Gary Bell

Preliminary Matters

Service

1. The Panel first considered the issue of service as the Registrant was not in attendance.

2. The Panel had been provided with the Registrant’s electronic mail address within the Certificate signed by the Registrar dated 24 March 2025.

3. The Panel had also been provided with the Notice of Hearing letter dated 24 March 2025 sent to the Registrant, on that date, to his registered electronic mail address. This confirmed the dates (12 – 15 May 2025) and times of the hearing as well as informing him that this would be a virtual hearing. It also offered the Registrant an opportunity to attend and/or make submissions at the hearing.

4. The Hearings Officer submitted that good service had been effected.

5. The Panel accepted the advice of the Legal Assessor who referred to the Health Professions Order 2001 and the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (“the Rules”), namely rule 6. The Legal Assessor advised that good service would be effected by notifying the Registrant of the time, date and venue (virtual) of the hearing at his registered electronic mail address, with 28 days’ notice.

6. The Panel was satisfied on the evidence before it, that fair, proper and reasonable notice of the hearing today had been served on the Registrant, having been sent to the Registrant at his registered electronic address on 24 March 2025. The Panel therefore determined that notice had been properly served in accordance with the Rules.
Proceeding in Absence

7. Mr Tobias submitted that the Panel should proceed in the Registrant’s absence. He submitted that the Registrant has waived his right to attend. Mr Tobias referred the Panel to an email contained in the bundle from the Registrant to the HCPC, dated 06 May 2025. In part, this states:

‘will I attend? No
will I have representation? No’

8. Mr Tobias submitted that the Registrant is not asking for a postponement or adjournment, and he has chosen not to attend, and waived his right to representation. Mr Tobias submitted that any adjournment would cause a significant delay to the proceedings being concluded, due to the current listing times.

9. Mr Tobias submitted that there is a public interest in proceeding with the case as soon as possible, and that the HCPC professional witnesses have made themselves available to give evidence today.

10. Mr Tobias submitted that proceeding in the absence of the Registrant was likely to create some disadvantage, resulting from the Registrant’s decision not to attend.

11. The Panel heard and accepted the advice of the Legal Assessor in relation to the factors it should take into account when considering proceeding in the Registrant’s absence. This included reference to rule 11 of the Rules and to the case of GMC v Adeogba [2016] EWCA Civ 162, R v Jones (Anthony) [2003] 1AC1 and Sanusi v GMC [2019] EWCA Civ 1172. The Panel also had regard to the HCPTS guidance ‘Proceeding in the Absence of the Registrant’ dated June 2022.

12. The Panel considered all the information before it, together with the submissions made by Mr Tobias on behalf of the HCPC. The Panel was satisfied that the notice of hearing letter had been sent to the Registrant on 24 March 2025 informing him of today’s hearing.

13. The Panel took into account the Registrant’s email to the HCPC as set out above.

14. The Panel concluded that it was reasonable and in the public interest to proceed with the hearing in the absence of the Registrant for the following reasons:

• The Registrant has shown himself able to communicate with the HCPC and has confirmed that he will not attend the hearing nor be represented. The Panel concluded that he had voluntarily and deliberately absented himself.

• The Registrant had not sought an adjournment of the hearing and there was no indication from him that he would be willing or able to attend on an alternative date. Therefore, re-listing this hearing would be unlikely to secure his attendance.

• The Panel recognised that there may be some disadvantage to the Registrant in not being able to make oral submissions. However, the Panel was content that the Registrant had been provided with sufficient notice, and he has provided a written document and testimonials, which the Panel can take into account when reaching its decision.

• The Panel considered that the public interest in proceeding with final hearings expeditiously, particularly as the professional witnesses are ready and able to give evidence, outweighed any disadvantage to the Registrant and concluded that the hearing should proceed in his absence.

Hearsay Application

15. Mr Tobias applied for two of the HCPC witness statements and exhibits to be admitted as hearsay evidence. The statements and exhibits had been provided to the Panel in advance of the hearing and were contained in the main hearing bundle.

16. Mr Tobias referred the Panel to his written hearsay application, as set out in the case summary. He also referred the Panel to the hearsay bundle which contains email correspondence between the HCPC and the two witnesses.

17. The application relates to the following witnesses:

• Witness ‘ML’, who at the time she signed her HCPC witness statement (17 August 2023) was a Registered Nurse. At the time to which the Allegation relates, she worked as the ward manager at Park Hill Hospital (“the Hospital”) along with the Registrant who worked as an Operation Department Practitioner (“ODP”).

• Witness ‘SS’, who at the time she signed her HCPC witness statement (25 January 2024) was a Registered Nurse. At the time to which the Allegation relates, she worked as a staff nurse at the Hospital.

18. Mr Tobias made the following written submissions which he adopted as part of his oral submissions:

‘The application is made to admit the following:

a. Witness statement of ML dated 17 August 2023 and exhibit ML1. The statement is hearsay as ML is not available to give oral evidence due to ongoing health issues.

b. Witness statement of SS dated 25 January 2024 and exhibit SS1. The statement is hearsay as SS is not available to give oral evidence due to being on holiday outside of the jurisdiction.

Sole and decisive

There is evidence from other sources to support the hearsay statement of ML.
The witness statement of SF [Theatre Manager at the Hospital] states how she was told about the incident on 25 March 2021 by ML. SF then spoke to the Registrant and reported the incident on the system.
There is evidence from other sources to support the hearsay statement of SS.
The witness statement of SF states how she was informed by SS on 26 March 2021 of the incident. SF then spoke to the Registrant and reported the incident on the system.

Challenge to the evidence

It is accepted that neither ML nor SS will give evidence in person, and therefore not open to cross-examination, however the admission of the statement and exhibits as evidence is to be balanced by the panel in terms of the weight given to it. There is no absolute right to cross-examine a witness.

Fabrication of evidence

There is nothing to suggest either ML or SS have fabricated the allegations, there is other evidence which supports the allegations, and there is no cogent reason to suggest otherwise.

Seriousness of the allegation

The allegations are serious, as they involve allegations about the Registrant’s conduct in relation to patient checks that were not carried out and therefore placing patients at risk.

Good Reason for ML and SS non-attendance

ML has signed her statement as being true to the best of her information, knowledge and belief.
[redacted]
Despite numerous efforts to engage ML, as shown in the bundle, she has indicated clearly that she will not engage in the proceedings further, and will not provide medical evidence… as she is not obliged to.
SS has signed her statement as being true to the best of her information, knowledge and belief.
Despite numerous efforts to engage SS, as shown in the bundle, she has explained that she is not available as she is away on a pre-booked holiday.
The HCPC has decided to apply to admit the evidence as it has not been possible to secure the attendance of either ML or SS in all the circumstances.

Submissions

It is submitted that it would be fair to rely on both the evidence of ML and SS as hearsay when assessing other evidence to be provided to the Panel.
It is further submitted that the evidence of the both is relevant to the case and supports the allegations.
The Registrant will have the opportunity, should he so choose, to give his account as to why the allegations are either true or not true. The fact that he will not be able to ask questions of either ML or SS, does not make the admission of the evidence unfair.
The Panel will also be able to apportion appropriate weight to the evidence once they have had the opportunity to consider all the evidence in the case.’

19. The Panel heard and accepted the advice of the Legal Assessor in relation to factors it should take into account in considering a hearsay application. The Legal Assessor referred to the principles derived from the cases of: Thorneycroft v Nursing and Midwifery Council [2014] EWHC 1565 (Admin), and Mansaray v Nursing and Midwifery Council [2023] EWHC 730. The Legal Assessor referred the Panel to the HCPTS Practice Note entitled ‘Evidence’ dated October 2024, paragraphs 31 – 36.

20. The Panel began its deliberations by asking itself whether the admission of the evidence would undermine the Registrant’s right to a fair hearing. The Panel took into account its duty to protect the public as well as its duty to ensure that hearsay evidence should only be admitted if it is relevant and fair.

21. The Panel considered the application in accordance with the approach set out in Thorneycroft v Nursing and Midwifery Council [2014] EWHC 1565 and the non-exhaustive list set out in the HCPTS Practice Note on Evidence.

22. The Panel considered that neither the evidence of ML or SS is the sole or decisive evidence in relation to any of the Particulars of the Allegation. Whilst the statements both contain first hand accounts from ML and SS there is other evidence relating to those accounts including some admissions by the Registrant.

23. In relation to the evidence of ML, this relates to Particular 3. The Panel took into account that ML raised the concern with SF, who in turn spoke to the Registrant about the concern. SF is giving oral evidence, and she exhibits to her statement a copy of the report she made on the Hospital’s incident system at the time of the events which includes details of her conversation with the Registrant. ML also exhibits to her statement a copy of the report she made on the Hospital’s incident system at the time of the events. There is also an investigation report exhibited in which the Registrant’s responses to the concern raised by ML are noted.

24. In relation to SS, this evidence relates to Particular 4b. The Panel took into account that SF provides evidence about this, having been informed about the events on the same day. SF then spoke to the Registrant about the concern raised by SS. Both SF and SS completed contemporaneous incident reports which are exhibited to their statements. SF’s report includes details of her conversation with the Registrant about the concern raised by SS. The investigation report also includes the Registrant’s responses to the concern raised by SS.

25. In relation to the nature of the material, the Panel noted that the statements were made in 2023 and 2024 and are primarily based on contemporaneous statements made in 2021, at the time, as part of the Hospital incident reporting process. ML and SS were both registered professionals at the time they made the statements to the HCPC. Their signed statements contain a statement that its contents were true to the best of their information, knowledge and belief. The Panel considered that these factors lend weight to the credibility and truthfulness of the contents. In terms of challenge to the content, the Panel took into account that the Registrant states that ‘some of the statements by other members of staff had facts that were simply not true or they were trying to quote me using their words, not what I would or had said.’ However, the Registrant does not specify whose statements for which part of those statements he means. In any event, in relation to Particular 3, the Registrant admits this Particular of the Allegation, and therefore does not seek to challenge ML’s statement in so far as it relates to the wording of the Particular.

26. The Panel considered that there is no suggestion that the witnesses had reasons to fabricate their allegations. They were registered professionals undertaking their jobs within the Hospital and they raised their concerns at the time of the alleged incidents, both to other members of staff and also on the internal incident reporting system.

27. The Panel considered the seriousness of the Allegation, taking into account the impact which adverse findings might have on the Registrant’s career. The Panel accepted that the Allegation is serious, however it noted that ML’s and SS’s evidence relates to only part of the Allegation, and it would be hearing from other witnesses who’s evidence addresses the same concerns.

28. The Panel considered that there was a good reason for the non-attendance of ML. In her email to the HCPC in 2023, she makes clear that she was not willing to attend a hearing due to her [redacted]. In her statement, dated 17 August 2023, she categorically states that she is not willing to attend a hearing to give evidence due to [redacted]. The Panel noted from the further correspondence between ML and the HCPC, in March 2025, that ML believes attending a hearing [redacted] and that she does not wish to receive any further communications.

29. The Panel also considered that there was a good reason for SS not attending the hearing. The Panel took into account the email evidence from SS that she would be out of the country on a pre-arranged holiday on the dates the hearing has been set for.

30. The Panel acknowledged that both ML and SS had been in regular communication with the HCPC, and it did not consider that their non-attendance was an attempt to prevent a proper evaluation of the evidence.

31. The Panel considered that the HCPC had taken reasonable steps to secure both ML’s and SS’s attendance. This is evidenced by the ongoing email exchanges which had been provided to the Panel in the hearsay bundle.

32. The Panel decided that it was not in the public interest or the Registrant’s interests, to adjourn the case to canvass further availability from SS, keeping in mind its obligation to deal with matters fairly and expeditiously.

33. The Panel accepted that the HCPC had given notice to the Registrant that the hearsay application would be made, and the reasons for it, as the details are set out in the case summary.

34. The Panel bore in mind that its role today was to addresses the matter of admissibility, and that once hearsay evidence is admitted it must still be assessed by the Panel as to the appropriate weight to attach to it.

35. Based on the evidence and information before the Panel, and for the reasons set out above, the Panel considered that it was fair to admit the written evidence of ML and SS.
Steps of the Hearing

36. The Panel asked for Mr Tobias’ submissions on the appropriate way to deal with the hearing in terms of whether it should retire after each step. Mr Tobias submitted that it was a matter for the Panel. The Panel decided that it would hear facts, grounds, and impairment together. The Panel decided that dealing with the hearing in this way would allow a better flow and also taking into account that Registrant would not be giving oral evidence. The Panel considered that the most efficient and fair way to conduct the hearing would be to hear all matters together, and it saw no reason to depart from this approach. The Panel kept in mind that in terms of its deliberations it would still need to keep facts, grounds and impairment as separate steps.

Background

37. The Registrant started work at the Hospital as an ODP on 25 January 2021.

38. The Registrant was managed by ‘SF’, Theatre Manager, who was part of the recruitment process when he was hired.

39. The Registrant’s role predominantly involved working on the anaesthetic side of the role.

40. During a shift on 16 March 2021, it came to light that a service user (“Service User A”) had not signed their consent form for surgery. It is alleged that the Registrant had collected Service User A from the ward, completed the ward handover and transferred Service User A into the anaesthetic room.

41. On 18 March 2021, it is alleged that the Registrant went to collect a service user from a ward but had left the patient collection slip behind.

42. On 18 March 2021, SF had a one-to-one meeting with the Registrant, with a Human Resources colleague also present. SF states that this is so the Registrant knew the meeting was official and that SF was taking the incident on 16 March seriously, as well as the incident which had occurred earlier that day.

43. It is alleged that despite the discussion on 18 March 2021, there was another incident on 25 March 2021, whereby the Registrant was about to take a service user to theatre without any handover from a ward staff member.

44. A further incident is alleged to have happened on 26 March 2021, involving the Registrant returning a service user to the ward without undertaking a handover with the ward nurse.

45. Also on 26 March 2021, when a service user was about to be operated on, having been anaesthetised and prepped for surgery, a check was made in respect of the World Health Organisation safety checklist. It had not been completed. It is alleged that the Registrant was responsible for ensuring the form was completed.

46. The Registrant was suspended by the Hospital on 29 March 2021, pending an investigation regarding the failure to comply with Hospital policies and procedures.

47. The Registrant resigned from the hospital on 31 March 2021. Within the resignation letter, amongst other things, the Registrant stated that he was not enjoying working at the Hospital, that the hours were not suiting him, and that he did not enjoy the ‘rush rush’ culture.

48. On 16 June 2021, the HCPC received a referral form from the Former Interim Head of Clinical Services at the Hospital, which is a part of Ramsay Health Care, in relation to concerns about the Registrant following a local disciplinary investigation having been completed.

49. For the purpose of this decision, the terms ‘service user’ and ‘patient’ are used interchangeably as both were used within the evidence.

Evidence

HCPC

50. The HCPC called the following witnesses to give live evidence:

• ‘KZ’, a HCPC registered ODP. At the time to which the Allegation relates, KZ was employed at Park Hill Hospital as an ODP. Her HCPC statement is dated 13 July 2023.
• ‘SF’, the Theatre Manager at the Hospital, who at the relevant time was the Registrant’s manager. Her statement is dated 20 July 2023.

51. The HCPC also relied on the hearsay evidence of ML and SS.

52. The live witnesses both gave evidence under affirmation and adopted their witness statements and exhibits as their evidence in chief. They were both asked supplemental questions by Mr Tobias, and they were asked questions by the Panel, who took into account that in the Registrant’s absence it had a responsibility to test the witness accounts.

The Registrant

53. The Registrant was not present. However, the Panel was provided with several written documents provided by the Registrant or provided on his behalf. The written evidence included:
• Email from the Registrant to the HCPC, dated 19 July 2021, confirming his employment details.
• Email from the Registrant’s manager at BMI healthcare, to the HCPC, dated 17 August 2021, confirming that none of the allegations have occurred whilst the Registrant has been employed by BMI as an ODP.
• Statement from the Registrant dated 24 July 2022.
• Multiple character references (undated).
• Resignation letter.
• Statement for this hearing, from the Registrant, dated 6 May 2025.
• Response to Notice of Allegation, dated 6 May 2025.

Legal Advice

54. The Panel heard and accepted the advice of the Legal Assessor in respect of the approach to take in determining findings of facts and the burden and standard of proof. The burden of proof rests on the HCPC and it is for the HCPC to prove the Allegation. The Legal Assessor provided advice on the issues of:
• Credibility and reliability, as per the guidance in R (Dutta) v GMC [2020] EWHC 1974 (Admin), Byrne v GMC [2021] EWHC 2237 (Admin), and Hindle v NMC [2025] EWHC 373 (admin).
• Wording of the Allegation.
• Admissions, as per the HCPTS Practice Note on Admissions.
• Weight of evidence including a direction on hearsay evidence in relation to ML, SS and the Registrant’s statement.
• Testimonials.
• Good character.
• Drafting decisions, as per the HCPTS Practice Note on Drafting.

Decision on Facts
1. On or around 16 March 2021 you did not undertake adequate checks and/or get Service User A to complete the consent form agreeing to the procedure prior to induction of anaesthetic.

55. The HCPC submitted that the Panel should rely on the evidence of KZ and SF to find this fact proved.

56. The Panel noted that in his response to the Notice of Allegation, the Registrant does not admit this Particular of the Allegation.

57. The Panel had regard to the evidence of KZ. The evidence provided by KZ is that due to the Hospital set up, it does not have escort nurses or porters who bring patients up to the anaesthetic room. It only has one theatre and therefore the ODPs undertake a dual role of collecting patients. KZ sets out the process of collecting a patient. KZ states that the ODP will go down to the ward to collect the patient and then the ward nurse and the ODP undertake a series of checks together to ensure the patient is okay to go to theatre. KZ said that the checks will include checking the patients name and their identification label. The consent form is to be checked that the operation is noted as the correct procedure, and it is checked whether the patient has been marked by the surgeon at the correct place. It is then ensured that the consent form is signed, as it should have been, and if the consent form was signed a few days prior to the operation then a consent stage two is to be signed. The ward nurse and ODP then sign the patient off ready to take to theatre. Within the consent form the risks and the benefits are noted as explained to the patient and whether they have consented to blood, photograph and x-ray during the procedure. KZ states that this process falls under the Ramsey Health Policy for checking patients and collecting prior to surgery, which she exhibits to her statement.

58. KZ states that, on 16 March 2021, the Registrant had gone and picked the patient up from the ward, whilst KZ was at the operating table preparing the instruments. The patient was then anaesthetised in the anaesthetic room and wheeled into theatre for putting onto the operating table and positioning. Once the patient was all settled and safe the consent form was checked. KZ states that she was checking the consent form and noticed the signature section was blank, and she told everyone to stop. At this point the surgeon was in attendance and KZ asked what we had to do now and asked why it was not picked up before the patient came off the ward. Usually if the consent form is unsigned it is picked up at the first point, on the ward and rectified before coming to theatre. KZ states that ‘I asked the Registrant who had signed off the patient on the ward and he shrugged his shoulders and when I challenged him further about why the consent form was unsigned, he explained he had gone to the ward and took the patient without signing them off and when I explained to him he could not do so, he said he had because the ward staff were all busy’.

59. KZ reported this incident on the hospital incident system and KZ exbibits this report to her statement. KZ reported the incident to SF.

60. The Panel had regard to the evidence of SF, who reiterates what she was told about this incident. SF states that ‘nowhere had the Registrant undertaken the correct checks or physically checked the patient off, where he should have noticed the unsigned consent form’. SF states that at the time the Hospital used a paper system, where you undertake a check on the ward before taking the patient to the theatre, the ODP then takes the patient to the anaesthetic room where the checks are undertaken once again with the anaesthetist.

61. SF states that she spoke to the Registrant about the incident on the same day and he accepted that he undertook the handover on the ward with a nurse, but he had not completed any further checks. The Panel noted that in the contemporaneous incident witness statement, SF states that she questioned Gary about the checks and he said ‘“NO, I did the checks on the ward with the nurse”. I reminded Gary that although the checks had been completed on the ward, it is policy that checks are to be completed and confirmed in the anaesthetic room also and that there was no evidence that the WHO theatre safety checklist (which is not part of the ward safety check) had been completed either.’

62. SF states that the checks undertaken when handing over with the nurse are different to the World Health Organization (WHO) safety checklist which is undertaken at the point of anaesthetic. SF’s view is that the unsigned consent form should have been picked up on the ward, there was a missed opportunity there, but the Registrant also did not pick up on it at the anaesthetic stage as he failed to complete any checks. This meant the patient was administered anaesthetic without the consent form being completed. SF exhibits the incident report she made on the Hospital system, together with the WHO checklist, her incident witness statement, and the Safe Transfer of Patients and Handover to Theatre policy.

63. The Panel had regard to the Registrant’s responses. In his May 2025 response, he states:
‘The WHO form episode for me was the most important. As I have previously reflected, I simply cannot understand how it slipped through that the patient got all the way through to being signed out before knife to skin without it being picked up that they had not signed the consent form on the day. I remember it very clearly, I checked the patient in in their room with a ward nurse present, went through the checklist both verbal and written, checked the site had been marked. The fact that I didnt fill the first part of the WHO form in for me was just a laspse as this could (and is often done) be done at a later time as long as the verbal checks had been done, The fact that this patient had been admitted, checked in by the ward staff, seen by the consultant on the day and site marked, the consultant signing the consent form with the patient and STILL the patient not having signed it by the time I went to collect them is unbelievable. Then to add to that the fact that both myself and the ward nurse didnt notice it before I took them to theatre, well it was really just a freak incident, one that has never happened before to me.’

64. In reaching its decision, the Panel first considered whether on or around 16 March 2021, the Registrant did not undertake adequate checks, prior to induction of anaesthetic. It is not in dispute that this incident occurred on 16 March 2021, nor is it disputed that the patient was anesthetised before the lack of consent issue came to light. Based on the evidence of SF and KZ, the Panel found that there were two steps to undertaking adequate steps which included ensuring that the patient had consented. The first of these steps was a two-person process done on the ward, with the ODP and the nurse. Those checks involved ensuring that the consent form was signed as well as ensuring other pertinent information such as NHS number, allergies, medications etc. The second step was the checks which took place in the anaesthetics room, which the ODP and the anaesthetist completed, and which included the WHO safety checklist and again checking that the consent form was signed.

65. The Panel was confident in relying on the evidence of SF and KZ in finding that the Registrant did not undertake adequate checks, prior to induction of anaesthetic. The Panel placed significant weight on the contemporaneous accounts made by both SF and KZ at the time of the incident which were detailed and either done on the day or soon thereafter, and prior to any knowledge that the matter would end up before the HCPC. Their subsequent written and oral evidence is consistent with their earlier contemporaneous accounts and is also consistent with each other. The Panel found both the evidence of SF and KZ to be fact based and patient focused. The Panel considered that neither witness sought to over or under play the incidents, rather they described what they recalled from the events, and what they say should have happened.

66. The Panel took into account that the although the Registrant denies this allegation, by his own account, given in writing for this hearing, he did fail to fill in the first part of the WHO form. Furthermore, in his statement dated 24 July 2022, he accepts that he failed to check that the consent form had been signed. His own evidence is therefore consistent with that of SF and KZ in that he did not undertake adequate checks.

67. The Panel next considered whether on or around 16 March 2021 the Registrant did not get Service User A to complete the consent form agreeing to the procedure prior to induction of anaesthetic. In considering this, the Panel had regard to the evidence of SF. Her oral evidence was that whilst the responsibility for doing the checks including checking the consent lay with the Registrant, it was the Consultant who was responsible for getting the Service User to complete the consent form. The Panel did not have any evidence before it that it was the Registrant’s responsibility to get Service User A to complete the consent form. Therefore, the Panel decided that this element of the Particular is not proved.

68. In conclusion the Panel found Particular 1 proved as follows:
• On or around 16 March 2021 you did not undertake adequate checks in relation to Service User A prior to induction of anaesthetic.

 

2. On or around 18 March 2021 you went to collect a Service User from a ward without the theatre collection slip.

69. The HCPC submitted that the Panel could rely on the evidence of SF to find this Particular proved.

70. The Panel had regard to the evidence of SF. She states that on 18 March 2021, the Registrant had gone to collect a service user from the ward, but he had left the collection slip in the anaesthetic room, so she knew that the Registrant had forgotten to take it with him whilst collecting the service user. SF states that she then discretely gave the collection slip to the Registrant whilst he was on the ward and reminded him of the process. In relation to the process, SF states that:
‘The process at the Hospital is to take the patient collection slip when you go to collect a patient for theatre, to ensure you know who you are going to collect. The ODP fills in the collection slip in the theatre, before collecting the patient, there is certain information on the collection slip note. The ODP then goes to the ward and states I have come to collect this patient, and undertakes a checks with the nurse to confirm the patient details whilst checking their wristband. The process for collecting patients falls under the Safe Transfer of Patients and Handover to Theatre Policy, which is part of the Ramsey Health Policy.’

71. The Panel had regard to the Registrant’s responses in relation to this concern. On the 19 April 2021, the Registrant was interviewed as part of the Hospital investigation into all the alleged incidents. The Hospital investigation report summary notes that the Registrant admitted that he had attended the ward to collect a patient for theatre without the collection slip, and that he was aware of the safe transfer of patients’ policy, which states that a collection slip must be used to enable safety checks prior to transfer of patients. It goes on to state that in his interview, the Registrant said ‘the Policy requires review as he didn't agree with its content. During the discussion with [the Registrant] regarding the incident he stated that he did not agree with the process of an ODP collecting a patient from the ward to escort them to theatre, and felt that the policy was in place for HCA's to follow as they should be the ones escorting patients to Theatre.’

72. In the Registrant’s email of 6 May 2025 to the HCPC, he admits Particular 2.

73. The Panel was confident in relying on the evidence of SF, which is corroborated by the Registrant’s own admission, in finding this Particular of the Allegation proved. The Panel placed weight on the evidence of SF, for the reasons already given in this decision, having found her evidence to be consistent and balanced.

74. The Panel concluded that on the balance of probabilities, on or around 18 March 2021 the Registrant went to collect a service user from a ward without the theatre collection slip.

75. Found Proved.

3. On or around 25 March 2021 you attempted to escort a Service User to theatre without undertaking the relevant checks in the presence of the ward admitting nurse.

76. The HCPC submitted that the Panel could rely on the evidence of ML and SF in finding this Particular proved.

77. The Panel had regard to ML’s hearsay evidence. This states that she was alerted by a HCA that the Registrant had come to collect a patient in room eight. ML states that she finished her conversation ‘approx. 1 minute’ and headed to room eight but by that time the Registrant was already coming up the corridor with the patient. ML states that she asked the Registrant whether the patient was checked off and his response was ‘I have done my checks’ ML states she was not happy with this and that they undertook the checks in the corridor which was not good for the patient’s privacy or dignity. ML states that it should never be the case that the collecting member of staff walks off without undertaking the two-person checks.

78. The Panel had regard to the incident report ML made on the Hospital system at the time of the incident, which sets out in similar terms the incident as described above.

79. The Panel also had regard to the evidence of SF. She states that on 25 March 2021, ML approached her about the incident. SF then spoke to the Registrant about the concern. SF states that the Registrant explained to her that the ward staff were not present and so he took the patient. She then reiterated the policy to him and in reply he stated that the list was overrunning and that he was trying to save time in taking the patient without waiting. The Panel noted that SF had also reported the incident on the Hospital reporting system.

80. The Panel had regard to the Registrant’s response given in his investigation interview as set out in the investigation report summary. This states that the Registrant admitted attending the ward and collecting a patient to take to theatre with no handover from the ward nurse. He stated that he had undertaken his checks but had been unable to locate a nurse to undertake the checks with him, so he made the decision to leave the ward even though he was aware of the policy and the correct process to follow.

81. In the Registrant’s email of 6 May 2025 to the HCPC, he admits Particular 3.

82. The Panel took into account that the evidence of ML is hearsay evidence. However, the Panel was confident in placing weight on it. The evidence provides a copy of the original incident report made to the hospital system which is a contemporaneous document and is consistent with the witness statement. ML also raised her concerns on the day of the incident, which enabled SF to investigate by speaking to the Registrant without any delay. ML’s evidence is supported by the Registrant himself who admits that this incident happened, albeit that he tries to justify why it occurred.

83. The Panel found on the balance of probabilities that on or around 25 March 2021 the Registrant attempted to escort a service user to theatre without undertaking the relevant checks in the presence of the ward admitting nurse.
84. Found Proved.

 

4. On or around 26 March 2021 you did not follow necessary procedure in that:
a. You did not complete the WHO safety checklist for a Service User prior to them being anaesthetised.

85. The HCPC submitted that the Panel could rely on the evidence of SF to find this Particular proved.

86. The Panel had regard to the evidence of SF. Her evidence is that she was checking the folder and hospital notes of a patient who was anaesthetised ready for surgery. She was looking for the WHO safety checklist but could not find it. SF states that she asked the Registrant where the WHO form was and he walked out of the theatre and into the anaesthetic room. SF followed him and when it was apparent he was not looking for the form and was instead cleaning up she asked him again where the form was and his response was to look at her, shrug his shoulders and continue cleaning. SF repeated her question, but the Registrant did not respond. SF asked someone else to fetch a copy of the WHO checklist and they completed the checks before the procedure began. SF recorded the incident on the Hospital system.

87. The Panel had regard to the contemporaneous incident record created by SF. The Panel noted that the detail accords with that reflected in SF’s written and oral evidence.

88. The Panel had regard to the Registrant’s responses. In the investigation report summary, the Registrant is noted as stating that he admitted not completing the WHO checklist prior to the patient being anaesthetised but that it ‘gets done afterwards because everything is always rushed’. The Panel noted that in the Registrant’s response to the Notice of Allegation he admits this Particular of the Allegation.

89. The Panel first considered whether the Registrant did not complete the WHO safety checklist for a Service User prior to them being anaesthetised.

90. The Panel was confident in relying on the evidence of SF for the reasons already set out in this decision. The Panel also took into account that in relation to this Particular, SF’s evidence is corroborated by the Registrant’s own admission. The Panel was therefore satisfied that the Registrant did not complete the WHO safety checklist for a service user prior to them being anaesthetised.

91. The Panel next considered whether that meant that the Registrant did not follow necessary procedure. The Panel took into account and relied on the evidence of SF in relation to what the relevant procedure was. The evidence in relation to the correct checking procedures is already set out in relation to Particular 1, but in summary it is the Hospital process for the WHO safety checklist to be completed by the ODP during the checks which are carried out in the anaesthetic room, prior to transfer to the theatre. These are different to the checks that are carried out when collecting a patient.

92. Given that the Registrant did not complete the WHO safety checklist for a Service User prior to them being anaesthetised, the Panel was satisfied that this was not following the necessary procedure, as the necessary procedure requires the WHO safety checklist to be completed prior to anaesthetising a patient.

93. Found Proved.

 

4. On or around 26 March 2021 you did not follow necessary procedure in that:
b. You returned a Service User to the ward without handing over to the ward nurse.

94. The HCPC submitted that the Panel could rely on the evidence of SS and SF in finding this proved.

95. The Panel had regard to the hearsay statement of SS who at the relevant time was a Staff Nurse at the Hospital. SS states that there was an incident at the start of her night shift, when theatre was still operating. She recalls the Registrant left a patient on the ward post operation without handing over to her or another nurse. SS stated that she questioned the Registrant, in relation to the patient safety viewpoint, and that his response was that he was told to bring the patient down. He also stated to her that he did not know what the post op instructions were for the patient. SS states that after the incident she spoke to her manager ML, and later completed her Hospital incident report, after being told that this was required.

96. The Panel also had regard to the evidence of SF, who states that on 26 March 2021, she was informed of the incident by SS. On the same day, SF spoke to the Registrant about the concern, and about the correct process for handing over. SF states that the Registrant’s response was ‘well I completed the checklist’. SF states that the process when you deliver a patient back to the ward is to hand over in reverse to when they were collected, and that this falls under the ‘transfer policy’. In other words, the ODP hands back over to the Ward Nurse and discusses the patient’s rehabilitation, how the procedure went and any complications such as blood loss. SF explains that this process is important for patient safety.

97. The Panel considered the Hospital Investigation report. This states that the Registrant admitted to returning a patient to the ward following a local anaesthetic injection in Theatre and not undertaking a handover with the ward nurse.

98. In the Registrant’s evidence (July 2022), he explains about ‘Handovers’. He states that:
‘On the day in question it was all back injections with no sedation on the list. Myself and the recovery practitioner were bringing patients from the ward and taking them back to their rooms on trolleys after the procedures. We were under constant pressure to 'go for the next'. On a couple of occasions when we took patients back there was no nurse immediately available (I believe there was actually only one qualified nurse working on that day) for a handover. On these occasions we sought out said nurse and gave them a verbal handover. The nurse was happy with this as they were minor procedures and the post op instructions were the same every time. Ideally we would have waited for the nurse to come to the patients room but when we did wait we got phonecalls from theatres asking what the delay was and the surgeon was not happy waiting.’

99. The Registrant’s most recent statement (6 May 2025) states that he, ‘would never leave a patient in their room without giving some sort of handover whether it be verbal or written’. In his response to Notice of Allegation, he denies this Particular.

100. The Panel was confident in relying on the evidence of SS. The Panel acknowledged that the evidence is hearsay, and that the evidence lacks the level of detail found in the statements provided by the other HCPC witnesses in this case. However, the Panel felt confident in placing weight on it because it was corroborated by the contemporaneous incident report, which was made soon after the incident. Further, SS reported her concerns to SF, who spoke to the Registrant about this on the same date. SF also made a contemporaneous entry onto the incident reporting system. The Panel noted that SF’s incident report was neutral and open minded as it states that SS ‘claims’ the Registrant returned the patient to the room without giving a staff handover. The incident report states that the Registrant’s response to this alleged incident was that ‘no one was coming’, and that the theatre list was running behind and he needed to catch up.

101. The Panel considered that it was inherently probable that the Registrant had returned the patient to the ward without completing the handover, within the context of the similar concerns that had been raised during this time. Both SS and SF are registered professionals and there is no evidence to suggest they have any reason to fabricate their evidence. Their evidence is consistent, both with their contemporaneous accounts and with each other. Their contemporaneous accounts both place emphasis on patient care, and the importance of patient handover, rather than being a mechanism to criticise the Registrant.

102. The Panel preferred the evidence of SS and SF over that of the Registrant. Although he denies this Particular of Allegation, and states that he did a verbal handover, this is contradictory to his earlier accounts, which were given closer to the time of the incident. The Panel therefore considered that this undermined his evidence. Further, his evidence could not be tested by cross-examination and therefore carried less weight.

103. The Panel was satisfied on the balance of probabilities that on or around 26 March 2021, the Registrant returned a Service User to the ward without handing over to the ward nurse. The Panel was satisfied that in doing so, the Registrant did not follow necessary procedure, because the necessary procedure was to complete a handover with the Ward Nurse to ensure that post operative patient safety was maintained.

104. Found Proved.

Decision on Grounds

105. Mr Tobias submitted that the facts found proved amount to serious professional misconduct.

106. Mr Tobias submitted that if any/all of the facts are found proved, it would amount to misconduct as the conduct of the Registrant falls short of what was proper in the circumstances, and the conduct is sufficiently serious. Mr Tobias submitted that the Registrant provided inadequate patient care relating to important pre and post theatre checks and procedures, which in turn opened up patients to a serious risk of harm.

107. Mr Tobias submitted that the Registrant’s conduct was in breach of the HCPC’s Standards, namely: 6.1, 6.2, 8.1, 8.4, 10.1, and 10.2.

108. The Panel heard and accepted the advice of the Legal Assessor, who referred to the cases of Roylance v GMC (no.2) [2000] AC 311 and Nandi V GMC [2004] EWHC 2317 (Admin). The Legal Assessor also referred the Panel to the HCPC Standards of conduct, performance, and ethics and the Standards of Proficiency for ODP’s, with a reminder that the relevant Standards were those in place at the time of the Allegation (2021). The Legal Assessor advised that there was no settled definition of misconduct, and it was for the Panel to say in the circumstances of the case whether the behaviour, crossed the threshold properly to be categorised as misconduct. The Panel could approach the question by deciding whether an act or omission on the part of the Registrant represented a serious falling short of the standards to be expected of a HCPC registrant. However, it is important to note that not every omission or wrongdoing necessarily constitutes misconduct.

109. The Panel at all times kept in mind the HCPC’s overarching objective of protecting the public which includes protecting services users, protecting public confidence in the profession and the regulatory process, and declaring and upholding proper standards of conduct and behaviour.

110. The Panel took into account the HCPC Standards of Conduct Performance and Ethics and the Standards of Proficiency for ODP’s. The Panel bore in mind that a departure from the Standards alone does not necessarily constitute misconduct.

111. The Panel concluded that the Registrant’s conduct and behaviour fell far below the standards expected of a registered ODP. The Panel determined that the Registrant’s conduct was in breach of the HCPC Standards of Conduct, Performance and Ethics (2016) namely:

1.4 You must make sure that you have consent from service users or other appropriate authority before you provide care, treatment or other services.
2.6 You must share relevant information, where appropriate, with colleagues involved in the care, treatment or other services provided to a service user.
6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
6.2 You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.
10.1 You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

112. The Panel determined that the Registrant’s conduct was in breach of the HCPC Standards of Proficiency for ODP’s (pre-2023), in particular standards: 1, 1.2, 2.1, 2.2, 2.7, 3.1, 8, 8.1, 8.2, 8.11, 9, 9.1, 9.2, 9.4, 15, 15.1, 15.2.

113. The Panel noted that both sets of Standards are interlinked in that the focus is on patient safety. In acting as he did the Registrant was not acting in the best interests of service users, communicating effectively, or working appropriately with others, all of which negatively impacted on establishing and maintaining a safe practice environment to reduce risk of harm to patients.

114. The Panel considered that the facts found proved all relate to a serious falling short of what was expected in the circumstances. They all relate to the Registrant’s inactions or failures to provide adequate patient care relating to important pre and post theatre checks.

115. The Panel took into account the unchallenged evidence it had before it about the significance of pre and post theatre checks and the potential negative consequences for patients if these are not adhered to. The Hospital policies and guidelines were in place to ensure a safe framework, crucially with the aim to achieve patient safety.

116. In relation to Service User A and the service user in the incident on 26 March 2021, they were both under anaesthetic for longer than was expected due to the procedures stopping whilst enquiries were made about the consent and the WHO form. If the correct pre and post theatre processes are not completed, it creates a number of potential risks including, a patient having surgery they do not consent to, the risk that patients are unaccounted for in the event of a fire, the wrong patient could be taken off a ward, the wrong procedure could be carried out, staff would not be aware to keep an eye on the patient if there had been complications in the theatre.

117. In reaching its decision on misconduct, the Panel had regard to the wider context in which the Registrant was practising. The Registrant describes the Hospital as an ‘accident waiting to happen’ and that the hospital was understaffed and had a ‘rush rush’ culture. The Panel considered all the evidence before it, including having explored these comments with SF and KZ in their oral evidence. The Panel did not accept that the Hospital was an accident waiting to happen or that it had a ‘rush rush’ culture. It was confident in the evidence it heard from both oral witnesses, which was corroborative, that the Hospital kept the momentum going and was efficient and effective but that it was not ‘rush rush’ as patient safety came first, hence the clear polices that were in place. The Panel heard no evidence to suggest that the Hospital was understaffed at the relevant time, and in any event the Hospital would have used agency staff if it was required.

118. The Panel considered that the evidence before it shows that the Registrant was an experienced ODP, and that he understood the polices in place, but that he disregarded them. It is not disputed by the Registrant that he was spoken to by SF after each of the incidents about the importance of following polices. Further, there was a one-to-one meeting on 18 March 2021, wherein the Registrant was again given the polices, to ensure he fully understood what was expected of him. There is clear evidence from both SF and contained in the investigation report that the Registrant acknowledged that he was aware of all the polices. The Panel considered the multiple observations, within the evidence, from a number of the HCPC witnesses, that states that in response to issues being raised the Registrant’s response was ‘shrugging’, dismissive, or a nonchalant reply. This evidence is supported by the responses provided by the Registrant within his Hospital investigation meeting wherein he states that he considers the safe transfer of patients’ policy is for HCA’s not for him, as he didn’t feel it was necessary. The Panel concluded from this that the Registrant knew about the policies, was competent and able to comply with them, and that he chose not to. In doing so, he worked contrary to what was expected and disregarded the policies and processes which directly impacted on the wider team and patient safety.

119. The Panel found that the proven facts, all of which relate to crucial pre and post theatre checks to ensure a safe process for patient safety, individually and collectively amount to the statutory ground of misconduct.

Decision on impairment

120. Mr Tobias submitted that if the Panel finds any/all of the facts proved and finds the statutory ground it met, then the Panel should find that the Registrant is impaired. Mr Tobias reminded the Panel to have regard to both the personal and public components of impairment.

121. The Panel heard and accepted the advice of the Legal Assessor in relation to impairment. The Legal Assessor reminded the Panel to take into account that it should have regard to both the personal and public components and keep in mind the wider public interest. The Legal Assessor referred the Panel to the HCPTS Practice Note ‘Fitness to Practise Impairment’ dated February 2025. The Panel was referred to the cases of, CHRE v (1) NMC & (2) Grant [2011] EWHC 927 (Admin), Cohen v GMC [2008] EWHC 581 [Admin], Cheatle v GMC (2009) EWHC 645 (Admin), Bolton v Law Society 1993, and PSA v HCPC + Doree [2017] EWCA Civ 319.
Panel Decision

122. The Panel considered the Registrant’s current fitness to practise firstly from the personal perspective and then from the wider public perspective and had careful regard to the Practice Note on impairment. The Panel also had regard to whether the conduct in this case is easily remediable, whether it has been remedied and whether it was highly unlikely to be repeated.

123. In deciding impairment, the Panel had regard to the factors identified by Dame Janet Smith in her 5th Shipman Report and cited in CHRE v (1) NMC and (2) Grant (“Grant”). The Panel considered whether:

124. The Registrant has in the past and/or is liable in the future to place service users at unwarranted risk of harm.

125. The Registrant has in the past brought and/or is liable in the future to bring the profession into disrepute.

126. The Registrant has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the profession.

127. In relation to (a) the Panel determined that the Registrant’s conduct had in the past had the potential to place patients at unwarranted risk of harm. Whilst the Panel had no evidence before it that the Registrant’s conduct had caused direct patient harm, it took into account the evidence relating to why the policies are in place, which was primarily provided by SF, but which was echoed by all the HCPC witnesses. The Panel accepted that in not adhering to the correct pre and post theatre processes, this had the potential for a patient to have surgery they do not consent to, the risk that patients are unaccounted for in the event of a fire, the wrong patient could be taken off a ward, the wrong procedure could be carried out, and/or staff would not be aware to keep an eye on the patient if there had been complications in the theatre. In relation to the degree of harm, the Panel had no evidence to suggest that the Registrant was seeking to intentionally cause harm, but his conduct in disregarding and not following the correct procedures had the potential to affect the safe and effective delivery of care to patients.

128. In relation to (b), the question of whether the Registrant has in the past brought the profession into disrepute, the Panel determined that he had. A significant aspect of public interest is upholding proper standards of conduct so as not to bring the profession into disrepute. The proven facts, all of which relate to the Registrant deciding not to adhere to crucial pre and post theatre checks to ensure a safe process for patient safety, does bring the ODP profession into disrepute.

129. In relation to (c), in finding that the Registrant did not conduct himself in such a way as to adhere to the HCPC professional standards, the Panel determined that he had breached fundamental tenets of the profession. The Panel found that the Registrant had breached a significant number of the professional standards. These include failing to communicate effectively and work in partnership with others, both of which are core components and key principles in the ODP profession and wider healthcare sector for ensuring patient safety.

130. The Panel considered the extent to which the misconduct in this case can be, and has been, remediated by the Registrant and whether it is likely to be repeated.

131. The Panel kept in mind that concerns do not relate to a lack of competence on the Registrant’s behalf, rather they relate to him choosing not to follow the correct pre and post theatre processes such that it placed patients at risk of harm. The Panel recognised that the misconduct occurred over a short space of time (10 days) in an otherwise long and unblemished career as an ODP. The Panel did think that the Registrant’s conduct could be easily remediated, if he could evidence insight into why the misconduct occurred and what he would do to avoid a repetition, which would be as simple as adhering to policies that are in place to ensure patient safety, even if he didn’t feel that they were necessary.

132. The Panel next had regard to whether the Registrant’s misconduct has been remediated. The Panel took into account the documentary evidence provided by the Registrant including the testimonials. The Panel considered that the written evidence did not give it confidence that the Registrant understands the seriousness of his actions, nor the impact that they could have on patients, and did have on his colleagues, who were left to deal with the issues that arose primarily through the fault of the Registrant. The Panel found a lack of accountability and a strong emphasis on passing the blame to others. Whilst the Panel acknowledged that the failure to check the consent for Service User A also involved missed opportunities by others, it does not detract from the fact that the Registrant was involved and needs to take accountability for his role.

133. The Registrant’s written evidence does not show that he is willing to concede that what he did, in relation to the proven facts, was wrong, even though he admits some of the Particulars of the Allegation.

134. The Panel did not find that the Registrant had expressed any remorse, either at the time or since, and his stance of seeking to apportion blame to others has remained consistent, in his investigation interview in 2021, his written evidence in 2022, and his current evidence provided for this hearing (6 May 2025). The Panel found that the Registrant’s evidence did not demonstrate any reflection or demonstrate a genuine understanding of the impact of his actions on others, and the ODP profession. The only information about impact is relating to that which the Registrant perceives was a failing by the Hospital in relation to working hours and the alleged ‘rush rush’ culture.

135. Based on the above, the Panel considered that the Registrant has a lack of insight into his misconduct.

136. The Panel considered whether there was any evidence of remediation. The Registrant did not provide any documentary evidence of any reflection or training, nor did he mention any in his written evidence.

137. The Panel took into account that the bundle contained various references relating to the Registrant. The Panel noted that most of these related to the Registrant’s work prior to 2021, however there are two references post the Allegation. On 17 August 2021, the Clinical Services Theatre Manager, BMI Healthcare, emailed the HCPC to state:
‘None of these allegations have occurred whilst he has been working in our theatres at BMI …Hospital…He is an excellent ODP who works within his professional scope of practice at all times. He is a strong advocate for patient care and speaks to patients in a professional and supportive manner. He works within our polices and protocols at all time and I have never been given reason to speak to him about anything other than to thank him for the high standards of care he provides to patients and support to colleagues.’

138. The same person provides an undated reference which is in similar terms to the above. Although it is undated, it is listed in the index alongside other documents provided in 2021/2022.

139. The Panel placed some weight on the references as it is clear that the author was aware of the HCPC Allegation. However, it is not current and offers no view on what has changed to suggest that the Registrant will no longer act in the way that he did at the Hospital if he found himself in similar circumstances.

140. The Panel considered whether the misconduct was likely to be repeated by the Registrant. The Panel took into account all it had read and heard about the misconduct. The facts found show that the Registrant had conducted a pattern of behaviour during a 10-day period in the short time he was working at the Hospital. This behaviour ceased because he was suspended and subsequently resigned. Given its finding that the Registrant has shown no insight and has only shown at best minimal remediation, as per his good reference, the Panel concluded that a real risk of repetition remained. The Panel found that given the lack of insight, there remains a potential for the Registrant to not undertake adequate pre and post theatre checks again, if he found herself in a similar position whereby, he perceived he was working in a ‘rush rush’ environment. This in turn could have a detrimental impact on the safe and efficient care of patients.

141. The Panel decided that the Registrant’s fitness to practise is currently personally impaired on the grounds of his misconduct.

142. The Panel next considered whether a finding of current impairment was necessary in the public interest. The Panel was mindful that the public interest encompassed not only public protection but also the declaring and upholding of proper standards of conduct and behaviour as well as the maintenance of public confidence in the profession. It took into account the guidance in the ‘Grant’ case:- ‘In determining whether a practitioner’s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances.’

143. The Panel considered its findings in relation to misconduct. The Panel took into account that ODP’s hold privileged professional positions within the healthcare setting. It is essential that the public can trust and rely on ODP’s to carry out adequate checks to ensure patient safety and communicate and work in partnership with colleagues for the benefit of patients. The failures of the Registrant, which occurred at the Hospital, as part of his ODP role, present a serious and unacceptable risk in terms of confidence in the profession.

144. Based on its findings in relation to the unwarranted risk of harm, the bringing the profession into disrepute and the breaching of the fundamental tenets of the profession, the Panel concluded that public confidence would be undermined if there were to be no finding of impairment. The Panel considered that not to make a finding of current impairment of fitness to practise in relation to the misconduct would seriously undermine public trust and confidence in the profession and would fail to uphold and declare proper standards.

145. The Panel therefore decided on the public interest element of impairment that the Registrant’s fitness to practise is currently impaired.

Decision on Privacy

146. During the course of the hearing, the Panel heard evidence from SF that the Hospital was small consisting of only one theatre.

147. In considering the written draft covering preliminary issues through to impairment, the Panel reflected that despite ML’s name being anonymised with the use of initials, given the small size of the hospital, it was likely she would be easily identifiable.

148. When handing down the written decision, the Panel invited submissions from Mr Tobias on the issue of privacy in relation to ML’s health issues. Mr Tobias submitted that it would seem entirely appropriate for any parts of the hearing and written decision which mention specific health issues to be heard in private.

149. The Panel heard and accepted the advice of the Legal Assessor and referred to the HCPTS Practice Note on ‘Conducting Hearings in Private’ dated February 2025.

150. The Panel acknowledged that there is a strong public interest in ensuring that hearings are conducted in public for transparency. However, a hearing can be held in private to protect the private life of a witness. The witness ML raises personal issues relating to her health. Whilst the witness’s details have been anonymised, the Panel did not consider this would be sufficient to protect her privacy due to potential jigsaw identification from other available evidence. The Panel concluded that this was a compelling reason for the parts of the hearing and written decision which mention ML’s health issues to be heard in private.

Decision on Sanction

151. Mr Tobias submitted that the HCPC remain neutral on sanction. Mr Tobias reminded the Panel to have close regard to the HCPC Sanctions Policy last updated March 2019.

152. Mr Tobias referred the Panel to its findings thus far, in that the Registrant has limited insight, and has not shown remorse, but that the conduct is easily remediable.

153. Mr Tobias acknowledged the Panel’s findings that the misconduct occurred over a brief time in an otherwise unblemished career but that there remained a risk of repetition if the Registrant found himself in similar circumstances.

154. The Panel heard and accepted the advice of the Legal Assessor, who referred it to the HCPC Sanctions Policy, which states that any sanction must be proportionate, is not intended to be punitive and should be no more than is necessary to meet the legitimate purposes of providing adequate protection to the public, to protect the reputation of the profession, maintain confidence in the regulatory system, and declare and uphold proper professional standards.

155. The Legal Assessor also referred to the following HCPTS Practice Notes:
- Conditions Bank (dated November 2023).
- Drafting fitness to practise decisions (dated November 2023).

156. The Panel applied the principle of proportionality by weighing the Registrant’s interests with the public interest and by considering each available sanction in ascending order of severity. The Panel considered the mitigating and aggravating factors in determining what sanction, if any, to impose.

157. The Panel identified the following aggravating factors:
• The lack of evidenced insight, remorse or apology.
• The lack of evidenced remediation.
• The potential for service user harm to be caused, particularly in relation to Service User A and the service user referred to in the incident on 26 March 2021, as they were both under anaesthetic for longer than was expected due to the procedures stopping whilst enquiries were made about the consent and the missing WHO form.

158. The Panel identified the following mitigating factors:
• The Registrant has a had a long career as an ODP and he was of previous good character. He provided evidence, in the form of testimonials, from various professionals, who have benefited from the Registrants mentoring in terms of his knowledge and experience. The Registrant has practised as a ODP since the events to which the Allegation relates. There have been no concerns raised, and he has evidenced positive feedback from his employer who is fully aware of the HCPC case against him.
• The facts found proved took place over a short period of time, in a new working environment for the Registrant.
• The misconduct is easily remediable.

159. The Panel started by considering the least restrictive sanction first, working upwards only where necessary. It took into account that the final sanction should be a proportionate approach and will therefore be the minimum action required to protect the public.

160. The Panel firstly considered referring the case to mediation. The Policy states that mediation is intended to resolve issues between the Registrant and another party. The findings in this case relate to the Registrant choosing not to adhere to pre and post theatre policies, which in turn gave rise to the potential risk of harm to patients. Therefore, mediation would not be suitable.

161. The Panel next considered taking no action. Given the Panel’s findings, that the Registrant is impaired on both the personal and public components, and that a real risk of repetition remains, the Panel found that taking no further action would not be appropriate or proportionate and would not meet the overarching objective.

162. The Panel next considered whether a Caution Order would be appropriate having particular regard to paragraph 101 of the Sanctions Policy. Whilst the Panel had found that the Allegation was isolated, in that it related to a 10-day period, it had not found it was limited or relatively minor in nature. The Registrant’s acts and omissions resulting in the finding of misconduct occurred five times within those 10 days, resulting in the potential for patient harm, and after which the Registrant was suspended. Further, the Panel has found that the risk of repetition remains and that the Registrant has not shown good insight or undertaken appropriate remediation. The Panel therefore concluded that a Caution Order was not suitable or appropriate in accordance with the Policy.

163. The Panel next considered whether to impose a Conditions of Practice Order. The Panel took into account the Sanctions Policy, in particular, paragraphs 106, 107 and 108. Whilst at this stage, the Registrant has not shown insight, the Panel has found that his misconduct is easily remediable, and that within the context of his otherwise unblemished career there are no persistent or general failures which would prevent the Registrant from remediating.

164. The Panel took into account that the Registrant has been in ODP practice since the time of the Allegation, and that it had been informed by his current line manager that in his role at BMI he was following policies and procedures and was a strong advocate for patient care. The Registrant did engage with the Hospital’s investigation and has partially engaged with the HCPC, including making written admissions as recently as 6 May 2025, in readiness for this hearing. With this in mind, the Panel was confident that the Registrant will comply with any conditions imposed on his registration. Further, that the restrictions imposed by a Conditions of Practice Order would be sufficient to mitigate the identified risks to patients.

165. The Panel determined that appropriate, proportionate, realistic and verifiable conditions could be formulated to sufficiently protect the public and meet the wider public interest.

166. The Panel did move on to consider whether a Suspension Order would be appropriate, but considered that the order would not be proportionate, given that the identified risks can be adequately addressed and managed by imposing a Conditions of Practice Order.

167. The Panel decided that it would impose the Conditions of Practice Order for a period of six months, as the Panel believes this is sufficient time to ensure that the Registrant is adhering to the HCPC Standards and gives an opportunity for reflection and insight into the Panel’s findings, such that a reviewing Panel will be able to determine whether or not the conditions have been met and whether the risk to the public has been reduced.

168. Throughout its decision making, the Panel had regard to proportionality and balanced the public interest against the Registrant’s interests. The Panel took into account the consequential personal, financial and professional impact a Conditions of Practice Order may have upon the Registrant. Whilst it is likely to have an impact on him this is in some way mitigated as the Order does allow him to continue in practice. In any event the Panel concluded that any negative impact on the Registrant by the imposition of an Order is significantly outweighed by the Panel’s duty to give priority to public protection and the wider public interest.

169. The Panel acknowledged that this final Conditions of Practice Order will be reviewed by a panel before it expires. The reviewing panel is likely to be assisted by the evidence provided under the terms of the Conditions of Practice Order, the Registrant’s engagement and attendance at the review hearing.

ORDER: The Registrar is directed to annotate the HCPC Register to show that, for a period of six months from the date that this Order takes effect (“the Operative Date”), you, Gary Bell, must comply with the following conditions of practice:

1. You must place yourself and remain under the indirect supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within one month of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations.

2. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice, it should demonstrate your knowledge and understanding of:

- the impact of human error on patient safety and research-based approaches to minimising risk;
- the policy and procedure for patient transfer and consent, pre and post theatre;
- the policies and procedures in your workplace and how they relate to patient safety.

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

4. You must meet with workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.

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

6. Having regard to the Panel’s decisions, you must produce a reflective practice profile detailing your part in the incidents, what went wrong, your learning and the impact upon patients, colleagues, the public, your profession and the regulator. This reflective practice profile must be shared with your workplace supervisor and the HCPC at least one month prior to the HCPC review hearing.

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

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

9. You must inform the HCPC within seven days if you take up work requiring registration with a professional body outside the United Kingdom. You must inform the HCPC within seven days of returning to practice in the United Kingdom.

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

- any patient safety incident you are involved in;
- any investigation started against you; and
- any disciplinary proceedings taken against you.

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

A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application);
D. any organisation through which you are undertaking professional training.

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

A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application);
D. any organisation through which you are undertaking professional training.

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.

Interim Order

Application

1. The Panel heard submissions from Mr Tobias on the need for an Interim Conditions of Practice Order, for six months, to cover the period during which an appeal may be made and, if one is made, whilst that appeal is in progress.

2. The Registrant was not present and therefore the Panel had, in accordance with the HCPTS Practice Note, first to decide whether to proceed to consider the Interim Order application in the absence of the Registrant.

3. The Panel heard and accepted the advice of the Legal Assessor.

Decision

4. The Panel decided that it was appropriate to consider the Interim Order application in the absence of the Registrant. In reaching this conclusion, the Panel took into account the contents of the Notice of Hearing sent to the Registrant, on 24 March 2025, where it is stated, ‘Please note that if the Panel finds that it is necessary to do so, it may also impose an interim order (under Article 31 of the Health Professions Order 2001) at any stage during the hearing. An interim order suspends or restricts a registrant’s right to practise with immediate effect.’ The Panel was satisfied this meant the Registrant was on notice that this was a possible outcome at this hearing.

5. The Panel remained satisfied that the Registrant had waived his right to be present at the hearing for the same reasons given for proceeding with the final hearing in his absence, as already detailed within this decision. The Panel could see no reason to adjourn the hearing in order to allow the Registrant to participate on a later date because there was no indication that he would do so on any other occasion. The Panel took into account the fact that it had identified there to be a continuing risk to the public if the Registrant were allowed to practise without restriction and decided it was clearly in the public interest to consider the Interim Order application today, even if that meant it was conducted in the absence of the Registrant.

6. The Panel made an Interim Conditions of Practice Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest. The Interim Order is in the same terms as the Substantive Order and is necessary in light of the risks to the public identified above. The Panel considered 6 months was appropriate and proportionate taking into account that it mirrors the length of the Substantive Order.

This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 6 months.

 

 

History of Hearings for Gary Bell

Date	Panel	Hearing type	Outcomes / Status
12/05/2025	Conduct and Competence Committee	Final Hearing	Conditions of Practice