committed to her profession and to safe practice. She had demonstrated in the past that she was capable of safe practice, the previous conditions of practise order having been discharged.

280. Mr Halliday addressed the Panel’s earlier findings regarding impairment and submitted that, whilst the Panel had not been satisfied that the Registrant had remedied her failings, it had accepted that she was remorseful. In relation to insight, Mr Halliday referred to the Supplementary Reflections that had been lodged that morning and submitted that they were detailed and were specific to the areas of concern and to the issues relevant to the case. As a preliminary point, Mr Halliday maintained that, as the Registrant had demonstrated in the past that she was able to take advantage of the benefits of a conditions of practice order, and to abide by conditions, if such was imposed by the Panel, then the Registrant would be able to continue to develop her insight and therefore ultimately remediate her failings. Mr Halliday submitted that the Registrant had taken responsibility and had shown that, where clarity about her failings had been provided, she had responded positively.

281. Mr Halliday went on to detail the mitigating and aggravating factors in this case. He accepted that there were concerns about the Registrant having repeated a number of the same failings which had led to the imposition of the previous conditions of practice order, but he maintained that the Registrant was now developing insight. He reminded the Panel that she had expressed remorse and that no actual harm had come to any patient. Furthermore, her five year break from practice meant that she would be required to complete a Return to Practice course which was another source of comfort and security for the Panel to take into account.

282. In relation to Aggravating factors, Mr Halliday submitted that none of the serious aggravating factors detailed in the SP applied to her, this not being a misconduct case.

283. As for the appropriate sanction, Mr Halliday confirmed that Taking No Action or imposing a Caution were not appropriate in this case. He did, however, commend a Conditions of Practice Order to the Panel as this would assist the Registrant. He referred the Panel to paragraph 106 of the SP and maintained that most of the factors listed therein, which indicated when a Conditions of Practice Order might be appropriate, applied to the Registrant. For instance, her insight was developing; her failings were capable of being remedied; although her failings had been persistent, this should not be a bar to remediation; conditions could include one-to-one supervision and a requirement to attend appropriate courses, including the Return to Practice course; the Registrant would comply with conditions as she had done so in the past; a review of the Conditions of Practice order would be appropriate and a condition that there be a report from the Registrant’s supervisor would assist such a review; and there was minimal risk - Mr Halliday referred to JG's evidence that, when the Registrant had been under supervision, although she made poor decisions, the risk was mitigated and consequently there was a limited risk of harm to patients.

284. In relation to paragraph 107 of the SP, Mr Halliday commented that this did not apply to the Registrant because she had engaged with the HCPC, she enjoyed her work, enjoyed helping people, and had been genuine and steadfast in pursuing her career as a Physiotherapist. Furthermore, none of the adverse factors listed in paragraphs 108, 111 and 112 applied to her. As for specific conditions, these could include conditions regarding education and training, practice restrictions (for instance in relation to patients who were receiving oxygen) and direct supervision if required.

Consideration of Supplementary Reflections
285. The Panel reminded itself of its findings regarding impairment and, in particular, whether the Registrant had insight into her actions. At paragraph 241 above, the Panel had accepted that the Registrant was remorseful and that she appeared to acknowledge that her remediation was incomplete.

286. At paragraph 256, the Panel noted that the Registrant displayed a tendency to blame others for her mistakes, and at paragraph 257, it had concluded that the Registrant’s reflections up to that point were limited and superficial and were not significantly related to her own failings. On the basis that she had blamed others and had not taken responsibility, the Panel had not been persuaded that the Registrant understood what she had done incorrectly, why she had done what she did, and how she would ensure such failings would not reoccur. Accordingly, she did not have insight into her lack of competence.

287. The Panel carefully considered the new reflections to ascertain whether the Registrant had developed insight since April of this year. It first noted that the document consists of some eight separate reflections, the first dated 23 March 2025, six dated early to mid-April 2025 and the last dated 22 May 2025, this last relating specifically to Patient B.

288. The Panel also noted that the Registrant has used several different “reflection proformas” across the reflections provided. The Panel considered that this, perhaps inevitably, has resulted in varying levels of reflection and insight being demonstrated. The Panel was unclear whether this suggested some lack of confidence and/or understanding of the reflective cycle and reflective learning.

289. As for the specific reflections, the Panel noted that pages 2-8, in the main, included bullet points of basic Exercise Physiology. However, the Panel found little reflection as to how such pathology as demonstrated by the patients concerned impacted on normal physiological behaviour. Whilst not absent completely, the reflections within these pages do not, in the Panel's judgement, show that the Registrant has taken the factual learning and applied it to the management of “poorly patients” as stated in the title.

290. The Panel also noted that in the section identified as “Evidence of Application of Learning to Own Area of Work” (which is apparent on a number of the forms) the Registrant has put in the words “For a later date”. The Panel appreciated that it would be difficult to put such theory and learning into practice if the Registrant was not currently practising or employed, but considered that it would have been possible to explore the application of the learning from a theoretical perspective and consider what she would do in the future.

291. Furthermore, the Registrant does not appear to have followed up on the “Identification of Further Review or Additional Reading/Learning Required”, namely further study around the mobilisation of unwell patients. In addition, her stated plan as to how to put her learning into practice appeared to the Panel to be couched in unspecific and very general terms, such as “Be aware of these physiological factors when approaching and assessing unwell and deteriorating patients” and that the learning “Provides pointers for discussions with seniors and colleagues when such a patient is first admitted.”

292. At pages 9-12 there is reflection on “When to Accept Deterioration in a Frail Elderly Patient”. The Panel accepts that there is some limited reflection demonstrated here, but the key learning point of “Discuss the case with the MDT and agree care plan” appears to the Panel to be simplistic as this would be a normal part of the care management for any elderly patient, and particularly frail individuals. The statement regarding applying this learning to the assessment of patients’ suitability for physiotherapy is relevant, but again, in the Panel’s view, basic.

293. At pages 13-14, there is a reflection entitled “Reflective Learning regarding Patients seen at hospital”. Once again, the Panel considered that this was at a very basic and generalised level and that there was no real analysis of what the Registrant had learned with respect of each of the five patients which were the subject of the allegations against her. Moreover, what stood out for the Panel were two observations from the Registrant, namely: “I had a different model of learning to the one in use” and “I did not have sufficient understanding of how to access the right understanding and guidance”. The Panel found these to be surprising and concerning as it considered that a registered physiotherapist should be responsible for their ongoing personal development and learning, but here the Registrant appeared to be saying that she did not have sufficient knowledge about how to access the right understanding and guidance. The Panel considered that, whilst this was a valuable reflection, in itself it was concerning as it implied that the Registrant could not fulfil the fundamental expectations of remaining up to date and knowing where to access relevant information.

294. Further, the way the statement regarding learning styles is worded implies that this is not her responsibility, and that allowances should be made, which did not reassure the Panel about what the Registrant might do differently in the future. The Panel considered that there are multiple models of learning, and many individuals, including those with additional learning needs, will identify how they best learn and apply that within their own practice. The Panel accepted that the Registrant’s method of learning was her own, but it was not satisfied that the Registrant accepted that it is her responsibility to ensure that she has a full understanding of the practitioner’s role and obligations of a registered physiotherapist.

295. At pages 15-16, there is a reflection specifically on Patient G. The Panel considered that, as it was so specific, it was a better reflection. However, the key learning points appear to contradict themselves. It stated: “The patient did not meet any criteria from this documentation to rule out sit to stand and sitting out in chair” but then went on to say “However, the patient was off his baseline, confused, unwell, deteriorating. his nutritional intake was poor. He was drowsy when seen by the dietitian.” Furthermore, the Plan to put this learning into practice: “Be aware and make sure to document increased risks and concerns regarding seeing a patient for physiotherapy and this can justify not seeing the patient for physiotherapy assessment where my role is rehabilitation and discharge planning and I am not part of the respiratory or neurological teams” appeared to the Panel to be very general and to contain very little analysis of how the Registrant would avoid the same outcome in the future.

296. At pages 17-18, there appears to be an overarching reflection regarding pages 2 to 12 above. Although mention is made of all five Patients, the Panel’s impression is that the reflections are generalised, and appear only to be listing the failings that have been identified to her by the Panel in its findings and by the expert witness.

297. Pages 19-21 purport once again to relate to Patient G. The Panel notes that it appears that the Registrant is seeking to apportion blame to others, namely MM and JG for the limited occasions when she was able to see the Patient and the librarian at the Chartered Society of Physiotherapy (“CSP”) who was not available to support her. The Panel believes that, as the Registrant was employed at the Hospital, she would have had access to learning resources through her Trust, so it has struggled to understand why she was so reliant on the CSP librarian. Whilst what is stated as having been learnt from her experience is valid, it again is not applied to the patient, nor does it indicate what she would do differently, or in future.

298. At pages 22-26 are two reflections focused on delirium. The Panel understands that this may be relevant to working in the type of environment that she found herself in at the time. However, delirium was not raised in the evidence presented to the Panel during the Facts stage as a significant issue. It is perhaps, as evidenced by JG, indicative of the Registrant identifying something of interest to her, but not specifically relevant to her practice, and expending time and effort on researching it.

299. Finally, at pages 27 to 31 there is a reflection specifically in relation to Patient B. The Panel accepts that there is some analysis about what went well and what went badly, but with regard to the latter, the Registrant simply stated “My risk assessment could have been better if I had not had that knowledge gap” with that “knowledge gap” being stated elsewhere as “The risk assessment of the session, the need for a handover, the parameters for progressing the patient, understanding the realistic prognosis. Expecting and being alert to addressing a vasovagal or medical emergency”. However, again, there is no detailed analysis as to what the Registrant would do differently.

300. In general, the Panel considered that it was particularly telling that there were no reflections on other matters raised by the Panel at the impairments stage, such as an acceptance by the Registrant of responsibility for her failings, particularly those which were resolved by the interventions of others. The Panel considered that the reflections, such as they are, were basic, incomplete and did not address how she would act in the future. The Panel also considered that they regularly lack specificity and appeared focused on what the Registrant was told in the Panel’s findings were her shortcomings.

301. Furthermore, the Panel noted that the issue of time management was mentioned only once and was not reflected upon at all. This was of concern to the Panel as time management was also a concern of the 2012 regulatory proceedings.

302. The Panel also noted that the Registrant has not provided any reflections on Particular 1(e) (the emergency bell matter). The Panel considered that this was evidence that, if faced by a challenge, the Registrant would not know how to address that challenge either by reference to her own knowledge and experience or by seeking “guidance”, for example by proactively calling on a colleague or supervisor for assistance.

303. In conclusion, the Panel considered that, at times, the Registrant has recognised what went wrong, noting that she admitted some of the particulars. It may also be that, as regards Patient B, whilst the Registrant has come close to demonstrating that she appreciated that she should have acted differently, she has not conducted similar in depth analyses of her failings with regard to the other four patients. Finally, in respect of all five patients, the Panel considers that the Registrant has failed to demonstrate that she understands how she can act in the future so as to ensure that what she did does not happen again. Accordingly, the Panel is inevitably drawn to the conclusion that the new reflections do not alter its view that the Registrant has very limited insight and has not remediated her failings.

Mitigating and Aggravating factors
304. The Panel considered whether there were Mitigating factors and found that:
• The Registrant has expressed remorse and has apologised;
• She had made some admissions in relation to the allegation against her;
• No actual harm was caused to any patient – however, the Panel considered that there was still a significant risk of harm.

305. The Panel notes that no further information has been presented to it in relation to the Registrant’s health issues at the time, so considers that its previous finding, that they did not play any part in her failings, stands and are not a mitigating factor.

306. The Panel also noted the following Aggravating features:
• The lack of any significant insight;
• the lack of any meaningful remediation, which in turn leads to an increased risk of repetition;
• The potential for harm to patients due to the Registrant’s lack of competence;
• The Registrant’s regulatory history.

307. The Panel wishes to emphasise that its concerns about the previous regulatory proceedings are that, despite having been through both an informal, and a formal, capability process, followed by a six-year Conditions of Practice Order, the Registrant, within six months of that order being discharged, and two months after commencing employment with the Hospital, found herself the subject of another capability process for the same issues which had been raised in the previous proceedings, namely Time Management, Risk Assessments and Clinical Reasoning, all such being basic and fundamental skills required of Physiotherapists. This suggests a complete failure on the part of the Registrant to understand why she continues to make the same errors, which in turn gives rise to concerns that she may struggle to understand why she keeps making the same mistakes.

Consideration of Sanction
308. The Panel first considered Taking No Action. However, given the nature and seriousness of the Registrant’s failings the Panel took the view that this was not a case that could be appropriately dealt with without a sanction. The Panel therefore went on to consider the various sanctions, beginning with the least onerous.

309. The Panel next considered a Caution Order. It took account of paragraphs 101 and 102, which state:

“101. A caution order is likely to be an appropriate sanction for cases in which:
• the issue is isolated, limited, or relatively minor in nature;
• there is a low risk of repetition;
• the registrant has shown good insight; and
• the registrant has undertaken appropriate remediation.

102. A caution order should be considered in cases where the nature of the allegations mean that meaningful practice restrictions cannot be imposed, but a suspension of practice order would be disproportionate. In these cases, panels should provide a clear explanation of why it has chosen a non-restrictive sanction, even though the panel may have found there to be a risk of repetition (albeit low).”

310. The Panel considered that none of these criteria applied to the Registrant. Accordingly, it considered that a Caution Order would be inappropriate and disproportionate to the seriousness of the Registrant’s lack of competence.

311. The Panel next considered whether it would be appropriate to impose the next most onerous sanction, that of a Conditions of Practice Order.

312. The Panel noted paragraph 106 of the Sanctions Policy which stated when a Conditions of Practice Order is likely to be appropriate. However, although the Panel accepts that the failings or deficiencies are capable of being remedied, it considers that the Registrant has very limited insight. Furthermore, the Panel considers that there are persistent concerns which might well prevent the Registrant from remediating, as evidenced by her continued failings in time management, risk assessment and clinical reasoning. Furthermore, although the Panel is confident that the Registrant would comply with any conditions that it deemed appropriate, the Panel doubted that proportionate, realistic and verifiable conditions could be formulated which were not tantamount to suspension. For instance, because of the Panel’s continuing concerns that the Registrant still poses a risk of harm to patients because of her lack of remediation and insight, a condition of direct, close and constant supervision would be deemed necessary. This may well be seen as unduly onerous by prospective employers.

313. The Panel also noted the provisions of paragraph 107 of the Sanctions Policy which states:
“Conditions will only be effective in cases where the registrant is genuinely committed to resolving the concerns raised and the panel is confident they will do so. Therefore, conditions of practice are unlikely to be suitable in cases in which the registrant has failed to engage with the fitness to practise process or where there are serious or persistent failings” [the Panel’s emphasis].

314. The Panel reminds itself that the Registrant has been practising as a physiotherapist for some 14 years yet she still makes the same mistakes in relation to the fundamental and basic skills expected of time management, risk assessment and clinical reasoning. Despite being given every opportunity to do so, the Registrant still has not demonstrated that she understands why she continues to make such errors or what she can do to remedy her practice so that those errors do not continue to be made. Accordingly, the Panel concluded that imposing another Conditions of Practice Order upon the Registrant when she still fails to demonstrate the insight one would expect from a physiotherapist of her experience, would not, in the Panel's opinion, achieve the desired result of her return to safe practice.

315. Taking all these factors into consideration the Panel concluded that a Conditions of Practice Order would not be the appropriate sanction in the Registrant’s case.

316. The Panel therefore considered imposing the next most onerous sanction, that of an order of Suspension. It noted paragraph 121 of the SP:
“A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:
• the concerns represent a serious breach of the Standards of conduct, performance and ethics;
• the registrant has insight;
• the issues are unlikely to be repeated; and
• there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings”.

317. The Panel considered each of these criteria in turn. It agreed that the concerns represent a serious breach of the standards. However, as stated above, the Registrant has not demonstrated that she has any real insight into her failings and therefore it follows that the issues are likely to be repeated. Finally, there is evidence to suggest that the Registrant is not likely to be able to resolve or remedy her failings since they have persisted for the majority of her career as a physiotherapist.

318. On that basis, it is arguable that a suspension order is not appropriate since most of the criteria outlined in paragraph 121 of the SP do not apply. However, the Panel considers that it is the most appropriate sanction for two reasons. The first is that the next most onerous sanction of striking off is not available to the Panel. The second is that the purpose of imposing a suspension order at this stage is to give the Registrant the opportunity of reflecting further as to why she continues to make the same basic and fundamental errors and ultimately to demonstrate insight.

319. The Panel therefore concludes that the most appropriate and proportionate sanction is a Suspension Order for the maximum period of 12 months, which it deems would be necessary to enable the Registrant to reflect further and develop her insight. The Panel would seek to remind the Registrant that, in her case, insight requires her, with respect to each of Patients A, B, E, F and G, and with regard to her time management, to (i) understand what went wrong; (ii) appreciate that she should have acted differently; and (iii) understand how she can act in the future to ensure that what she did does not happen again.

320. The Panel further directs that, towards the end of the 12 month suspension period, the order be reviewed. A reviewing panel would be assisted by:
a) Detailed reflections on the issues of time management, risk assessment and clinical reasoning, as outlined above;
b) Details of any continuing CPD; and
c) any references or testimonials.

321. The Panel does wish to commend the Registrant for her consistent commitment and engagement in these proceedings which is noted and appreciated by the Panel.

 

That the Registrar is directed to suspend the registration of Ms Jenny Rudston for a period of 12 months from the date this order comes into effect.

Right of Appeal
You may appeal to the High Court in England and Wales against the Panel’s decision and the order it has made against you.

Under Article 29(10) of the Health Professions Order 2001, any appeal must be made within 28 days of the date when this notice is served on you. The Panel’s order will not take effect until the appeal period has expired or, if you appeal, until that appeal is disposed of or withdrawn.

Application for Interim Order
1. Having determined to conclude this case by imposing a Suspension Order on the Registrant for a period of 12 months, the Panel heard an application by Mr Bellis for an Interim Suspension Order for 18 months (to cover any appeal period).

Application for Interim Suspension Order
2. Mr Bellis submitted that such an order was necessary on both public protection and public interest grounds on the basis that the Panel had found that the Registrant was currently impaired due to her lack of competence and had considered that she should be made subject to a Suspension Order for a period of 12 months. He reminded the Panel that the Panel had found that the Registrant did not have any real insight and had not remediated her failings. This was against the backdrop that the Registrant had struggled with capability processes and fitness to practise proceedings for almost the whole of her career. Finally, an interim order on the grounds of public protection and public interest properly reflected the Panel's decision and not to impose an interim suspension order would be inconsistent with the sanction of suspension that the Panel had considered to be appropriate in this case.

3. In answer to a question from the legal assessor, Mr Bellis confirmed that there was no current interim order against the Registrant.

4. Mr Halliday indicated that he opposed the application and submitted that, as there was no current interim order, the Registrant could have practised unrestricted. Furthermore, there would be protection for the public in that the Panel's decision would be displayed on the HCPC's website and would be there for prospective employers to check should the Registrant apply for employment as a physiotherapist. Accordingly, Mr Halliday concluded by stating that it was not necessary for the Panel to make an interim order in the particular circumstances of this case.

5. The Panel accepted the advice of the Legal Assessor, who referred it to paragraphs 133 to 135 of the SP, which state:
“What is an interim order?
133. If a panel imposes a conditions of practice order, suspension order, or striking off order, Article 31 of the Order provides the panel with the discretionary power to also impose an interim conditions of practice order or an interim suspension order. This will apply from the imposition of the substantive order, until the end of the appeal period, or where an appeal is made, the end of the appeal process.
When is an interim order appropriate?
134. The power to impose an interim order is discretionary, and so panels should not consider it to be an automatic outcome. The panel should carefully consider whether or not an interim order is necessary and should provide the parties with an opportunity to address the panel on whether an interim order is required.
135. An interim order is likely to be required in cases where:
• there is a serious and ongoing risk to service users or the public from the registrant’s lack of professional knowledge or skills, conduct, or unmanaged health problems; or

• the allegation is so serious that public confidence in the profession would be seriously harmed if the registrant was allowed to remain in unrestricted practice.”

6. The Panel also took account of the Practice Note on Interim Orders and first considered whether an interim order was necessary. It noted that the Registrant had not practised as a Physiotherapist for over five years. Moreover, it had found that the Registrant was currently impaired due to her lack of competence and that there was a lack of insight and remediation. The Panel was therefore satisfied that there was a serious and on-going risk of harm to service users and/or the public and that, for the same reasons, public confidence in the profession or the regulatory process would be seriously damaged if the Registrant was allowed to practise unrestricted.

7. Having determined that an interim order was necessary, the Panel then considered the appropriate form of such order, beginning with the least restrictive. It therefore first considered whether an Interim Conditions of Practice Order would be sufficient to protect the public, would meet the wider public interest or would be in the Registrant’s own interests. For the same reasons as given when deciding not to impose a substantive Conditions of Practice Order on the Registrant, the Panel decided that such an Interim Order would not be appropriate to manage the risks identified by the Panel and that it would be perverse to impose an order inconsistent with the substantive order of Suspension.

8. The Panel therefore concluded that an Interim Suspension Order was the appropriate and proportionate order. It also determined that it should be for a period of 18 months to cover any appeal period since, if there was an appeal, the substantive order would not come into effect.

 

History of Hearings for Jenny Rudston

Date	Panel	Hearing type	Outcomes / Status
02/07/2025	Conduct and Competence Committee	Final Hearing	Suspended
11/03/2025	Conduct and Competence Committee	Final Hearing	Adjourned part heard