Mazen Alkasem

Preliminary Matters
Hearing in Part in Private
1. The Registrant’s Representative supported by the HCPC, made an application for part of the hearing being heard in private in relation to the Registrant and his family. The Panel had before it, documentation relating to the wellbeing of a member of the Registrant’s family which, if referred to, should be afforded the right to be heard in private. The Panel was therefore invited to use its discretion to go into private to consider the impact of this family health issue upon the Registrant and his practice.

2. The Panel sought the Legal Assessor’s advice on this issue and was informed that the starting point was for all hearings to be held in public. That public interest in open justice could be outweighed by the right to a private life which is enshrined within the Human Rights legislation. In this instance it was the right to privacy of a member of the Registrant’s family. The Panel was informed that the HCPC (Conduct and Competence) (Procedure) Rules 2003 (the Rules) provide the Panel with a discretion to consider such issues of a personal or health nature in private. It was therefore a matter for the Panel to consider and weigh the public interest with that of this family member and to consider whether it was possible for any consideration of this health issue to be done in a discrete part of the hearing. The Panel was referred to the HCPTS guidance within the Practice Note entitled ‘Conducting hearings in private’.

3. The Panel accepted this advice and carefully considered the matter. The Panel noted that the Registrant’s Representative had indicated that his reference to those private matters could helpfully be restricted to a discrete portion of his submissions. The Panel considered that it was appropriate and proportionate for those issues to be referenced in private and so concluded that it would grant the application to go into private for part of the hearing.

Background
Academic and professional training
4. The Registrant is an HCPC Registered Physiotherapist. The facts relevant to his fitness to practise concerns date from 16 July to 24 September 2018, when he was working for the Salford Royal NHS Foundation Trust for a probationary period. The matter was referred to the HCPC on 4 October 2018 and considered by the Investigating Committee on 4 May 2020.

5. The Registrant trained as a physiotherapist in Saudi Arabia, in the Rehabilitation and Physical Therapy department, King Saud University, Riyadh, and graduated in 2001 in physical therapy and rehabilitation. As part of his internship year in 2001 he worked at the Central Riyadh Hospital for five months and the King Faisal Specialist Hospital and Research Centre in Riyadh for seven months. He was also a trainee in the physical therapy department in the Dallah Hospital, Riyadh.

6. The Registrant had practised in Saudi Arabia, before moving to the UK to continue his extended studies in October 2011 when he started a PhD in sport injury rehabilitation at Salford University. His thesis title was ‘Investigation of causes and management for patients with patellofemoral pain syndrome’. He also obtained a Diploma in Community Development from Manchester Trinity College in May 2013. In 2015 and 2016 his papers on patellofemoral pain syndrome were published in the British Journal of Sports Medicine, the Physiotherapy Journal, and an international conference journal. He was employed as a physiotherapy assistant from September 2016 to January 2017 at the Alfa Physio Clinic, Manchester.

7. The Registrant gained HCPC registration at the end of 2017. The Registrant has had no patient complaints or other issues raised, other than those referenced within these fitness to practise proceedings.

The concerns
8. In 2018 the Registrant was granted indefinite leave to remain in the UK and in the July of that year he obtained employment in Salford as a Band 5 Physiotherapist. He was placed on probation under supervision and was made the subject of an Action Plan, however he was unable to meet the standards required. The issues raised were in relation to the Registrant’s lack of competence in relation to his clinical practice which was not of the required standard and to issues of communication.

9. The concerns raised were summarised as being that whilst working between 16 July 2018 and 24 September 2018, the Registrant did not meet the standards expected of a Band 5 Physiotherapist in that he:
• Did not adequately conduct and/or record patient assessments.
• Used non-specific and / or non-clinical terminology in patient notes.
• Demonstrated a lack of knowledge regarding clinical and / or non- clinical terms and/or physiotherapy practices.
• Demonstrated poor communication with patients.
• Did not adequately prepare for patient assessments.

10. The Registrant was dismissed from his employment within the NHS in September 2018.

Most recent practice
11. In September 2018, the Registrant applied for other physiotherapy roles and in November 2019 the Registrant started working as a Musculo-skeletal physiotherapist at the Aactiv Physio Clinic in Manchester city centre. He treated around 500 patients whilst there, with most service users seeing good improvement as the result of his treatment. At the substantive hearing the Registrant supplied a testimonial from Aactiv’s managing director GA.

12. The Registrant ceased practising in June 2020 when an Interim Order of Suspension was made. This interim order was changed to Conditions of Practice in November 2021, however the Registrant was unable to find physiotherapy work at this time. This inability was partly because the Registrant provided a significant amount of care for a family member. The Registrant has since then been working as an administrator whilst also looking at options to continue his PhD studies.

Other factors
13. There were personal factors that co-existed with the concerns identified and were influential, in the Registrant’s case, in inhibiting his ability to gain and demonstrate competence in a Band 5 role.

14. The Registrant experienced language barrier issues which also impacted on his doctoral studies. Two of his children were unable to join him in the UK as a consequence of being unable to renew their UK visas. The Registrant acknowledged that he was professionally unprepared to practice in a Band 5 role and at the substantive hearing he acknowledged that “…in hindsight I should have taken steps to refresh my knowledge before returning to practice”.

15. The Registrant has not practised professionally since June 2020 and has worked, when available, in an administrative role outside of his profession. The Registrant has acted in an almost full-time capacity in providing care to his son. He has received six hours of support a week with those care responsibilities.

16. At the first review it was anticipated that in January 2024, the Registrant’s son would enter the adult care support system on attaining the age of 18 years. The Registrant anticipated that his son would become eligible for more substantial external care and facilities which would then lessen the demand placed on the Registrant. It was therefore hoped that in those circumstances, the Registrant will be able to devote greater time and resources to addressing the conditions of practice in place and seeking an opportunity to resume work in his professional capacity.

Impairment 12 October 2022
17. On 12 October 2022 the substantive hearing panel made the following decision in relation to the Registrant’s then current impairment.
There is a lack of insight by the Registrant in respect of the matters giving rise to these proceedings. He has undertaken some Continuing Professional Development since these matters arose but this has not been sufficiently focused, to address the issues raised on the proved facts and his lack of competence. The Registrant has produced historic character evidence and a supportive testimonial from his employer who states there have been no complaints against the Registrant and he is professional. The current work being undertaken by the Registrant is of a limited nature. He has engaged with the HCPC and with this hearing but he has not focused sufficiently on the key issues raised.
These matters are remediable but in the current circumstances there is a high risk of repetition. The Registrant is currently impaired under the personal component for public protection reasons. His communication problems and lack of basic clinical skills show he is lacking in relation to the necessary attributes and the fundamental tenets of the profession, for safe practice. He did not recognise the risk to patients and demonstrated a lack of insight when he gave evidence to the Panel. He referred to “mistakes which anyone could make”. This demonstrated a limited understanding of the risk to patients and the concept of harm arising from the proved facts and the extent of his lack of competence. The Registrant does not accept that his fitness to practise is currently impaired. He states that he is safe to return to practice and appears to take the view that the incidents giving rise to the proved facts are not serious. The Panel finds he has no meaningful insight into the risks posed to service users, colleagues, members of the public and the profession.
The Panel has also taken into account there are important public policy issues. The Registrant is currently impaired on public policy grounds because public confidence in the profession and the regulatory process would be undermined, if a finding was made that his fitness to practice is not currently impaired. There is a high risk of harm due to the Registrant’s lack of competence and the nature of his impairment under the personal component. Despite the lapse of time there has been no significant improvement in the level of risk of harm to the public and the public interest posed by the Registrant if he returns to practice.
Accordingly, the Panel finds that the Registrant’s fitness to practise is currently impaired on both the personal and public components.’

18. On 12 October 2022 the substantive hearing panel made the following decision in relation to the sanction of conditions of practice imposed.

19. The substantive hearing panel had a particular concern in relation to the issue of the insight shown by the Registrant, concerning the potential risks to service users through his failings in practice. The Panel noted the HCPC submission that in respect of the Registrant’s insight “it was not as fully formed as the regulator would wish”. The lack of full insight and the consequential increased risk of repetition required the Panel to ensure that any formulated conditions of practice would satisfy the primary responsibility to protect the public and the reputation of the profession.

20. The substantive hearing panel was able to formulate workable and practicable conditions of practice that adequately addressed the risks and were proportionate to the proved facts and did not amount to suspension.

21. The substantive hearing panel then imposed a 12-month Conditions of Practice Order.

Substantive Review on 12 October 2023
22. The Conditions of Practice Order imposed at the substantive hearing in October 2022 was reviewed under Article 30 of the Health Professions Order 2001 (the Order), on 12 October 2023. That reviewing panel was informed by the parties that little had changed since the substantive hearing, and it was accepted that the Registrant’s fitness to practise remined impaired. The Panel agreed that there was nothing before it to show that there had been full remediation of the failings identified in the Registrant’s practice.

23. That reviewing panel noted the impact that the Registrant’s family situation had upon his ability to address and comply with the conditions that had been imposed at the substantive hearing.

24. The reviewing panel considered that the condition requiring a reflective piece of writing had not been satisfied. The reflective piece of writing submitted by the Registrant had, in that panel’s view, shown insufficient insight into his failings and so the period within which that condition could be fulfilled was extended by four months. The Conditions of Practice Order, with this slight variation, was continued for a period of 18 months. The Conditions currently in place at this second review are:

1. Within four months of the operative date (9 November 2023):
You must produce a written reflective piece that explains your understanding of the potential impact of your identified practice deficiencies on service users, colleagues, and the reputation of the physiotherapy profession. This must be forwarded to the HCPC and will be made available to any subsequent panel.

2. Prior to commencing work as a physiotherapist:
You must contact the HCPC and successfully complete its recommended process for a “Return to Practice”.

3. If you undertake employment as a registered physiotherapist, you must place yourself and remain under the supervision of a workplace supervisor, who is a physiotherapist of band 6 or higher and registered by the HCPC.

4. You must supply details of your supervisor to the HCPC within one week of returning to practice as a physiotherapist, attend upon that supervisor as required and follow their advice and recommendations.
5. You must work with your nominated supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:
a. Effective communication with service users and colleagues.
b. Conducting comprehensive and effective patient assessments.
c. Recording comprehensive and effective patient assessments.

6. Before undertaking physiotherapy practice without direct supervision, you must complete refresher training in the following subjects:
a. Obtaining and recording service user consent for treatment.
b. Obtaining and recording service user clinical history.
c. Obtaining and recording service user assessments.
d. Obtaining and recording clinical reasoning.
e. Obtaining and recording SMART service user goals.
f. Obtaining and recording service user SOAP notes.
g. Mental capacity.
h. Activities of Daily Living.
i. Red flags and sinister pathologies.
j. Deep vein Thrombosis.

7. You must detail the areas of required refresher training within your Personal Development Plan and have them confirmed by your nominated supervisor when they are successfully completed.
8. You must meet with your nominated supervisor on a monthly basis to discuss and document your progress towards achieving the objectives set out in your Personal Development Plan and provide copies of these documents to the HCPC at least 28 days before the review hearing.

9. Once you have completed the specified refresher training you must undertake a period of directly supervised physiotherapy practice for a minimum of 3 months.
10. You must not commence physiotherapy practice without direct supervision until your nominated supervisor has confirmed your overall fitness for safe unsupervised practice and you have provided evidence of this to the HCPC.

11. Within three months of commencing practice as a physiotherapist you must forward a copy of your Personal Development Plan to the HCPC.

12. You must allow your nominated supervisor to provide information to the HCPC about your progress in attaining your objectives within your Personal Development Plan.

13. You must promptly inform the HCPC if you cease to be employed by your current employer or take up any other or further employment.

14. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

15. 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 (at the time of application); and
c. any prospective employer (at the time of your application).

Any condition requiring you to provide information to the HCPC is to be met by you sending it marked for the attention of the relevant Case Manager or the FTP department.

25. That Order took effect from 9 November 2023 for a period of 18 months.

Documentation placed before this Panel
26. The Registrant had provided the Panel with the following documentation:
• A reflective piece of writing of 11 pages. This had, in compliance with the conditions of the Order, been submitted to the HCPC on 12 March 2024.
• An 8-page health assessment relating to a member of the Registrant’s family.
• Letter from HMCTS dated 21 August 2024 and attached Court Order relating to the Registrant’s family member.
• Email from the Registrant’s Representative of 3 pages.
• Certificates of Continuing Professional Development of 57 pages. Those related to online courses undertaken by the Registrant, the majority of which related to the area of musculo-skeletal practice.

Submissions by the HCPC
27. The HCPC submitted that there had not been any substantial changes to the circumstances of this case since the substantive hearing in October 2022. This being the case, there was nothing to indicate that the failings which had been identified at the substantive hearing had been addressed. It was therefore the position of the HCPC that the Registrant’s fitness to practise remained impaired.

28. The HCPC accepted that so far as the Registrant was able, he had taken steps to comply with the conditions of the Order. He had undertaken extensive online training and had supplied a reflective piece of writing within the time specified.

29. The HCPC also acknowledged the continuing difficulties which the Registrant faced due to his family circumstances.

30. The HCPC reminded the Panel that the onus at this review was upon the Registrant to provide evidence of compliance and remediation and in the view of the HCPC he had failed to do so. This being the case, the Panel should consider that there remained a risk to the public and service users which should be addressed through the imposition of some form of restriction on the Registrant’s practice. In the HCPC’s view a Conditions of Practice Order remained the proportionate and appropriate level of restriction. The HCPC did not recommend any period for such conditions but reminded the Panel that the maximum period that such an order could be imposed was three years.

Submissions by the Registrant
31. The Registrant has registered with his professional society’s mentoring scheme and has recently been seeking a mentor who would undertake a supervisory role. The Registrant is still intending to return to practice and accepts that having been out of his profession for nearly five years he will need to undertake and complete a Return to Practice course.

32. The Registrant has fully engaged with the HCPC process and, so far as his family and financial situation has allowed him to, undertaken as much Continued Professional Development (CPD) as possible to maintain his knowledge. It was accepted that his skills have not yet been tested.

33. The Registrant’s Representative submitted that the road back to practice would take time and that conditions which provided for this would be appropriate. The Registrant’s Representative made a request on behalf of the Registrant to seek the maximum period of three years for this. In the Registrant’s Representative’s view, the terms of the current conditions remained workable and achievable.

34. Within the Legal Assessor’s advice there had been reference to the fact that there had now been a period of two and a half years under the terms of a Conditions of Practice Order, and that therefore Article 29(6), (which prohibited a striking off order being imposed in a case involving competence) no longer applied. The Panel therefore had at this second review the full range of sanctions available to it. In response to this point the Registrant’s Representative stated that a striking off was totally disproportionate in a case like this where there has been engagement and a continued willingness to return to practice. He also stated on behalf of the Registrant that a period of suspension would serve no purpose and would in essence be a striking off by another means.

35. The Registrant’s Representative drew the Panel’s attention to the fact that within the decision of the previous reviewing panel there were two significant errors. First, there was reference to the Registrant having ceased working in June 2018. This was not correct, and the true position was as set out in the substantive decision, and that was that the Registrant had continued working outside of the NHS from September 2019 to June 2020 without cause for concern and had only stopped practising when placed under an interim suspension order. Secondly, there was reference to the Registrant having a conviction. This was not the case and never had been.

Decision
36. The Panel accepted the Legal Assessor’s detailed advice. The Panel referred to the Practice Note relating to Fitness to practice and the HCPTS Sanction Policy. The Panel noted the submissions of the parties and carefully considered all the documentation placed before it.

37. The Panel was conscious that its purpose today is to conduct a comprehensive review with a view to determining whether the Registrant is fit to return to unrestricted practice. In order to do this the Panel will use its independent judgement whilst undertaking this task.

38. The Panel was aware that if the evidence before it was sufficient to show that there has been full remediation and full insight gained, such that there is little or no likelihood of a repetition of the failings found in the Registrant’s clinical skills, the Panel may come to the conclusion that there is no continuing impairment and, in such a situation, the Panel may allow the current Order to lapse on its expiry date.

39. Conversely if the Panel determined that the Registrant’s fitness to practise remains impaired, then the Panel must go on to consider what restriction, if any, should be imposed.

40. The Panel noted in particular that both parties considered that there had been meaningful engagement by the Registrant and compliance as far as possible with the terms of the Order. Both parties supported the continuation of the current order which they considered to be a proportionate and appropriate level of restriction in the circumstances.

41. The Panel noted the errors which had been recorded in the previous decision which had been brought to its attention by the Registrant’s Representative.

42. The Panel considered the reflective piece of writing submitted by the Registrant. In the Panel’s view that piece of writing displayed and addressed the concerns which the previous reviewing panel had about insight into the impact of his failings upon service users, colleagues and his profession. The Panel therefore concluded that condition one had been fulfilled.

43. The Panel gave the Registrant credit for acknowledging that he had not been able to more fully engage with the conditions and that his fitness to practice remained impaired. The Panel also acknowledged that the Registrant’s family and personal circumstances had not changed significantly and still impacted heavily on his abilities to fully fulfil the terms of the order.

44. The Panel noted the extensive number of certificates of CPD which showed that the Registrant is taking steps to maintain his knowledge. However, there was no evidence of the knowledge gained having been assessed and graded. Also, until the Registrant gains a position where he can work in a clinical setting there is no ability to judge if that knowledge is being successfully applied in practice. The Panel noted that the range of courses was heavily focused upon areas of practice which the Registrant already had a detailed understanding, such as musculo-skeletal practice. The Panel would have liked to have seen a wider range of study for instance in relation to communications.

45. The Panel considered that the Registrant’s failings, with regard to clinical and communication skills, continued to be capable of being remedied. However, in the absence of any tangible evidence that they have been addressed there was, in the Panel’s view, a continuing risk to the public. The Panel therefore concluded that the Registrant’s fitness to practise remained impaired.

46. This being the case, the Panel moved on to consider what form of restriction would best provide the requisite level of public protection, whilst at the same time provide the Registrant with the opportunity to return to safe practice. In the Panel’s view taking no action and letting the current order lapse would not provide any public protection and would expose service users to risk of harm. A Caution Order would similarly provide no public protection and so was also discounted as a suitable option.

47. The Panel considered that the particular circumstances of this case, a Conditions of Practice Order continued to be the appropriate and proportionate measure. This would address the public interest considerations and provide the public with the requisite level of protection and would provide the public with the benefits of a qualified practitioner remaining within his chosen profession.

48. The Panel gave careful consideration to the terms of the current order to assess whether they remained the most appropriate, workable and achievable set of conditions. The Panel considered that the duty to provide a well-reasoned piece of reflective writing had been discharged by the Registrant and so decided to dispense with condition 1. The remaining conditions were, in the Panel’s view, still applicable, and, although they will take time to fulfil, they were appropriately focused upon a path that would lead to autonomous safe practice. The Panel therefore could not identify any changes other than the deletion of Condition 1.

49. Before confirming its decision, the Panel considered whether it should exercise its power to impose a suspension order. In the Panel’s view this level of sanction served no purpose, removing, as it did, any means or incentive for a return to practice. A striking off order would, in the Panel’s view, be contrary to the public interest and disproportionate in the circumstances of this case where there has been engagement throughout the process.

50. The Panel has therefore confirmed its decision that the appropriate and proportionate level of sanction is a Conditions of Practice Order in the terms set out below. In confirming this level of order, the Panel also took into account the need for any restriction to adequately address the public interest. Those interests are the upholding standards and the maintenance of the reputation of the profession. In the Panel’s view this level of restriction would address and reflect those needs.

51. In relation to the length of time those conditions should be imposed for the Panel took into account the Registrant’s representations and the fact that not only would the Registrant be required to complete a Return to Practice course there were elements of his personal situation that may impact on his ability to start such a course. The Panel has therefore concluded that it will impose the order for the maximum period it can do so. Three years will give the Registrant sufficient time to fulfil the terms of the Order. In making this decision that Panel was mindful that should circumstances permit the Registrant to fulfil the terms of the Order sooner, he can, under Article 30(2), make an application for an early review.

The Interim Conditions of Practice Order made on 9 November 2022 is varied. The conditions are:
1. Prior to commencing work as a physiotherapist:
You must contact the HCPC and successfully complete its recommended process for a “Return to Practice”.

2. If you undertake employment as a registered physiotherapist, you must place yourself and remain under the supervision of a workplace supervisor, who is a physiotherapist of Band 6 or higher and registered by the HCPC.

3. You must supply details of your supervisor to the HCPC within one week of returning to practice as a physiotherapist, attend upon that supervisor as required and follow their advice and recommendations.

4. You must work with your nominated supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:
a. Effective communication with service users and colleagues.
b. Conducting comprehensive and effective patient assessments.
c. Recording comprehensive and effective patient assessments.

5. Before undertaking physiotherapy practice without direct supervision, you must complete refresher training in the following subjects:
a. Obtaining and recording service user consent for treatment.
b. Obtaining and recording service user clinical history.
c. Obtaining and recording service user assessments.
d. Obtaining and recording clinical reasoning.
e. Obtaining and recording SMART service user goals.
f. Obtaining and recording service user SOAP notes.
g. Mental capacity.
h. Activities of Daily Living.
i. Red flags and sinister pathologies.
j. Deep vein Thrombosis.

6. You must detail the areas of required refresher training within your Personal Development Plan and have them confirmed by your nominated supervisor when they are successfully completed.

7. You must meet with your nominated supervisor on a monthly basis to discuss and document your progress towards achieving the objectives set out in your Personal Development Plan and provide copies of these documents to the HCPC at least 28 days before the review hearing.

8. Once you have completed the specified refresher training you must undertake a period of directly supervised physiotherapy practice for a minimum of 3 months.

9. You must not commence physiotherapy practice without direct supervision until your nominated supervisor has confirmed your overall fitness for safe unsupervised practice and you have provided evidence of this to the HCPC.

10. Within three months of commencing practice as a physiotherapist you must forward a copy of your Personal Development Plan to the HCPC.

11. You must allow your nominated supervisor to provide information to the HCPC about your progress in attaining your objectives within your Personal Development Plan.

12. You must promptly inform the HCPC if you cease to be employed by your current employer or take up any other or further employment.

13. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

14. 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 (at the time of application); and
c. any prospective employer (at the time of your application).

Any condition requiring you to provide information to the HCPC is to be met by you sending it marked for the attention of the relevant Case Manager or the FTP department.

The Order imposed today will apply from 8 May 2025. This Order will be reviewed again before its expiry on 8 May 2028

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

History of Hearings for Mazen Alkasem