Doris Anne Jones
Profession: Physiotherapist
Registration Number: PH24465
Hearing Type: Review Hearing
Date and Time of hearing: 10:00 19/05/2025
End:
17:00 19/05/2025
Location:
Virtual via video conference.
Panel: Conduct and Competence Committee
Outcome: No further action
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Allegation
As a registered physiotherapist (PH24465) your fitness to practise is impaired by reason of misconduct and/or lack of competence. In that:
1. Between February 2018 and February 2020, you did not record discharge summaries in accordance with local agreed policies.
2. Between February 2018 and February 2020, you did not complete MSK healt questionnaires for patients being discharged from your services.
3. Not proven.
4. Not proven.
5. When treating Patient B:
a. You did not undertake detailed questioning of the patient;
b. You did not ask the patient about changes in sexual function;
c. You did not complete a full neurological assessment of the patient;
d. You did not complete an assessment of the patient's back.
6. When treating Patient C:
a. You tested myotomes and dermatomes when this was not necessary;
b. Not proven.
7. When treating Patient D:
a. You did not ask all the obstetric and/or cauda equina questions required to fully assess the patient;
b. You did not do a full pelvic girdle pain assessment.
8. When treating Patient E, you did not complete the objective assessment forms.
9. When treating Patient F:
a. You did not complete a full obstetric assessment of the patient;
b. You did not complete a neurological examination of the patient;
c. You recommended an exercise that was inappropriate for the patient.
10. When treating Patient G:
a. Not proven;
b. Not proven;
c. You did not complete a back assessment for the patient;
d. You did not complete a neurological assessment for the patient;
e. Your records did not clearly record the exercises recommended to the patient.
11. Not proven.
12. When treating Patient I:
a. You did not record which myotomes and dermatomes were assessed;
b. Not proven.
13. When treating Patient J:
a. You did not complete an objective assessment;
b. You did not complete a full back assessment;
c. You did not complete a neurological assessment;
d. You did not complete an obstetric assessment;
e. You recommended an exercise, which may have been inappropriate for the patient because a risk assessment was not completed.
14. You did not carry out required vaginal examinations on Patient K, Patient L, Patient N, Patient Q, Patient R, and/or Patient S.
15. The matters set out in particulars 1 – 14 above constitute misconduct.
16. By reason of your misconduct, your fitness to practise is impaired.
Finding
Preliminary Matters
1. The Registrant and her representative were present and no matter was raised in relation to service and indeed no other further preliminary matters were raised.
Background
2. The Registrant qualified as a Physiotherapist in 1978, and after qualifying she worked in a number of different roles for a number of different employers. In 1995, the Registrant commenced employment with Mid Staffordshire NHS Trust, working at Cannock Chase Hospital. Subsequently, that Trust merged with the Royal Wolverhampton NHS Trust (“RWT”). Following that merger, the Registrant continued to work at Cannock Chase Hospital, but also at New Cross Hospital. By the time of the events which formed the basis of the Allegation faced by the Registrant she was working as a Band 7 undertaking both musculoskeletal physiotherapy (“MSK”) and women’s health physiotherapy (“WH”). She was employed on a part-time basis, working 17.25 hours a week over Mondays, Tuesdays, and Wednesday afternoons.
3. In early 2020, a Consultant Gynaecologist raised concerns about a patient (a person identified at the substantive hearing as “Patient S”) who was not making the progress that had been expected. Ms LH (WH Team Lead Physiotherapist) saw the patient and discovered that she was incorrectly undertaking exercises which she, Ms LH, considered to be necessary. Ms LH also discovered that no vaginal examination had been carried out by the Registrant. Ms LH then looked at the clinical records of other current patients assigned to the Registrant, and she discovered that the notes confirmed that vaginal examinations were not being carried out.
4. A wider investigation into the Registrant’s practice (including MSK patients) followed, and the results of that investigation are reflected in the Allegation currently being considered by the Panel.
5. Both the oral and documentary evidence provided to the Panel at the substantive hearing included information about an earlier capability process that had been undertaken with regard to the Registrant between 2016 and 2017. At the conclusion of that process, the Registrant had returned to her duties. None of the factual issues which the panel at the substantive hearing was required to decide involved matters either before or during that capability process; all of the factual particulars alleged in the referral and substantive hearing concerned alleged events following the conclusion of the capability process.
6. At the substantive hearing the Panel had made various factual findings and those are indicated in the amended Allegation set out at the beginning of this determination. Having made those finding the panel had considered the issue of the reasons for those failings and concluded that they did not stem from a lack of competence but as a result of misconduct. The panel then considered which of those factual findings could be considered as sufficiently serious as to constitute misconduct and again made a variety of decisions again indicated above on the Allegation.
7. In its determination the panel at the substantive hearing made the following observations.
8. In relation to the issue of impairment the Panel noted at paragraph 87:
With regard to the personal component, the Panel was satisfied that shortcomings of the type represented by the findings that were described as serious in paragraph 82 above are conceptually capable of being remediated. When the Panel asked itself whether the Registrant had in fact remediated them, the conclusion of the Panel was that she had not. The Panel did not overlook the fact that the Registrant has not been practising since she was suspended from the relevant employment and she has since retired. That fact would limit her ability to demonstrate remediation. The Panel also acknowledged that admissions were made by the Registrant to some of the proven particulars, and that an admission of a shortcoming in circumstances where the practitioner has the ability to perform the task goes some way towards suggesting that the issue might not recur. Again, the Panel acknowledged that the Registrant provided some reflective comments, but these were partial. Overall, the Panel would categorise the Registrant’s insight as limited. When the Panel stood back and asked itself the question of whether there was a risk of repetition, the answer to that question was that it could not be said there was no risk that issues of the type identified by the findings would recur. For this reason, the Panel concluded that the Registrant’s fitness to practise is impaired upon consideration of the personal component.
9. In relation to the imposition of a sanction the Panel noted at paragraph 95:
‘The Panel considered that the fact the shortcomings underpinning the Panel’s findings occurred a very short time after the earlier capability process was one which added to the seriousness of the case. That capability process took place in 2016 - 2017, and concluded with the Registrant being deemed fit to return to practice as a Band 7 practitioner. The risk of harm to patients has already been mentioned in explaining why the findings identified as serious justified a conclusion of misconduct, but it was one which was relevant in deciding the issue of sanction. The risk of future harm already described by the Panel arose because the Panel found that the Registrant’s insight into her actions was not complete, and that in part was because she had not accepted full responsibility for her own professional failings. The Panel accepted that there was no evidence the condition of any patient was positively worsened by the Registrant’s acts or omissions, but there was evidence that the physical recovery of Patient S was delayed, as was her return to work as a consequence. Additionally, there was a risk that patients would lose confidence in physiotherapy intervention if treatments were not appropriately undertaken.
The Panel in paragraph 96 went on to record:
‘In favour of the Registrant, the Panel took account of a number of factors. There had been no previous fitness to practise issues recorded against the Registrant, and she had submitted a very positive testimonial from a former colleague. Further, it accepted that it was the Registrant herself who referred the fitness to practise concerns to the HCPC, and thereafter she had fully engaged in the fitness to practise process. It was also fair to record that the Registrant admitted some (but not all) of the matters found proved by the Panel, and that she had expressed an apology and remorse in relation to her admitted failings.’
10. During the Panel’s consideration of whether to impose a condition of practice upon the Registrant’s registrant it noted at paragraph:
‘…..However, the conclusion arrived at by the Panel was that there would be no difference in substance between any conditions that could be formulated now and the regime under which the Registrant worked while undergoing the 2016 - 2017 capability process, which proved not to have any lasting effect. It followed that when the Panel had regard to the factors listed in paragraph 106 of the Sanctions Policy as those which are likely to be presented in conditions of practice cases, there were a number which did not apply in the present case. In short, in the light of the history of the earlier capability process, the Panel could not be confident that the imposition of conditions of practice would reduce the risk of harm to a sufficiently low level that the Registrant should be able to return to practice even while subject to those conditions.’
11. The panel at the substantive hearing having discounted the imposition of a Conditions of Practice Order considered the imposition of a Suspension Order, which appeared to the Panel the appropriate measure. However before confirming this as the proportionate sanction that panel considered Striking-off Order should be imposed and came to the conclusion that this would be disproportionate in all the circumstances of the case. The one-year suspension order imposed by that panel comes to an end on 28 May 2025. In making that order the Panel indicated to the Registrant that having made a finding of misconduct she should be aware that a future reviewing panel had the same range of options as this substantive hearing panel and that included a Striking Off Order which would permanent removal from the register from the Register.
HCPC
12. The HCPC stated that it was neutral on the issue of whether the Registrant had demonstrated her fitness to practise and it was a matter for the Panel’s judgment.
Registrant
13. The Registrant’s Representative submitted that the previous panel’s decision showed that it considered that the failings identified were capable of being remedied. It was submitted that the documentation supplied by the Registrant showed she had accepted the findings of that previous panel and produced evidence that she had identified and remediated her previous failings. It was submitted that this was the case, notwithstanding that she has been unable to demonstrate this within a clinical setting.
14. The criticism of the Registrant that she had not gained sufficient insight into the events which had led the previous panel to find that there was a risk of repetition, had, it was submitted, been addressed through the deep reflection undertaken by the Registrant and which she has expressed within her lengthy reflective piece of writing. The Panel should also take into account the significant amount of CPD undertaken by the Registrant which demonstrated her current level of knowledge. The Registrant’s Representative stated that ‘going forward’ the Registrant had no intention to practice again, having effectively retired in 2020. This being the case there was no future risk of repetition.
15. If the Panel found that the Registrant’s fitness remained impaired it was suggested that the Panel may wish to exercise taking no further action or the imposition of a Caution Order. Both it was suggested would be appropriate and proportionate. Conditions of Practice could be considered appropriate to the circumstances of this case and would have to be drafted to reflect the fact that the Registrant had been out of practice for some length of time. In the Registrant’s Representative’s view, extending the period of suspension or a Striking-off Order would be disproportionate.
Decision
16. The Panel noted that at this review the onus was upon the Registrant to provide evidence that she had successfully addressed the matters which had been established as falling below that expected of a registered physiotherapist.
17. The Panel noted that at the substantive hearing the panel had not provided the Registrant with a suggested list of matters she should present on review but had chosen to leave that to the discretion of the Registrant. The Panel had before it today a substantial bundle of evidence from the Registrant which consisted of:
• Reflective piece of writing of 12 pages.
• Statement of 2 Pages
• A trial exercise programme of 6 pages.
• Trial on Fermor Acetabular impingement rehabilitation (FAIR)of 15 pages.
• Record of the Registrant’s rehabilitation of 6 pages.
• Extensive CPD record of 53 pages which included (amongst other things) details of 26 online courses relating to key areas of practice and 5 research papers specifically aimed at red flag events.
18. The Panel noted the submissions made by the parties. The Panel sought and accepted the advice of the Legal Assessor and applied that advice to its consideration of whether as of today, the Registrant’s fitness to practise remains impaired. In undertaking that task the Panel appreciated that this is a review process and not a rehearing of the matters previously alleged.
19. The Panel noted at the outset the Registrant’s stated position, which is that she has not practised since 2020 and to all intents and purposes she had retired. She has stated that she does not intend to return to practice and would have been fully retired if it were not for this continuing HCPC process. Her future intentions are to spend more time with her family and to dedicate herself to local community programmes.
20. The Panel took the opportunity of asking the Registrant questions about how her courses of study reflection during the last year had informed her thinking. The Registrant’s responses demonstrated that she had gained good insight into what the issues were that had previously led to a finding of impairment. The Panel gave careful consideration to the reflective piece of writing and has concluded that this demonstrated full insight into what should have been done in terms of altered approach, initial assessments, questioning of service users, treatment and recording. The Registrant was also able to explain fully how she would implement this learning in the future.
21. In terms of record keeping, the Panel noted that within the Registrant’s review of her own health condition, which she had taken as a case study, she had made and produced detailed and concise clinical notes which were of a standard expected of a Band 7 practitioner. The Panel gave the Registrant great credit for her intellectual creativity in identifying her own health condition as a means to demonstrate process and clinical reasoning, in the absence of her being able to see patients. That was a sensible way of being able to demonstrate knowledge, understanding and application of a well-known Australian protocol for addressing hip issues. This had been accompanied by photos and commentary which set matters out in a logical and understandable format.
22. The documentation showed that the Registrant had recognised her shortcomings and had identified what she should have done and expressed an understanding of what she ought to have done. The only element the Registrant has not been able to demonstrate is the application of that knowledge and understanding which she could not do whilst suspended. The Panel considered that on all levels the Registrant had been able to demonstrate remediation other than in practical clinical surroundings and was able to conclude that on the personal component the Registrant had been able to demonstrate full remediation.
23. Whilst the Panel considered that the risk of repetition was negligible this lack of clinical application was of concern to the Panel. Members of the public may be concerned about a practitioner, who has had no experience in five years, and who had previously had concerns about their practice identified on two occasions returning to practice. In this regard, the Panel noted that as the Registrant had been out of practice since 2020 and a HCPC mandatory Return to Practice requirement of no less than 60 days duration was necessary. This course would, in the Panel’s view, address any limited residual concerns it may have in relation to the public protection.
24. In relation to the wider public interest the Panel considered evidence from the Registrant of full remediation and the successful completion of a HCPC mandatory Return to Practice requirement would fully address any concerns the public may have about her ability to function as a fully autonomous practitioner. The Panel therefore makes a finding of no current impairment in the wider public interest.
Order
ORDER: The Registrar is directed to allow the current suspension order placed upon Doris Anne Jones to lapse on the 28 May 2025.
Notes
No notes available
Hearing History
History of Hearings for Doris Anne Jones
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 19/05/2025 | Conduct and Competence Committee | Review Hearing | No further action |
| 15/04/2024 | Conduct and Competence Committee | Final Hearing | Suspended |