Philip Welburn

Preliminary Matters
Witness Key
1. Throughout this decision, the witnesses will be referred to as follows:
• MP, who at the relevant time was employed as Director of Pharmacy at Wrightington Wigan and Leigh Teaching Hospitals NHS FT (WWL) (“the Hospital”). MP is registered with the General Pharmaceutical Council.
• CW, who at the relevant time was the Theatre Lead (Anaesthetics) at the Hospital. CW is registered with the HCPC as an Operating Department Practitioner (“ODP”).
• BG, who at the relevant time was employed as an Anaesthetic Nurse at the Hospital. BG is registered with the Nursing and Midwifery Council (“NMC”) as a Nurse.
• RB, who at the relevant time worked as an Anaesthetist Assistant at the Hospital. RB is registered with the NMC as a Nurse.
• HH, who at the relevant time was working as an Aspirant Nurse at the Hospital. HH is the Aspirant Nurse referred to in Particulars 8 and 10 of the Allegation.
• LB, who at the relevant time worked as a Theatre Practitioner and Theatre Lead at Pall Mall Medical (“Pall Mall”). LB is a registered Nurse with the NMC.
• LW, who at the relevant time was a patient at Pall Mall and is the patient referred to in Particular 16 of the Allegation.
• HI, who at the relevant time was an ODP at Pall Mall. HI is not a HCPC witness, but her hearsay evidence is referred to within the statement of LB.

Service
2. The Panel first considered the issue of service as the Registrant was not in attendance. The Panel was referred to the service bundle which had been provided to the Panel in advance of the hearing.

3. The Panel had been provided with a Certificate signed by the Registrar dated 13 January 2025, detailing the Registrant’s registered email address on the HCPC Register.

4. The Panel had also been provided with the Notice of Hearing letter dated 13 January 2025 sent to the Registrant, on that date, to his registered electronic mail address, as it appeared in the HCPC Register. The Notice of Hearing letter confirmed the dates (19 – 30 May 2025) and times of the hearing as well as informing the Registrant that this would be a virtual hearing. It also offered the Registrant an opportunity to attend and/or make submissions at the hearing.

5. The service bundle also contained a delivery notice provided by Microsoft Outlook to confirm that delivery of the email took place on 13 January 2025, at 4:13pm.

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

7. 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.

8. 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 13 January 2025. The Panel therefore determined that notice had been properly served in accordance with the Rules.

Proceeding in Absence
9. Mr Kerruish-Jones submitted that, having found good service, the Panel should proceed with the hearing in the Registrant’s absence. He submitted that the Registrant had voluntarily absented himself.

10. Mr Kerruish-Jones submitted that these matters have been ongoing for four years, and that the witnesses are available and ready to give evidence in the coming days. He submitted that it is in the interest of the witnesses and the wider public interest, that evidence is provided without further delay due to the effect of delay on memory.

11. Mr Kerruish-Jones submitted that there is no explanation for the Registrant’s absence and there is no indication that he wished to be legally represented. The Registrant has not asked for a postponement or adjournment, and there is no indication he would attend at a later date if the hearing was postponed or adjourned. In all the circumstances, Mr Kerruish-Jones submitted that it is in the public interest for the Panel to proceed with the hearing in the Registrant’s absence.

12. 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.

13. The Panel considered all the information before it, together with the submissions made by Mr Kerruish-Jones on behalf of the HCPC. The Panel was satisfied that the Notice of Hearing letter had been sent to the Registrant on 13 January 2025 informing him of the hearing.

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 not communicated with the HCPC in response to the Notice of Hearing letter. He has voluntarily and deliberately absented himself.
• The Registrant has not sought an adjournment of the hearing and there is 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.
• This case is an old one with the Particulars of Allegation dating back to 2019, and the witnesses are lined up to give evidence this week. Any delay would cause inconvenience to the witnesses, and the further passage of time if the case was adjourned could have a negative impact on memory.
• The Panel recognised that there may be some disadvantage to the Registrant in not being able to give evidence or make oral submissions. However, he has provided some information to the HCPC, in which he denies the Allegation, and this information is included within the bundle for the Panel to take into account when reaching its decisions.
• The Panel considered that the public interest in proceeding with final hearings expeditiously, particularly as the witnesses are ready and able to give evidence, outweighed any disadvantage to the Registrant and concluded that the hearing should proceed in his absence.

Privacy Application
15. At the outset of the proceedings, Mr Kerruish-Jones submitted that the Panel should proceed in private where it was necessary to do so to protect the health and personal aspects relating to the Registrant.

16. The Panel heard and took into account the advice of the Legal Assessor and had regard to the HCPTS Practice Note ‘Conducting Hearings in Private’ dated February 2025.

17. The Panel accepted the submissions made by Mr Kerruish-Jones. The Panel acknowledged that there is a strong public interest in ensuring that hearings are conducted in public for transparency. However, the health issues relating to the Registrant should be kept private, as he has a right to protection of his private life, so far as it relates to his health. Similarly, matters which relate to personal aspects of his life such as his family/relationships should be heard in private. The Panel was satisfied that the elements of the evidence which relate to the Registrant’s health and personal matters can be easily separated from other evidence, and thus only part of the hearing should be held in private.

18. During the course of the hearing, and prior to witness ‘LW’ giving evidence, Mr Kerruish-Jones made a further privacy application. He stated that LW was a patient at Pall Mall medical and is the service user referred to in Particular 16 of the Allegation. He submitted that the parts of her evidence that relate to her health should be heard in private for the protection of her private life.

19. Mr Kerruish-Jones made the same application in relation to witness ‘HH’, whose hearsay statement was read into the transcript. HH’s statement gives details about her own health which are not directly relevant to the proceedings.

20. The Panel heard and accepted the advice of the Legal Assessor who referred to rule 10 of the Rules and to the HCPTS Practice Note.

21. The Panel was satisfied that it was appropriate to hear any evidence relating to LW or HH’s health in private in order to protect their privacy.

Offer no evidence and amendment of Allegation
22. At the outset of the hearing, Mr Kerruish-Jones submitted that the HCPC would be offering no evidence in relation to Particular 17 of the Allegation. He informed the Panel that an application to admit hearsay evidence to support Particular 17, had been made to a preliminary panel of the HCPTS, but the application was refused. Therefore, the HCPC has no evidence on which to rely to prove Particular 17.

23. Mr Kerruish-Jones submitted that the HCPC would also be offering no evidence in relation to Particular 19, because that is a secondary allegation of dishonesty and relies on Particular 17 being found proved.

24. Mr Kerruish-Jones submitted that the Allegation should be amended to reflect the above. Further, in light of offering no evidence in relation to Particulars 17 and 19, Particular 20 also requires amending to reflect that the HCPC submits Particulars 1-16 and 18 amount to misconduct.

25. The Panel heard and accepted the legal advice of the Legal Assessor who referred to the HCPTS Practice Note ‘Discontinuance of proceedings’ dated August 2023 and its inherent power to amend an Allegation providing that fairness to the parties is maintained and having regard to the HCPC’s overarching objective.

26. The Panel was satisfied that it was appropriate for the HCPC to offer no evidence in relation to Particulars 17 and 19, as there is no realistic prospect of the HCPC proving the facts of those Particulars due to the application to rely on hearsay evidence having been rejected.

27. The Panel was satisfied that making the consequential amendments to the Allegation would not result in any prejudice to the Registrant.

28. Later in the hearing, Mr Kerruish-Jones made a further application to amend the Allegation. This application was made after witness ‘MP’, the Director of Pharmacy, had given oral evidence. Mr Kerruish-Jones submitted that the drugs register exhibited to MP’s evidence, shows that the date relating to Patient E is 19 November 2019 and not 30 November 2019. Mr Kerruish-Jones submitted that the amendment is a minor one, which more accurately reflects the documentary evidence, and which does not create a prejudice to the Registrant. Mr Kerruish-Jones submitted that it was likely that the 30 November 2019 date had been inserted in error as there had been significant redaction of the bundle in relation to patient names on the drugs register.

29. Mr Kerruish-Jones referred the Panel to the case of Professional Standards Authority v Health and Care Professions Council and Doree [2017] EWCA Civ 319. He submitted that it would be fair to amend the Allegation at this stage, as the Panel has yet to hear all the evidence and had not made a decision on facts.

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

31. The Panel kept in mind the overarching objectives of HCPC, and the importance of a fair balance being struck between the aims of public interest and fairness to the Registrant.

32. Having regard to fairness to the Registrant the Panel was satisfied that the amendment does not heighten the seriousness of the Allegation, and better reflects the evidence provided by MP in relation to Patient E. The Panel considered that no new evidence is being introduced, and this minor amendment reflects the drugs register entry, which is already in the bundle, which the Registrant has been sent. The Panel therefore accepted the submissions of Mr Kerruish-Jones and agreed that the Allegation should be amended.

33. For ease of reference, the amended Allegation is set out at the start of this decision, with strikethrough text to represent deletions and Bold text to represent additions. The amended Allegation also includes the strikethrough text which was deleted following a decision to refuse hearsay evidence, further details of which are set out below.

Admissibility of material, potential fairness, and the power to ask for further evidence
34. During the examination in chief of MP, he gave evidence about the contents of the drug register which is exhibited to his HCPC witness statement and included in the bundle. Within this drug register as well as referring to the patients who are subject to the Allegation, reference is also made to Patient F, and to an entry on 28 March 2020 for a broken ampule which is signed off by the Registrant.

35. Given that this evidence does not directly relate to any of the Particulars of the Allegation, the Panel chair asked whether this was admissible evidence.

36. Mr Kerruish-Jones submitted that this was not evidence on which the HCPC sought to rely but that it was to assist the Panel in understanding the context of the evidence of MP, as referenced to the drugs register. He submitted that this was the evidence that was referred to the Police, who ultimately took no further action.

37. The Legal Assessor provided legal advice with reference to the admissibility of evidence, as per rule 10 of the Rules. The Legal Assessor advised that evidence should be relevant and fair, also having regard to the overarching objective of public protection. The Legal Assessor advised that whilst the HCPC submit this evidence is for background context, the Panel may also consider whether the evidence is prejudicial and whether it would impact on the Panel’s ability to fairly and properly adjudicate on the Allegation before it.

38. Mr Kerruish- Jones made further submissions to reiterate that this material was not included in the bundle to militate against the Registrant but is contextual background to present a full picture of MP’s evidence.

39. The Panel accepted the advice of the Legal Assessor. The Panel was satisfied that the evidence, in relation to these two matters arising, was simply giving context to the investigation that was conducted by MP. The Panel took into account that this is evidence which has been served on the Registrant and which he has had opportunity to comment on if he objected to its inclusion in the bundle. In any event, the Panel did not consider the evidence to be prejudicial to the Registrant, and given that it is provided as background information, it would not form part of its later decision making on facts.

40. After all the live witnesses had been called, Mr Kerruish-Jones made an application to admit the evidence of HI, which is contained within LB’s statement as hearsay evidence. Mr Kerruish-Jones stated that the application had arisen having heard LB’s oral evidence in which she stated, word to the effect that, “HI came to tell me…that the Registrant would not leave the patient and that he was angry and raging, and that when she left he said to the patient ‘I’m not leaving she is a cheeky bitch’ and his arms were flaying and he broke a mug…slamming his fist on the side table.”

41. Mr Kerruish-Jones submitted that the oral evidence given suggests that those comments/that behaviour was witnessed by HI. Whereas in LB’s statement, she states:
‘21. [HI] also informed me that Patient A had told her that when she had gone to recovery to speak to me about the Registrant, he had said "she is a cheeky bitch, I'm not going in there". I cannot say for certain who he was referring to but as [HI] was the only person around, except for Patient A, I would think he was referring to [HI] regarding asking him to go to theatres.
22. [HI] then informed me that Patient A had reported to her that after this comment, the Registrant had slammed his fists down on a side table resulting in a mug that was on the table to bounce in the air. The side table is fixed to the wall and held up by a metal pole and was located in recovery next to bay one where Patient A was. I am not aware that anyone else witnessed this incident except for Patient A…’

42. Mr Kerruish-Jones submitted that due to the HCPC’s understanding that it was only Patient A who had observed those mattes, it had not made any enquires with HI about the matters. It was the HCPC’s understanding that LB was simply repeating what HI had told her that Patient A had said.

43. Mr Kerruish-Jones informed the Panel that Patient A is LW, who has produced a witness statement and who has given oral evidence. In relation to these matters, she states:

‘I have been asked whether I recall someone saying “She is a cheeky bitch, I’m not going in there” and whether I recall someone shouting and/or slamming their fists on a table resulting in a mug being broken. I do not remember anything of this.’

44. Mr Kerruish-Jones submitted that HI’s evidence should be looked at in the context of the evidence as a whole, which includes references to LB’s observations of the Registrant’s unusual presentation and behaviour that day which resulted in the theatre surgeon asking for the Registrant to be removed from the theatre.

45. Mr Kerruish-Jones submitted that HI’s evidence is the sole and decisive evidence as LW has no recollection of the alleged conduct. Mr Kerruish-Jones submitted that the extent of the challenge to the evidence is unknown as the Registrant has not participated. Mr Kerruish-Jones submitted that it was open to the Panel to admit the evidence but in due course attach no weight to it. Mr Kerruish-Jones submitted that HI’s non-attendance is reasonable as it was understood that she was simply reporting what a direct witness, LW, had said to her.

46. The Panel noted that LW’s statement was dated 30 July 2024, and this states that she has no recollection of this alleged conduct. The Panel asked Mr Kerruish-Jones, why given the passage of time during which the HCPC has known this, has HI not been approached to make a statement. Particularly, as the evidence of LB includes HI’s full name, and the fact that she is an ODP, which is a registered HCPC title, thus her contact details will be on the Register.

47. Mr Kerruish-Jones did not have specific instructions to respond to the query but did explain that there had been a change of solicitors’ firm dealing with the case.

48. In conclusion, Mr Kerruish-Jones submitted that the evidence of HI is admissible, although he acknowledged that the Registrant has not had a fair opportunity to respond.

49. The Panel heard and accepted the advice of the Legal Assessor. The Legal Assessor first referred to the case of El Karout v NMC [2019] EWHC 28 (Admin) in that the Panel should first consider admissibility of the evidence. If it admits the evidence, then at the facts stage it can decide what weight to place on it.

50. The Legal Assessor then advised the Panel of the 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 also referred the Panel to the HCPTS Practice Note entitled ‘Evidence’ dated October 2024, paragraphs 31 – 36.

51. 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.

52. 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.

53. In relation to the nature of the material, the Panel noted that LB’s written statement which contains HI’s hearsay evidence, was dated July 2024, and it exhibits a contemporaneous document called a Significant Event Record, dated 17 October 2020, which mentions what HI had allegedly been told/witnessed. However, there is nothing in writing from HI, either at the time or subsequently.

54. The Panel noted that the evidence of LB and LW is the evidence relied on by the HCPC in relation to parts of Particular 16. The Panel considered whether the evidence of HI is the sole and decisive evidence in relation to parts of that charge. The Panel took into account that LB is simply reporting what she was told by HI in relation to the ‘cheeky bitch’ comment and the Registrant’s banging of his hand on the table. LB does provide her own account of seeing a broken mug. The Panel took into account that despite the evidence purportedly coming from LW, she has no recollection of this alleged conduct. Therefore, HI’s evidence about this is the sole and decisive evidence.

55. In relation to the extent of challenge to the evidence, the Panel took into account that the Registrant has received the bundle and has not made any representations to challenge the content of the statement. However, the Registrant has not been made aware of this hearsay application, as it has arisen mid-hearing and he is not present. He has therefore not had the opportunity to respond to it.

56. The Panel noted that in the transcript of Police interview, dated 7 December 2020, this specific allegation is not put to him, but he does comment about Pall Mall and states:

‘No, I didn't become verbally -- there was an ODP that came in that
completely took over from what I was doing, completely belittled me in front of a patient and just completely just -- oh, anyway, erm, we had a bit of a falling out with a member of staff, which I then walked away and then that was it, then I broke down into tears and was sent home.’

57. The Panel took into account that there was no suggestion that LB was fabricating what she was told by HI, and it formed the impression from the evidence that the reporting by HI to LB was contemporaneous, and that matters were progressing, and escalating during a short period of time. In terms of HI’s position, the Panel noted that the Registrant states in his Police interview that he felt belittled by her. However, there was no information before the Panel to suggest that HI was fabricating what she saw or was told.

58. The Panel considered the seriousness of Particular 16, taking into account the impact which adverse findings might have on the Registrant’s career. The Panel accepted that whilst Particular 16 is serious and involves the alleged breaching of professional boundaries in front of a patient, it only relates to part of what is alleged against the Registrant. The totality of the other matters alleged against him relate to matters of a more serious nature involving amending controlled drug records and dishonesty.

59. The Panel considered that there was no good reason for the non-attendance of HI and whether the HCPC had taken all reasonable steps to secure her attendance. Whilst the HCPC believed that HI’s evidence came from the direct witness LW, the HCPC has known since July 2024, that LW had no recollection of this. Further, given that HI’s full name is included in LB’s statement, and the fact HI is a registered ODP, means that the HCPC could have taken proactive action to obtain a statement from HI and called her as a witness.

60. Based on the evidence and information before the Panel, and for the reasons set out above, the Panel considered that it would not be fair to admit the hearsay evidence of HI. It is the sole and decisive evidence, and it is not capable of being tested by other evidence.

61. The Panel advised Mr Kerruish-Jones that it would require a new bundle, to include a redacted version of LB’s statement and exhibit to remove the relevant parts of HI’s hearsay evidence which it had deemed inadmissible.

62. Mr Kerruish-Jones submitted that Particular 16 would still be pursued in part, in relation to the issue of the broken mug. He indicated that his instructions were that it was not in the public interest to delay the hearing to attempt to contact HI with a view to taking a statement.

63. The Legal Assessor advised the Panel that as it plays an active, inquisitorial role, in regulator proceedings, having regard to the overarching objective, it could of its own motion adjourn the hearing and request that further investigation is made in relation to obtaining a statement from HI. The Legal Assessor reminded the Panel of the need to make fair and proportionate decisions, and to have regard to the public interest in the expeditious disposal of the case, as per Article 32(3) of the Health Professions Order 2001 which imposes a statutory obligation on Panels to conduct proceedings expeditiously.

64. The Panel decided that it would not be in the public interest to adjourn the hearing to allow for further investigation to be made into HI’s evidence. The Panel took into account that HI’s evidence relates to only a small part of the Allegation, and that some of the matters pertaining to the Allegation date back to 2019. Therefore, it is not proportionate to adjourn the hearing and would be contrary to the expeditious disposal of the hearing.

65. In the interests of fairness, taking into account that the hearsay application had been made late in the proceedings, with the Panel having heard all of the HCPC evidence, the Legal Assessor addressed the Panel on the issue of perceived bias, given that it had seen and heard evidence, which it had subsequently deemed inadmissible.

66. The Panel heard and accepted the advice of the Legal Assessor who referred to the cases of Porter v Magill [2002] 2 AC 357 and R (Mahfouz) v GMC [2004] EWCA Civ 233, and the description of a fair-minded person as per Helow v Secretary of State for the Home Department [2009] 2 All ER 1031.

67. The Panel considered that the evidence it had seen in relation to HI is potentially prejudicial to the Registrant. However, the Panel determined that it was able to consider the remaining part of Particular 16 in isolation based solely on the evidence put before it as to what LB had herself observed of the broken mug and not be influenced by the information that had originally been provided in the bundle relating to what HI said.

68. Having regard to the case law, the Panel considered that a fair minded and informed observer would be aware that this is a professionally constituted Panel with experience of regulatory cases and that an independent Legal Assessor also assists the Panel by providing legal advice. Panel members, both in this role and other roles, are frequently required to make decisions which require them to distinguish between relevant and irrelevant information and base any decision solely on admissible evidence.

69. In these circumstances the Panel concluded that it would have no difficulty completely disregarding the evidence provided by HI. Furthermore, the Panel was satisfied that it could proceed with this hearing and ensure not only that the hearing is fair, but it is seen to be fair. In reaching this conclusion the Panel had in mind the quotation from ‘Helow v Secretary of State for the Home Department [2009] 2 All ER 1031’ that the fair-minded observer is not unduly sensitive or suspicious.

Background
70. Between July 2019 and July 2020, the Registrant worked as a locum Operating Department Practitioner (“ODP”) at the Hospital.

71. CW worked as the Theatre Lead (Anaesthetics) at the Hospital and oversaw booking the Registrant’s shifts with his agency, Pertemps.

72. The Hospital has a Standard Operating Procedure for the preparation and administration of controlled drugs when completing the Controlled Drugs Register (the Register) which states:

‘4. Entry in the Controlled Drugs Register
4.1 Make an entry in the warn or department CD register. Each entry must include the:
4.1.1 Full signatures of both practitioners (giving and witnessing)
4.1.2 Date and time of administration.
4.1.3 Name of the patient.
4.1.4 Quantity/dose administered.
4.1.5 Name, formulation and strength.
4.1.6 Running balance.

4.2 *Theatre registers require a witness for supply and destruction of controlled drugs but the administration doesn’t need a witness if carried out by an anaesthetist. If nurses/ODP administers the drug then they do require a witness for administration.
4.3 The ward Controlled Drugs Register must be completed immediately before the administration of a controlled drug.

4.4 Mistakes in the register must not be crossed out/obliterated. The wrong information must be bracketed, signed and dated by the member of staff in the margin and the correct information clearly added in the appropriate place.’

73. On 15 July 2020, BG, an Anaesthetic Nurse at the hospital, and RB, an Anaesthetist Assistant were checking the Controlled Drugs Register. RB recalled that he noticed that his entry under morphine 10mg for 13 July 2020 for the first patient had been altered from 10mg to 20mg, and the stock balance number had been altered. RB also noticed further alterations for the quantity of drug issued for a patient operated on later in the day, and the stock balance. BG recalled doing the check with RB and him asking whether she had given out any more morphine to RB’s patient after he had left for the day. BG recalled that she had not given out any more morphine for the patient and that she had written 8mg with 2mg wasted by the anaesthetist who had signed the register, with BG witnessing the signature.

74. The same day, BG and RB alerted CW to changes within the Controlled Drugs Register. This prompted an internal investigation at the Hospital. CW suspected that it could have been the Registrant who was responsible for the amendments as he had been working in that theatre and covering a lot of shifts during that period, and she observed he was not being his normal self. CW noticed a change in the Registrant’s behaviour, as he was acting erratically, seemed on edge, sweaty, and irritated with pinpoint pupils.

75. CW recalls speaking with the Registrant about his health and that he was blasé about her concerns. In CW’s opinion, it seemed that the Registrant was under the influence of some form of drug. She therefore reported the matter to her manager, who in turn notified the Registrant’s locum agency.

76. On 15 July 2020, MP, Directory of Pharmacy at the Hospital, was alerted by CW to the Controlled Drugs Register records, from 13 July 2020, for the two patients identified by RB and BG. Upon reviewing these records, it became apparent to MP that there had been amendments by overwriting the amounts supplied, given and destroyed. Furthermore, MP noted there had been obvious attempts to obliterate and change the stock balance such that the entries had been amended after theatre staff had made their entries.

77. MP and CW proceeded to review the Controlled Drugs Registers, prescriptions and theatre records (paper and online) made by the Registrant over a period of time. They identified a number of issues, such as preparing morphine in advance of a procedure that did not usually involve morphine, multiple amended controller drug register entries for Schedule 2/Class A controlled drugs and acting as a witness for an entry of Oxycodone injection when the Registrant should have signed as ‘responsible person’.

78. MP recalled that the level of concern was further raised due to CW describing the Registrant as sweaty and erratic.

79. MP stated that he acted in accordance with his duties by sharing the information with the Professional Adviser for Greater Manchester & Social England Area Team and the Greater Manchester Police.

80. MP states that from a safeguarding perspective, the Hospital was concerned about the Registrant’s welfare, as he had been led to believe that the Registrant or others could be at risk from the misuse or diversion of Class A controlled drugs. This also raised an obvious concern about patient safety.

81. With respect to the oxycodone injection/signing as the responsible person, it transpired that a student (aka aspirant) nurse, HH, had signed the responsible person section in error. This section can only be signed by doctors, registered nurses and ODPs for the purpose of administering a controlled drug.

82. MP states that the Registrant should have signed this section, and not HH. As such, there was a risk that the Registrant had not taken responsibility in line with the expected recording standards, thus taking advantage of a junior colleague who might not have been fully familiar with her responsibilities and regulations around controlled drugs.

83. HH recalls two incidents concerning the Controlled Drugs Register, for which she produced a statement on 30 July 2020 for the Hospital. Incident 1 related to an unspecified date, when she mistakenly signed for a broken ampoule of oxycodone in the responsible person section (as mentioned above) where the Registrant witnessed her signature. HH recalls the Registrant opening the Controlled Drugs cupboard and saying the ampoule was broken and that she was to watch him throw it in the bin. Despite the Registrant saying this, she did not actually see him dispose of the ampoule as she was on the other side of the room. By the time she signed the book, the Registrant had already signed the witness section. Incident 2 related to the 10 June 2020, when HH states that one of her entries was amended concerning a dosage for a morphine IV injection. She accepts that she had signed the register as responsible person with the Registrant, but that the amendment had been made after she had signed it and was not her writing.

84. HH noted that the Registrant’s approach to assessment of patient pain differed from other colleagues. Where most other staff would use a scoring system, the Registrant would simply ask ‘are you in pain’. If the answer was affirmative, he would go straight for IV morphine. At the time she did not feel the need to question his decision or reasoning.

85. Due to events arising at the Hospital in July 2020, the Registrant was not offered any further shifts at the hospital.

86. Further concerns then arise at Pall Mall, where the Registrant worked as an agency ODP, in or around October 2020.

87. On 17 October 2020, LB was on duty at Pall Mall and working in theatre with the Registrant, this being his second agency shift with Pall Mall. Whilst a patient was under local anaesthetic, she noticed that the Registrant could not keep his hands steady while holding on to the instruments. She recalls the Registrant going towards the patient’s face with scissors because he needed to cut a stitch and his hands were visibly shaking. She also observed that the Registrant was sweating profusely, that he was very pale, appeared agitated and did not look right. LB recalled that the surgeon said to her that he was not happy with the Registrant and did not feel he was safe. LB recalled that as a result she asked the Registrant to leave the theatre and go and work in recovery.

88. Sometime later that morning, LB came across the Registrant in the recovery area. She recalled that he was talking to himself, clenching his fists and appeared angry. She formed the view he was trying to calm himself down. As he appeared very agitated, she elected not to interact with him.

89. Later that afternoon, a patient (LW), was admitted to recovery, having undergone surgery under general anaesthetic. The Registrant was allocated to her care. Thereafter some concerns were raised with LB by a colleague with regard to the Registrant’s behaviour, which included him allegedly breaking a mug. LB recalls that as a result of this conversation, she went straight to find the Registrant. She spoke to him alone and asked what was going on. She recalls that the Registrant told her that his life was falling apart and that he has lost everything. She noticed that the whole time she was engaging with him that he appeared agitated and he was twitching and sweating. At this point, LB looked at the side table and could see her mug was on the table, but the handle had broken off. She asked about this, and the Registrant said sorry, and that he has knocked it by mistake and it broke. He then grabbed some change from his bag and said here is a few quid, buy yourself a new one. He was then sent home as LB did not believe he was fit to be at work. Thereafter, such was LB’s concern that she completed a Significant Event report.

90. Within days of this incident, the Registrant texted LB saying ‘I am really upset I’m not allowed to work at pall mall anymore after that know it all ODP took over the care of my patient … I am sorry that I wasn’t 100 percent that day cost I would of put her in her place ha ha ha.’

91. The Registrant was never prosecuted for any criminal offences. The Registrant has no history of previous allegations or disciplinary actions recorded against him.

92. On 24 May 2023, the Registrant was spoken to by HJ, a case worker for the HCPC. HJ made a telephone attendance note in which the Registrant alleged he had been suffering with a health condition in July 2020, seeking to explain his appearance as being due to his health.

93. On 28 June 2023, the Registrant emailed HJ and denied all allegations of dishonesty. He referred to his Police interview to explain Particulars 1 to 16, essentially denying all of the factual allegation. His Police interview, on 7 December 2020, followed his arrest on suspicion of theft by an employee and was the subject of no further action following a decision by the Crown Prosecution Service.

Evidence
HCPC
94. The HCPC called the following witnesses to give live evidence:
• MP. MP’s initial witness statement is dated 21 April 2024, and it exhibits a letter to the HCPC dated 25 February 2021 (which attaches copies of the drugs registers and relevant patient theatre records) and a copy of the relevant Hospital policies and procedures in relation to the supply, administration and destruction of controlled drugs. MP’s supplementary witness statement is dated 20 September 2024, and it exhibits a number of emails that MP sent to Capsticks LLP, who were originally dealing with this case, on behalf of HCPC. It also exhibits an email MP sent to HJ on 22 March 2023.
• CW whose statement is dated 18 July 2024. CW exhibits the registers of attendance which are signing in sheets for locum staff to sign when they start each shift.
• BG whose statement is dated 31 July 2024. BG exhibits her Hospital statement dated 15 July 2020.
• RB whose statement is dated 31 July 2024. RB exhibits a personal reflection dated 15 July 2020 and a more detailed account which was subsequently signed on 12 July 2024 when he was contacted by HCPC to provide a statement.
• LB whose statement is dated 29 July 2024. LB exhibits a copy of the significant event report which she made at Pall Mall on 17 October 2020, and an image of a text message sent to her by the Registrant on a date following the alleged incident on 17 October 2020.
• LW whose statement is dated 30 July 2024.

95. HH’s statement dated 27 September 2024 was admitted as hearsay evidence at a preliminary hearing which took place on 17 February 2025. Whilst the Panel was not provided with a copy of that panel’s decision, HH’s statement exhibited her Hospital statement drafted on 30 July 2020.

96. The witnesses who gave live evidence did so under affirmation or oath. They adopted their witness statements and exhibits as their evidence in chief. They were asked supplemental questions by Mr Kerruish-Jones. The witnesses were also 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
97. Included in the bundle was various correspondence between the Registrant and the HCPC. In summary the information he provided is as follows:
• Self-referral dated 3 February 2021
• Notification of no further action by the Police (undated).
• Email to HCPC dated 25 July 2022 to apologise for any behaviour and documentation concerns that he has caused during this investigation. The Registrant states ‘As an odp I understand the reason for professional conduct and precise information keeping at work and this I will admit has not been my best work.’
• Telephone attendance note dated 24 May 2023, made by HJ following a telephone call between the Registrant and HJ. This records the Registrant as asking how many people had had access to the registers aside from him. He said he ‘wasn’t even on shift’ on some days. He attributed his actions at Pall Mall as due to his health condition.
• Email from HJ to the Registrant on 23 June 2023, replying to his query about which of the Particulars of Allegation were covered in his Police interview.
• Email to HJ from the Registrant dated 28 June 2023 dealing with points raised in the investigation report (NB the Panel did not have access to the investigation report). Essentially the Registrant seeks to rely on his Police interview in response to the HCPC Allegation. He denies any dishonesty and sets out his understanding of the impact bad record keeping can have.
• Transcript of Police interview dated 7 December 2020, wherein the Registrant is interviewed under caution with a solicitor present, following his arrest for Theft by an employee.

Legal Advice
98. 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.
• Dishonesty as per the test in Ivey v Genting Casinos (UK) Ltd t/a Crockfords [2017] UKSC 67, and with reference to the HCPTS Practice Note on ‘Making decisions on a registrant’s state of mind’ dated January 2025.
• Weight of evidence including directions on hearsay evidence and on circumstantial evidence.
• Cross-admissibility with reference to the guidance set out in PSA v GMC & Garrard [2025] EWHC 318 (Admin).
• Good character.
• Drafting decisions, as per the HCPTS Practice Note on Drafting.

Decision on Facts
99. Before turning its attention to each individual Particular of the Allegation, the Panel had regard to the fact that it was being invited by the HCPC to find the evidence in relation to all the Particulars cross admissible on the ground of rebutting coincidence.

100. The Panel had heard and accepted the advice of the Legal Assessor only on the ground of the evidence being considered as cross admissible to rebut coincidence.

101. The Panel next considered whether the evidence in question is capable of being cross admitted, by evaluating whether there is a sufficient connection and similarity between the facts of the Particulars.

102. The Panel took into account that the Particulars, excluding 16, all relate to the Registrant undertaking his ODP job at the Hospital, within a theatre setting, wherein he had access to the controlled drugs cabinet which contained Class A drugs, and to the Controlled Drugs Register, which is the legal document completed by the Hospital theatre staff to ensure compliance with the Misuse of Drugs Act.

103. In relation to Particular 16, the Panel took into account that this relates to Pall Mall rather than the Hospital. Nonetheless the evidence in relation to this Particular, relates to the Registrant’s alleged poor conduct within a theatre setting, and wherein he is said to display erratic behaviour and present with a concerning appearance, of the same type that was allegedly witnessed at the Hospital.

104. On the basis of the above, the Panel concluded that there is a sufficient connection and similarity between the facts of the Particulars, such that the evidence is capable of being cross admitted.

105. As the evidence is cross admitted to rebut coincidence, the Panel noted that before attaching weight to the evidence it needed to exclude collusion or contamination as an explanation for the similarity before it can assess the force of the argument that the allegations are unlikely to be the product of coincidence.

106. The Panel was satisfied that there had not been collusion or contamination of the evidence. In relation to the Hospital, the Panel took into account that it is RB who initially raises the issue of alleged amendments which relate to the entries on 13/14 July 2020, as he states that he knows that the alteration was not made by him, and BG who is with him at the time, states it was not her. He reports this immediately to CW but with no indication or accusation as to who might have changed the register. His oral evidence was that given the apparent alterations did not follow policy, and had not been made by him, he escalated it.

107. The Panel also took into account that CW had independently already identified concerns of her own which related to the Registrant’s change in appearance and demeanour. The combination of these concerns caused matters to be escalated.

108. The Panel took into account that MP then conducted his investigation, which it accepted was a methodical one, looking at the drugs register entries and associated records. It was MP’s job to do this as part of his Hospital role and the Panel found he had no other agenda. He then referred the matters to external agencies in line with expectations, given the nature of the concerns involving Class A drugs.

109. In relation to HH, there was no evidence before the Panel to indicate that she was made aware of the other drug register entry concerns, as her statement made close to the time of the events, simply refers to two incidents about which she is asked to provide a statement to explain the nature of the incidents and her account of what happened.

110. The Panel took into account that all the Hospital witnesses are registered professionals. It considered that each had taken separate steps in raising and/or recording their concerns independently of each other.

111. The Panel were equally confident and satisfied that there had been no collusion or contamination of the evidence from Pall Mall. There is no evidence to suggest that Pall Mall staff had any awareness of the events that were alleged to have taken place at the Hospital or the way the Registrant was said to have been physically presenting. In fact, to the contrary, LB gave oral evidence, that the reason she had booked the Registrant for an ODP shift was because he has been recommended to her as being “reliable and hard-working”.

112. Having excluded collusion or contamination of evidence, the Panel acknowledged that when considering the evidence as a whole, the fact that there are multiple allegations of a similar type reduces the likelihood of there being an innocent explanation for them.

113. The Panel noted that it was not necessary for it to find one Particular of the Allegation proved before relying upon the evidence in respect of that Particular in support of the other Particulars. It therefore considered all the incidents together, holistically rather than sequentially.

114. In undertaking its exercise of considering the evidence to decide whether the HCPC had found each individual Particular of the Allegation proved, the Panel paid particular attention to the documentary evidence, and undertook a cross check of the relevant drugs register entry, patient notes, and anaesthetic records.

Particular 1 – Found Proved
1. On or around 25 November 2019, you did not record the name of the patient in the Controlled Drugs Register when purporting to document discarded Morphine Sulphate.

115. The Panel had regard to the drug register entries for morphine on 25 November 2019, as exhibited by MP. The Panel was confident that the documents provided by MP are exact copies of the relevant registers and records and were contemporaneous. These are the same documents that he examined as part of his investigation following the concerns raised by CW.

116. The Panel noted that there is an entry on 25 November 2018 which states ‘one amp discarded’ in the section which is supposed to state the patient’s name and NHS number. The Panel noted that the Registrant has put his name stamp and signature under the witness column and that the responsible person column contains a different signature. The Panel noted that the entries either side of the ones made on 25 November by the Registrant included the date as being 2019, as did all other entries on the page. The Panel therefore concluded that the recording of the date as 2018, was an administrative error, and the date it was actually recorded was 2019.

117. The Panel was satisfied, on the basis of the documentary evidence that on 25 November 2019, the Registrant did not record the name of the patient in the Controlled Drugs Register when purporting to document discarded Morphine Sulphate.

118. Whilst the Panel found this proved, in accordance with the wording of the Particular, it did keep in mind the oral evidence it heard from MP. He told the Panel that the responsible person would make sure that the patients name is recorded and take responsibility for the record. He accepted in response to a question from the Panel that in this example, it was not the Registrant who had the responsibility to record the patient’s name as he signed as the witness not the responsible person. The Panel considered that this evidence from MP would be relevant for later considerations on the issue of whether this conduct was dishonest and whether it amounted to misconduct.

Particular 2 - Found Proved
2.On or around 28 November 2019, you amended entries in a Controlled Drugs Register for the administration of Fentanyl to Patient A.

119. The Panel considered the drugs register entries for this date, for Fentanyl, in accordance with the evidence of MP. The register shows that on 28 November 2019, for Patient A, 200 micrograms was drawn up, 200 micrograms was administered and 0 micrograms destroyed. The stock balance in the register shows 10.

120. The Panel relied on the evidence of MP that the register record had been amended by overwriting the drawn up, administered, and balance entries. MP’s evidence was that the underlying entries read 100 micrograms drawn up, 100 micrograms administered, and balance was 11. The Panel considered that MP’s evidence accorded with the documentary evidence which clearly showed amendments as per MP’s evidence. The Panel was confident in relying on the evidence of MP because it found him to be a reliable witness. His evidence was measured, and with close regard to the contemporaneous documents which were created at the time. He did not seek to make assumptions about the reason the alleged amendments had been made and was essentially a witness of fact describing the investigation he conducted.

121. Having satisfied itself that on 28 November 2019, there had been entries amended in the Controlled Drugs Register for the administration of Fentanyl to Patient A, it next considered whether those amendments had been made by the Registrant.

122. In conducting the task, it kept in mind its decision on cross-admissibility and that it could consider all the incidents together holistically. Whilst, the evidence that the Registrant allegedly amended the register, is circumstantial the Panel was nonetheless satisfied on the balance of probabilities that it was the Registrant who made the amendments.

123. The signing in sheets exhibited to CW’s statement note the Registrant as signing in at 09:30 and out at 19:00 on 28 November 2019 and signing in on 29 November 2019 at 08:00 and out at 18:00.

124. Whilst the Registrant was apparently not involved from a record keeping point of view for Patient A, he was involved in the next entry, which was on 29 November 2019, which provided an opportunity for him to amend the previous entry.

125. In reaching its decision, it took into account that the Registrant had the opportunity to make the amendments, as he had access to the drugs cupboard and registers as part of his role. Whilst the Registrant’s email to HJ enquires about who else had access, the Panel was confident that only limited staff members could access the drugs cupboard and the drugs register. MP, CW and RB gave corroborative evidence about the tight procedures which are in place to ensure access to Class A drugs is limited.

126. The Panel considered that the evidence taken holistically shows a pattern of events, whereby amendments are made on the drugs register for patients that the Registrant is dealing with or for entries whereby the Registrant is dealing with the next patient in time, or the patient preceding his patient. The Panel considered that this is not a coincidence given the proximity of the Registrant to the events in question. Further, the Registrant’s presentation at the time the allegations came to light gave rise to concerns that he may be misusing drugs. He was presenting as sweaty and erratic such that it raised alarm bells with CW, prior to her being aware of the alleged amendments to the register. When considering matters holistically, the Panel also took into account the evidence from the Hospital that in relation to breakages of Class A drugs, the Registrant’s breakages were completely out of keeping with other ODPs or Nurses at the Hospital. It also took into account the evidence of MP that it was not a single event that caused the Hospital to have concern, ‘rather the totality of the events involving controlled drugs that are unusual’ and raise suspicion about potential diversion.

127. Since the time the events came to light the Registrant has also stated in his Police interview that he thinks he was responsible for some of the amendments as some of them have been initialled by him, and that in hindsight he should have started a fresh line for any changes.

128. In conclusion, the Panel found proved that on or around 28 November 2019, the Registrant amended entries in a Controlled Drugs Register for the administration of Fentanyl to Patient A.

Particular 3 - Found Proved
3. On or around 29 November 2019, you amended entries in a Controlled Drugs Register for the administration of Fentanyl to Patient B.

129. The Panel considered the drugs register entries for this date, for Fentanyl, in accordance with the evidence of MP. The register shows that on 29 November 2019, for Patient B, 100 micrograms was drawn up, 35 micrograms was administered and 65 micrograms destroyed. The stock balance in the register shows 9, although Patient B falls directly under Patient A, wherein the stock balance has been altered from 11 to 10.

130. The Panel relied on the evidence of MP that the register record in relation to Patient B, had been amended by overwriting the administered and disposed entries. The register shows the Registrant as signing as the witness for Patient B and his signature includes use of his name stamp. The Panel considered that MP’s evidence accorded with the documentary evidence which clearly shows amendments as per MP’s evidence. The Panel was confident in relying on the evidence of MP for the reasons it has already set out within this decision.

131. For the same reasons as those set out in paragraphs 125-127 the Panel was satisfied that it was the Registrant who had made the amendments.

132. The Panel therefore found proved that on or around 29 November 2019, the Registrant amended entries in a Controlled Drugs Register for the administration of Fentanyl to Patient B.

Particular 4 – Found Proved
4. On or around 29 November 2019, you amended entries in a Controlled Drugs Register for the administration of Fentanyl to Patient D.

133. The Panel considered the drugs register entries for this date, for Fentanyl, in accordance with the evidence of MP. The register shows that on 29 November 2019, for Patient D, 200 micrograms was drawn up, 200 micrograms was administered and 0 micrograms destroyed. The stock balance in the register shows 15. The evidence also shows that the Registrant was at work on that date.

134. The Panel relied on the evidence of MP that the register record had been amended by overwriting the drawn up, administered, and balance entries. MP’s evidence was that he believed the underlying entries read 100 micrograms drawn up, 100 micrograms administered, and balance should have been 16. The Registrant is the witness for Patient D’s register record. MP’s evidence also referred to Patient D’s anaesthetic record, which shows that in theatre Patient D only received 100 micrograms of Fentanyl.

135. The Panel considered that MP’s evidence accorded with the documentary evidence which clearly showed amendments as per MP’s evidence, the figures of which were contrary to those contained within Patient D’s theatre records. The Panel was confident in relying on the evidence of MP for the reasons already given in this decision.

136. For the reasons set out at 125 – 127 the Panel was also satisfied that it was the Registrant who has made these register amendments.

137. The Panel found proved that on or around 29 November 2019, the Registrant amended entries in a Controlled Drugs Register for the administration of Fentanyl to Patient D.

Particular 5 - Found Proved
5.On or around 30 November 2019, you amended and/or obliterated entries in a Controlled Drugs Register for the administration of Fentanyl to Patient C.

138. The Panel considered the drugs register entries for this date, for Fentanyl, in accordance with the evidence of MP. The register shows that on 30 November 2019, for Patient C, 100 micrograms was drawn up, 100 micrograms was administered and 0 micrograms destroyed. The stock balance in the register shows 6 which appears to be a change to the underlying entry. The evidence also shows that the Registrant was at work on that date, on a night shift, albeit in relation to Patient C he is neither the responsible person nor the witness. However, the Registrant does put his initials by the change in the stock balance column.
139. The Panel relied on the evidence of MP that the register record had been amended by overwriting the stock balance entry. MP’s evidence said this was a concern because why was the amendment to an entry made, which on the face of it was ok, and which the Registrant’s initials were used when he appeared not to have been involved with Patient C.

140. The Panel considered that MP’s evidence accorded with the documentary evidence which clearly showed amendments as per MP’s evidence. The Panel was confident in relying on the evidence of MP for the reasons already given in this decision.

141. The Panel noted that in the Registrant’s Police interview he talks in general terms about errors and how to deal with them. The Registrant says that if there is an error or you have to cross everything out, you cross it out so you can roughly see what’s been crossed out and then initial any amendments to any drug books.

142. For the reasons set out at 125 – 127 the Panel was also satisfied that it was the Registrant who has made these register amendments.

143. The Panel found proved that on or around 30 November 2019, the Registrant amended and obliterated entries in a Controlled Drugs Register for the administration of Fentanyl to Patient C.

Particular 6 - Found Not Proved
6.On or around 19 November 2019, you amended and/or obliterated entries in a Controlled Drugs Register for the administration of Remifentanil to Patient E.

144. The Panel considered the drugs register entries for this date, for Remifentanil, as exhibited to MP’s witness statement. The Panel noted that for this Particular of the Allegation there are no other pieces of documentary evidence to support it.

145. In oral evidence MP stated that he could see from the drugs register he had exhibited that there is an overwrite, in relation to the supplied amount, but that the supplied and administered amount matched. Further, he said that Patient E was not a case that the Hospital looked into.

146. Whilst the Panel could see what appeared to be an amendment in the drugs register relating to Patient E, it did not have other evidence before it that the amendment could be directly linked to the Registrant as unlike other Particulars of the Allegation, Patient E was not part of the Hospital investigation nor did the register entry show that the Registrant was involved with the next patient, which distinguishes Patient E from other alleged amendments to other patients. Patient E appears in the register on 19 November 2019, followed by entries on 22 November 2019, 26 November 2019, and an entry to note drugs ‘received from pharmacy’ on 28 November 2019. It is not until an entry on 30 November 2019 that the Registrant’s name appears, as a witness to a patient on that date.

147. In the absence of evidence from MP that the Registrant had amended and/or obliterated entries in a Controlled Drugs Register for the administration of Remifentanil to Patient E, the Panel found this not proved.

Particular 7 - Found Proved.
7.On or around 03 April 2020, you amended and/or obliterated entries in a Controlled Drugs Register for the administration of Morphine to Patient G.

148. The Panel considered the drugs register entries for this date, for Morphine, in accordance with the evidence of MP. The register shows that on 03 April 2020, for Patient G, there are two entries for 10mg morphine. Entry 1 shows 10mg was drawn up, 10 mg was given, and the Registrant does not appear to be involved in this entry. Entry 2 shows 10mg drawn up, 4 mg administered and 6mg destroyed. The evidence also shows that the Registrant was at work on that date, and he is the witness to the 2nd entry.
149. The Panel relied on the evidence of MP that the register record had been amended by overwriting the administered entry. MP’s evidence was that he believed the underlying entry read 10 mg administered. MP’s evidence also referred to Patient G’s anaesthetic theatre record, which shows that in theatre Patient G had a dose of 4mg and then 6mg. This would account for the 1st entry. The theatre record also has a separate comment on it which suggests Morphine 14 which MP believed referenced that 14mg has been given and looked like the Registrant has written it.

150. The Panel considered that MP’s evidence accorded with the documentary evidence which clearly showed amendments as per MP’s evidence. The Panel was confident in relying on the evidence of MP for the reasons already given in this decision.

151. For the reasons set out at paragraphs 125 -127, the Panel was also satisfied that it was the Registrant who has made these register amendments.

152. The Panel found proved that on or around 03 April 2020, the Registrant amended and obliterated entries in a Controlled Drugs Register for the administration of Morphine to Patient G.

Particular 8 - Found Proved
8.On an unknown date between 09 June 2020 and 22 June 2020, you failed to follow standard procedure in that you requested and/or permitted an Aspirant nurse to sign the Controlled Drugs Register as the responsible person when purporting to document a broken ampule of Oxycodone.

153. The Panel considered the drugs register entries for this date period, for Oxycodone, in accordance with the evidence of MP. The entry whereby both the Aspirant Nurse and Registrant’s signatures are present is undated but falls after an entry on 1 April 2020 and before an entry dated 22 June 2022. MP’s evidence was that the Hospital checked administration records on HIS of Oxycodone in theatres and ICU between the dates of 9 June 2020, when HH started and 22 June 2020 when the next vial was booked out to a patient. Therefore, concluding that this entry must have been made between 9 to 22 June 2020.

154. MP said the drug register entry for this date was poor because it was undated, and it was signed as a responsible person by HH, which is in breach of the policies and procedures and not in line with the Misuse of Drugs regulations.

155. The documentary evidence exhibited by MP shows in the section which should include a patient name the comment ‘one Amp found broken’ and in the responsible person section HH has signed and in the witness section the Registrant has signed and used his name stamp.

156. The Panel also had regard to the ‘Procedure for the Prescribing of Controlled Drugs’ policy which was in place at the Hospital at the time. This states that:

‘All CD’s must be checked and administered by two people, one of whom must be a Registered Nurse/Midwife/ODP or Medical Practitioner. The second person (witness) should be a Registered Nurse/Midwife/ODP, Pre-Registration Nurse*/Midwife, Medical Practitioner or Pharmacist. An appropriately trained Assistant Practitioner* may be used as a second check provided no dose calculations are required.’

157. MP’s evidence was that standard procedure in the Hospital was that doctors, registered Nurses or ODPs can act as a responsible person, but that a student/Aspirant Nurse cannot act as a responsible person because they are not yet registered. They can act as witness to controlled drugs administration towards the end of their training period.

158. MP’s evidence was that the issues with the Registrant acting as a witness is because it was his responsibility to sign as the responsible person because he was the registered staff member.
159. The Panel had regard to the statement of HH which was admitted as hearsay evidence. This exhibits the statement that HH made to the Hospital on 30 July 2020. This states that:

‘On the day (I cannot recall the exact date) a broken ampoule was signed for mistakenly by myself in the ‘responsible person’ section and Phil (ODP Agency) as witness / 2nd checker with no date documented in the controlled drug book.

During the incident, I was setting up the monitoring for the patient at top end (patient head end) of the trolley and attaching to the patient and undertaking the patient’s observations whilst Phil (ODP) was at the patient’s foot end of the trolley (approx. 2 feet away) in the controlled drugs cupboard stating the patient needed oxycodone.

Whilst I was attending to the patient, the cupboard was unlocked and opened by Phil (ODP) and he said to me [HH] his is broken; you are watching me throw it in the bin’. I didn’t actually see for myself that the ampoule was broken as I was at the other side of the room. I looked at Phil as he said it and saw him move over to the blue bin (which was on the other side of the room to him) and saw his arm and hand move over the bin and I presumed that he had disposed of the ampoule. I didn’t see the ampoule enter the blue bin however I was on the other side of the room and his arm movement didn’t lead me to question that it hadn’t entered the bin. Phil said ‘I’ve signed for it, can you sign it?’

I finished what I was doing with my patient and went to sign the controlled drug book. This was approx. 5 minutes after he had asked me to sign the controlled drug book. I mistakenly signed in the section as ‘responsible person’. Phil had already signed in the section as ‘witness’ before I added my signature into the book.’

160. The Panel placed significant weight on the evidence of MP and HH. Whilst HH’s evidence is hearsay, she relies solely on her account which was set down in writing shortly after the events arose. Her account also corroborates with the evidence of MP.

161. The Panel therefore found proved that on an unknown date between 09 June 2020 and 22 June 2020, the Registrant failed to follow standard procedure in that he requested and permitted an Aspirant nurse to sign the Controlled Drugs Register as the responsible person when purporting to document a broken ampule of Oxycodone.

Particular 9 - Found Proved
9.On or around 10 June 2020, you amended entries in a Controlled Drugs Register for the administration of Morphine to Patient H.

162. The Panel considered the drugs register entries for this date, for Morphine, in accordance with the evidence of MP. The register shows that on 10 June 2020, for Patient H, 10mg was drawn up, 5mg was administered and 5mg was destroyed. The stock balance shows 18amps. The evidence also shows that the Registrant was at work on that date.

163. The Panel relied on the evidence of MP that the register record had been amended by overwriting the administered and destroyed entries. MP’s evidence is that the underlying entries read 4mg administered and 6 mg destroyed. MP also referred to the theatre record which shows that only 4mg of morphine was administered in two 2mg administrations.

164. The Panel considered that MP’s evidence accorded with the documentary evidence which clearly showed amendments as per MP’s evidence. The Panel was confident in relying on the evidence of MP for the reasons already given in this decision.

165. In relation to who had made these amendments, the Panel was satisfied that for the reasons set out at paragraphs 125 – 127, it was the Registrant who has made the amendments. In further support of this is the contemporaneous Hospital statement of HH, in which she states the amendments are not in her handwriting and that she added her signature after the Registrant had signed the register but that the amendment was not present when she signed. Although HH did not give oral evidence, the Panel was satisfied that it could rely on her evidence, given the contemporaneous nature of it, and given that it accords with evidence given by other registered professionals in that amendments had been made to the register which they knew had not been made by them.

166. The Panel found proved that on or around 10 June 2020, the Registrant amended entries in a Controlled Drugs Register for the administration of Morphine to Patient H

Particular 10 - Found Proved
10.On 10 June 2020, you failed to follow standard procedure in that you requested and/or permitted an Aspirant nurse to sign the Controlled Drugs Register as the responsible person for Morphine administration.

167. The Panel considered the drugs register entry for this date, for morphine. The documentary evidence exhibited by MP shows the responsible person section having been signed by HH and in the witness section the Registrant has signed and used his name stamp.

168. The Panel had regard to the ‘Procedure for the Prescribing of Controlled Drugs’ policy which was in place at the Hospital at the time. This states that ‘All CD’s must be checked and administered by two people, one of whom must be a Registered Nurse/Midwife/ODP or Medical Practitioner. The second person (witness) should be a Registered Nurse/Midwife/ODP, Pre-Registration Nurse*/Midwife, Medical Practitioner or Pharmacist. An appropriately trained Assistant Practitioner* may be used as a second check provided no dose calculations are required.’

169. MP’s evidence was that standard procedure in the Hospital was that doctors, registered nurses or ODPs can act as a responsible person, but that a student/Aspirant Nurse cannot act as a responsible person because they are not yet registered. They can act as witness to controlled drugs administration towards the end of their training period.

170. MP’s evidence was that the issues with the Registrant acting as a witness is because it was his responsibility to sign as the responsible person because he was the registered staff member.

171. The Panel had regard to the statement of HH which was admitted as hearsay evidence. This exhibits the statement that HH made to the Hospital on 30 July 2020. This acknowledges that she did sign the register as the registered person but that she did not administer and IV medication.

172. The Panel placed significant weight on the evidence of MP and HH for the reasons already set out in this decision.

173. The Panel found proved that on 10 June 2020, the Registrant failed to follow standard procedure in that he requested and permitted an Aspirant nurse to sign the Controlled Drugs Register as the responsible person for Morphine administration.

Particular 11 - Found Proved
11.On or around 12 July 2020, you amended and/or obliterated entries in a Controlled Drugs Register for the administration of Fentanyl to Patient I.

174. The Panel considered the drugs register entries for this date, for Fentanyl, in accordance with the evidence of MP. The register shows that on 12 July 2020, for Patient I, 200 micrograms was drawn up, 200 micrograms was administered and 0 micrograms destroyed. The stock balance in the register shows 16.

175. The Panel relied on the evidence of MP that the register record in relation to Patient I, had been amended by overwriting the drawn up, administered and balance entries. MP’s evidence was that the anaesthetist confirmed that only 100 micrograms was given. This accords with the contemporaneous anaesthetic records for Patient I.

176. The register shows the Registrant as signing as the witness to this patient and his signature includes use of his name stamp. The Panel considered that MP’s evidence accorded with the documentary evidence which clearly showed amendments as per MP’s evidence. During the police interview the Registrant admitted that the amendments against Patient K were made by him and he had added in his initials. The Panel noted that the amendments in relation to Patient I were similarly obliterated. The Panel was confident in relying on the evidence of MP for the reasons it has already set out within this decision.

177. For the same reasons as those set out in paragraphs 125 – 127 the Panel was satisfied that it was the Registrant who had made the amendments.

178. The Panel therefore found proved that on or around 12 July 2020, the Registrant amended and obliterated entries in a Controlled Drugs Register for the administration of Fentanyl to Patient I.

Particular 12 - Found Proved
12. On or around 13 July 2020, you amended entries in a Controlled Drugs Register for the administration of Morphine to Patient J.

179. The Panel relied on the evidence of MP in relation to Patient J, as per the exhibited documents.

180. The Theatre Records show Morphine 7mg given in 3 aliquots (2mg, 2mg and 3mg). The Theatre care plan shows morphine 8mg was given and a further 10mg via PCA (patient-controlled analgesia). The 10mg PCA is confirmed in 3 aliquots (4mg, 3mg and 3mg) in the post- operative recovery record.

181. The drugs register on 13 July 2020 for Morphine injection 10mg in 1ml shows 20mg drawn up, 18mg administer and 2mg destroyed. The stock balance in the register shows 8 amps.

182. MP’s evidence was that the record has been amended in the register by overwriting the drawn up, administered and balance entries. MP believed the underlying entries read 10mg drawn up, 8mg administered and balance of 9 amps.

183. MP said that he could not explain why the two values differ in relation to the 7mg and 8mg because they were recorded by two different people at different times, but they should have been the same.

184. MP’s evidence was that the theatre staff involved confirmed that their entries had been amended and that these were not their amendments. MP stated that whilst the Registrant is not noted as being involved in Patient J’s care, he is recorded as being involved with the next patient, on the same date.

185. The Panel also relied upon the evidence of RB, noting that this was the patient entry which had caused him concern, and which had caused matters to be raised with CW, resulting in an investigation by MP.

186. RB’s evidence is that on 15 July 2020, whilst conducting a drugs check with BG, he noticed that his entry for 10mg of morphine for the first patient on 13 July has been altered from 10mg to 20mg, and that the stock balance had also been altered. RB considered that the alteration was apparent and that it was unusual to give 20mg of morphine.

187. The Panel also took into account and relied upon the statement of BG. She recalls that the Registrant had taken over the shift from her on 13 July 2020. She further recalls that on 15 July 2020, when she was conducting a drugs check with RB, it was noted that the records had been amended. BG stated that she was asked if she had made the alteration after RB had left on 13 July 2020. BG states that she had not given out any more morphine and that she had written 8mg given and 2mg destroyed. BG stated that there was no reason for the register to have been amended as changes are not allowed. If more drugs are needed, the information is written out again, i.e. the patients name, time etc.

188. The Panel was satisfied it could be confident in relying on the evidence of RB. The Panel considered him to be a reliable witness whose evidence was given with precision and with an eye to detail. He was measured and did not seek to speculate. His evidence accorded with the other evidence before the Panel, namely that from CW, MP and BG.

189. The Panel was also satisfied that it could be confident in relying on the evidence of BG. Whilst her recollection was not as detailed as that of RB, she gave similar corroborative evidence and was clear that she has not made those amendments.

190. For the same reasons as those set out in paragraphs 125 -127 the Panel was satisfied that it was the Registrant who had made the amendments. This was further supported by the direct evidence from BG and RB who both confirmed in their written and oral evidence that they had not made the amendments, despite their names being associated with the patient entry.

191. The Panel found proved that on or around 13 July 2020, the Registrant amended entries in a Controlled Drugs Register for the administration of Morphine to Patient J.

Particular 13 - Found Proved
13.On or around 13 July 2020, you amended entries in a Controlled Drugs Register for the administration of Morphine to Patient K.

192. The Panel relied on the evidence of MP in relation to Patient K, as per the exhibited documents.
193. The Theatre Records show Morphine 15mg given in 3 aliquots (5mg, 5mg and 5mg), though one of these appears to have been written in red then overwritten with a black pen. The Theatre care plan shows morphine 15mg was given in theatre though the underlying entry shows 10mg having been overwritten.

194. The drugs register on 13 July 2020 for Morphine injection 10mg in 1ml shows 20mg drawn up, 20mg administer and 0mg destroyed.

195. MP’s evidence was that the anaesthetist recalls 2 x 10mg morphine being requested through the case and thought that his trainee anaesthetic colleague may not have amended the CD register to reflect the theatre record. MP’s evidence was that their remains a discrepancy of 5mg from the theatre record to the drugs register.

196. The drugs register shows the stock balance as 6.

197. MP’s evidence was that the record has been amended in the register by overwriting the drawn up, administered and balance entries. MP believed the underlying entries read 10mg drawn up, 10mg administered and stock balance of 7 amps. The drugs records show the Registrant as witnessing the patient record and countersigning with his initials by the side of the amended stock balance.

198. The Panel also relied upon the evidence of RB, who when noticing that his record for Patient J had been amended, also noticed further alterations for the quantity of drug issued and stock balance for the patient later in the day. Again, this caused RB concern as it was outside policy, hence his escalation to CW.

199. The Panel was satisfied it could be confident in relying on the evidence of MP and RB, for the reasons already set out in this decision.

200. For the same reasons as those set out in paragraphs 125 – 127 the Panel was satisfied that it was the Registrant who had made the amendments. Further, in relation to Patient K, the Registrant acknowledged in his Police interview that it was him who changed the register from a 10 and a 10, to a 20 and 20. He stated that he cleared this with the anaesthetist and acknowledged that he had put his initials to show who had made the change.

201. The Panel found proved that on or around 13 July 2020, the Registrant amended entries in a Controlled Drugs Register for the administration of Morphine to Patient K.

Particular 14 - Found Not Proved
14.On or around 14 July 2020, you amended entries in a Controlled Drugs Register for the administration of Morphine to Patient L.

202. The Panel had regard to the evidence of MP and the documentation exhibited. It noted that in relation to Patient L, the drugs record for morphine, for 14 July 2020, shows 10mg supplied, 0 administered and 10 destroyed, and the stock balance as being 5. The Registrant has witnessed this recording.

203. MP’s evidence in relation to Patient L was that the Morphine was drawn up without the consultant requesting it and that the consultant was surprised as Morphine is not usually required for the procedure the patient was having. MP said that the consultant did not use the Morphine and believes that he destroyed it. MP said that this is consistent with the drugs records and with the anaesthetic record which lists all the drugs and fluids given to Patient L, but that list does not include Morphine.

204. Based on the information before it, the Panel could not see any evidence to support any amendments being made to the Controlled Drugs Register for Patient L. MP confirmed that there was no concern about any amendments to the records for Patient L, the concern was purely related to the drawing up of the drug without clinical reason.

205. The Panel therefore found not proved that on or around 14 July 2020, the Registrant amended entries in a Controlled Drugs Register for the administration of Morphine to Patient L.

Particular 15 - Found Proved
15.On or around 14 July 2020, you drew up and signed as supplied the administration of Morphine without clinical reason.

206. This Particular of Allegation relates to Particular 14, Patient L. As stated above, the evidence of MP was that the concern in this case was that the consultant arrived to find that the Registrant had already drawn up Morphine 10mg. The consultant was surprised as Morphine is not usually required for Oesophagogastro duodenoscopy (OGD). The consultant did not use the morphine and believes he destroyed it.

207. MP’s evidence was that as an experienced practitioner the Registrant should know that Morphine is not routinely used in the procedure that was being undertaken.

208. The Panel took into account the transcript of Police interview, in which the Registrant is asked about this allegation. The Registrant acknowledges that he did draw up the drugs and did it because it was a query procedure and sometimes, they have to do laparotomies for these cases. The Registrant states that when he found out it was wrong, he just discarded the drugs and recorded it in the drugs register. The Registrant states that he drew the drugs up in the first place to save time. In response to the Police questioning about why this was done if it was not required, the Registrant stated that: “Every anaesthetist is different, and we just discarded it. It's not -- it wasn't a big issue. I just said: "Right, no problem, I'll just chuck it away." Just me trying to save time.”

209. Whilst the Registrant purports to provide a rationale for what he did, the Panel was nonetheless satisfied that the alleged conduct was done without clinical reason. In concluding this, the Panel preferred the evidence of MP which was that Morphine was not usually used for OGD procedures, hence the consultants surprise. The Panel was confident in placing weight on MP’s evidence as he carried out a methodical and triangulated investigation into the matters, and gave oral evidence, on affirmation, about the matters which was consistent with all of his previous accounts and documents.

210. Based on all the evidence before it, the Panel found proved that on or around 14 July 2020, the Registrant drew up and signed as supplied the administration of Morphine without clinical reason.

Particular 16 - Found Not Proved
16.On or around 17 October 2020, you broke a mug in front of a service user.

211. In relation to this Particular of the Allegation, the HCPC submitted that the Panel should rely on the evidence of LB, who at the time was the Theatre Lead at Pall Mall.

212. LB’s evidence describes several events which occurred on 17 October 2020 whilst she and the Registrant were working at Pall Mall.

213. LB’s evidence is that the Registrant was presenting as agitated, pale and that he was sweating profusely. Such was the extent of this, that the surgeon had asked LB to remove the Registrant from the theatre, as he did not consider him to be safe.

214. LB states that the Registrant then went to work in recovery whereby he was caring for Patient LW. Later in the day, LB states that she went to speak with the Registrant to ask him what was going on as she did not think he should be at work. LB states that the Registrant told her about his personal issues. LB stated that she told the Registrant that she was really sorry to hear about what he was going though. At this point she looked at the side table in the room in which the patient LW had been. LB could see her own mug on the table but with the handle broken off. LB states that she asked what happened to her mug. In response the Registrant said ‘sorry, I knocked it by mistake and it broke’. He then grabbed his bag, which was on the floor in recovery, grabbed a load of change from his bag and threw it on the side table before saying, ‘There is a few quid, buy yourself a new mug’.

215. The Panel was satisfied that it could rely on the evidence of LB as to the events arising at Pall Mall on 17 October 2024. It found her evidence to be compelling; it being primarily based on her contemporaneous significant event record made on 17 October 2020. It considered her evidence to be measured and balanced and within it she acknowledged the Registrant’s good character noting that Pall Mall had booked him for a shift as he had been recommended for his “experience and hard work”.

216. Based on LB’s evidence, the Panel was satisfied that on or around 17 October 2020, the Registrant broke a mug. However, the Panel had no evidence before it that this occurred in front of a service user (aka LW). LB’s conversation with the Registrant takes place whilst they are alone in the room, after LW had already been taken to a ward. LW’s evidence is that whilst she remembers raised voices, she does not know who the voices belonged to or what was said. She does not recall anything about a mug being broken.

217. In the absence of any evidence to corroborate that the broken mug incident occurred in front of LW, the Panel found not proved that on or around 17 October 2020, the Registrant broke a mug in front of a service user.

Particular 18 - Found Proved in relation to 2, 3, 4, 5, 7, 9, 11, 12, and 13
18.Your conduct in relation to particulars 1-7, 9,11-14 was dishonest in that you attempted to conceal and/or misrepresent the amount of medication that had been supplied and/or administered and/or destroyed and/or the amount of medication remaining in balance.

218. The Panel considered the oral and written evidence and took into account the legal test of dishonesty as set out within case law and the HCPTS Practice Note. The Panel first considered what the actual state of the Registrant’s knowledge or belief was as to the facts in which the alleged dishonesty arose. The Panel then went on to consider the question of whether the conduct was honest or dishonest by applying the objective standards of ordinary decent people with full knowledge of the facts of the case.

219. The Panel noted that it had found Particulars 6 and 14 not proved and therefore did not consider whether those facts amounted to dishonesty.

220. In relation to Particular 1, the Panel noted that this related to the Registrant not recording a patient name in the drug register. Whilst the Panel had found the Registrant did not do this, it also found that it was not the Registrant’s responsibility to do this. The responsibility lay with the responsible person who had signed the drug register whereas the Registrant was only a witness. The Panel concluded that the Registrant was likely to know, based on his experience, that it was not his responsibility to record the patient’s name, and therefore his actions in not recording the patient’s name, were not dishonest. The Panel concluded that an ordinary decent person would be aware that it was not the Registrant’s responsibility to record the patient’s name, and therefore not recording it was not dishonest. It was the responsibility of the responsible person to have recorded the patient’s name.

221. In relation to Particulars 2,3,4,5,7,9,11,12, and 13, the Panel noted the facts it had found proved are all similar, and all involve the Registrant amending and/or obliterating entries to the Controlled Drugs Register.

222. The Panel took into account that the Registrant is an experienced ODP who has many years of experience working in a theatre environment with Class A drugs. In fact, both the evidence from the Hospital and Pall Mall is that the Registrant had a reputation for being hard working and experienced.

223. The Panel noted that the standard operating procedure for the Hospital in relation to recording of controlled drug use is very clear. It heard evidence from MP that the policy was in place to adhere to the Misuse of Drugs legislation in relation to the appropriate recording of controlled drugs. So, whilst it was a Hospital specific policy, it was a one size fits all policy which would have been replicated by other hospitals, all of whom are required to comply with the recording of controlled drugs, in accordance with the legislation.

224. The Panel kept in mind the evidence that it has heard from RB that amendments were not commonplace and that if they did happen, they were made in accordance with the standard operating procedure. This evidence was also mirrored by BG who made it clear that if an error was made or amendment required then a new entry for the patient should be started.

225. The documentary evidence and facts found proved show nine separate incidences of discrepancies on the Controlled Drugs Register identified as part of the pharmacy audit by MP.

226. The Panel was satisfied that it could infer that the Registrant knew or should have known of the correct procedure to follow, but he failed to do so, instead he made amendments and obliterations in relation to his own patients register entries and other patients on the register in close proximity. In his Police interview his response to what procedures should be followed is inconsistent and vague. However, being an experienced ODP, the Panel considered that if he had been uncertain, he should have checked. Further, it is clear that he did understand the importance of the register and he helped educate others. HH’s evidence is that the Registrant, ‘spent time educating [her] regarding anaesthetics and critical-care, with his stamp he informed [her] “It is good having this stamp – therefore if anything does come back it indicates my identity” which…[she] thought was good practice.’

227. The Registrant denies dishonesty and is a person of good character, however, the Panel considered that he was less than transparent in his Police interview. He is asked if he has done any other work since the Hospital and he does not provide a clear answer consistent answer to start with, then he confirms that he has not worked as an ODP for about four months. It is not until the Police directly refer him to his work at Pall Mall (which was less than two months previous) that he says he remembers working there.

228. The Panel kept in mind the evidence that the frequency of discrepancies was much higher for the Registrant than any others.

229. The Panel also had regard to the evidence it had before it from two witnesses from separate workplaces about the Registrant’s unusual presentation, behaviour and appearance.

230. The Panel found that the evidence about the Registrant’s presentation, behaviour and appearance, was highly suspicious in circumstances where drugs register records were amended and/or obliterated with no apparent justification, and with no cogent explanation offered by the Registrant as to why they were necessary.

231. The Panel concluded that on the basis of the evidence before it, there is no honest explanation for the amendments/obliterations, and that the Registrant knew this to be the case when he made the amendments/obliterations.

232. The Panel concluded that taking into account the Registrant’s understanding of the circumstances, as set out above, an ordinary decent person would find the conduct as dishonest. The Panel considered that amending/obliterating Class A drugs registers without any reason to do so, and contrary to the standard procedure would be held to be dishonest upon an objective test.

Decision on Grounds
233. Mr Kerruish-Jones provided written submissions in relation to misconduct. Mr Kerruish-Jones supplemented his written submissions with oral submissions.

234. Mr Kerruish-Jones submitted that the facts found proved, show that the Registrant was dishonest which is a serious departure from the expected conduct of an ODP such to amount to misconduct.

235. Mr Kerruish-Jones submitted that the Registrant’s conduct breached standard 9 of the HCPC Standards of Conduct, Performance and Ethics and Standards (2016).

236. The Registrant was not present to make submissions, but the Panel had regard to the information he had provided to the HCPC which is included in the bundle.

237. The Panel heard and accepted the advice of the Legal Assessor in relation to Misconduct. The Legal Assessor referred the Panel to the case of Roylance v GMC (no.2) [2000] AC 311 and to the HCPC Standards. 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, if found proven, 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.

238. 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.

239. The Panel took into account the HCPC Standards of Conduct Performance and Ethics. The Panel bore in mind that a departure from the Standards alone does not necessarily constitute misconduct.

240. The Panel concluded that the behaviours of the Registrant in relation to facts found proven do individually and collectively amount to serious professional misconduct, with the exclusion of Particular 1, as the Panel had found as a fact that it was not the Registrant’s responsibility to record the name of the patient in the Controlled Drugs Register, on that occasion.

241. 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), in particular standard:
‘9 Be honest and trustworthy
Personal and professional behaviour
9.1 You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.’

242. Based on its findings of fact, the Panel considered that the misconduct falls into three interlinked areas relating to him undertaking his ODP role at the Hospital: i) dishonestly amending and/or obliterating entries to the Controlled Drugs Register; ii) requesting and permitting an Aspirant Nurse to sign the Controlled Drugs Register as the responsible person; and iii) drawing up and supplying the administration of Morphine without clinical reason.

243. In relation to (i), the dishonesty, the Panel took into account that based on the evidence which it had accepted, the Registrant had repeated this conduct on numerous occasions across numerous dates spanning a period of over nine months. The Panel concluded that this is serious dishonesty as it involved changes being made to the Controlled Drugs Register, which is in place to ensure compliance with the Misuse of Drugs legislation given the inherent risks involved with Class A drugs. The Registrant’s dishonest conduct also impacted on his colleagues who were consequently implicated in the amendments/obliterations. The Registrant’s colleagues had made genuine entries on the Controlled Drugs Register only to discover, or be told later, that amendments/obliterations had been made to their entries, for which they were not responsible. The Panel kept in mind RB’s evidence that in practice a lot of documentation and control of drugs issued has to be undertaken on trust.

244. The Panel concluded that the Registrant’s conduct demonstrated not only a disregard for colleagues and their trust, but also the trust that is placed in registered ODPs who are expected to act with honesty and integrity.

245. In relation to (ii), the misconduct involving the Aspirant Nurse, the Panel took into account that this occurred on two occasions and found it to be a serious departure from what was expected in the circumstances. A responsible person is someone with suitable qualifications and given authority to undertake a specific task. In the case of the Controlled Drugs Register, the responsible person is charged with ensuring the correct storage and record keeping around controlled drugs in line with the Misuse of Drugs legislation. Given the Registrant’s level of experience, he should and was aware that the Aspirant Nurse could not act as a responsible person. In acting as he did the Registrant did not take responsibility in line with the expected recording standards and this resulted in him taking advantage of a more junior colleague who was less familiar with their responsibilities and the regulations around controlled drugs. The Panel had regard to HH’s evidence which was that as a ‘student nurse the Theatre environment was new to me therefore I put my trust in [the Registrant] to educate me because of their in-depth experience…’

246. In relation to (iii), the drawing up and supplying the administration of Morphine without clinical reason, the Panel also considered this to be serious such as to amount to serious professional Misconduct. The Panel had in mind that this occurred within the context of the dishonest amendments/obliterations which were made on the two preceding days. The Panel took into account that the Registrant was an experienced ODP and he would have known that Morphine was not required. Given the Registrant’s experience, the Panel did not accept that this was a mistake or a misjudgement. It was a deliberate act. Drawing up and supplying Morphine without clinical reason can have safeguarding risks due to the nature of Class A drugs.

247. The Panel found that the proven facts, with the exception of Particular 1, amount to the statutory ground of misconduct.

Decision on Impairment
248. Mr Kerruish-Jones referred the Panel to the case summary which contained some written submissions in relation to impairment. Mr Kerruish-Jones supplemented these with oral submissions in light of the Panel’s findings to date.

249. Mr Kerruish-Jones submitted that in relation to impairment, the HCPC invite the Panel to find that the Registrant is currently impaired. He submitted that there is little, if any, insight into the Allegation, and there has been little, if any, engagement with these proceedings, such that there remain serious concerns about his honesty and behaviour generally.

250. Mr Kerruish-Jones submitted that the Registrant has had a fair opportunity to respond to the Allegation. In relation to the Registrant’s denials of dishonesty, Mr Kerruish-Jones submitted that although dishonesty was a secondary allegation, the Registrant was less than transparent in his Police interview.

251. Mr Kerruish-Jones submitted that there is no evidence to say that this behaviour will not be repeated and therefore the risk of repetition remains.

252. Mr Kerruish-Jones submitted that both the personal and public components of impairment are engaged. He submitted that given the nature of the facts found proved, which include dishonesty, public confidence in the profession and the regulatory process would be undermined if there were no finding of impairment.

253. The Registrant was not present, but he had provided some information to the HCPC which the Panel has already referred to within this decision. To the Panel’s knowledge, the most recent correspondence from the Registrant to the HCPC, is dated 28 June 2023.

254. 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, PSA v HCPC + Doree [2017] EWCA Civ 319 and The General Medical Council v Armstrong [2021] EWHC 1658 (Admin).

Panel Decision
255. The Panel considered the Registrant’s current fitness to practise firstly from the personal component and then from the wider public component. 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.

256. 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:
a- The Registrant has in the past and/or is liable in the future to place service users at unwarranted risk of harm.
b- The Registrant has in the past brought and/or is liable in the future to bring the profession into disrepute.
c- The Registrant has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the profession.
d-The Registrant has in the past acted dishonestly and/or is liable to act dishonestly in the future.

257. In relation to (a) the Panel determined that whilst there was no evidence that the Registrant’s conduct had in the past caused service users harm, it did consider that his conduct placed service users at unwarranted risk of harm. The Panel had in mind the evidence from MP who had said that adherence to the policy in relation to the Controlled Drugs Register was to ensure compliance with the Misuse of Drugs legislation. The policy is in place to maintain safety within the organisation, and to ensure accountability for any loss, and to ensure an accurate running total of stock. MP’s evidence was that if the records are not accurate, this impacts on all subsequent records, and it is hard to understand the discrepancy. If the stock balance is low and recorded incorrectly then this may mean an inadequate amount of drugs are available for patient care. The Registrant’s conduct also had the potential to place his colleagues at unwarranted risk of harm, and impacted on their mental well-being, as they were consequently implicated in the amendments/obliterations.

258. In relation to (b), as to whether the Registrant has in the past brought the profession into disrepute, the Panel determined he had. A significant aspect of public interest is upholding proper standards of behaviour so as not to bring the profession into disrepute. The dishonest behaviour and other misconduct found against the Registrant does bring the ODP profession into disrepute.

259. 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 considered that honesty and integrity are fundamental tenets of ODP practice.

260. In relation to (d), the Panel determined that the Registrant had in the past acted dishonestly and had done so on numerous occasions over numerous dates showing a pattern of behaviour. Further, he had sought to implicate others by amending/obliterating records for patients that he was not involved with.

261. 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.

262. The Panel was conscious that issues such as character, including dishonesty, may be harder to remediate. However, the Panel did think that the Registrant’s dishonest conduct could potentially be remediated, subject to, sufficient insight, reflection, and remediation. However, at this juncture the Panel was unable to find this. This is because it would involve the Registrant accepting his misconduct, understanding how and why it occurred, and understanding its consequences for those affected.

263. Whilst the Panel considered that all dishonesty is serious, it found the conduct in this case to be particularly serious as the misconduct persisted over a period of nine months and was repeated on multiple occasions. It related to the amending/obliterating of the Controlled Drugs Register, which is a document completed to comply with the Misuse of Drugs legislation and required due to the inherent risks involved with controlled drugs.

264. In relation to insight, the Registrant accepted that this had ‘not been his best work’, but he denied the Allegation and any dishonesty. Whilst the Panel took into account that dishonesty in this case was pleaded as a secondary allegation, the Panel considered the actions in relation to the amending/obliterating of the Controlled Drugs Register were inherently dishonest in that the Registrant was making the amendments/obliterations with no apparent justification or necessity. He was an experienced ODP, and the Panel found that he knew or should have known the correct procedure to follow. Although the Registrant appears to accept some of the primary facts within his Police interview, he does not provide any cogent explanation as to why he made amendments to the Controlled Drugs Register.

265. The Registrant’s written evidence provided no confidence to the Panel that the Registrant understands what led to the events which are the subject of the Allegation, nor that he recognises what went wrong, nor that he has accepted his role and responsibilities in relation to the events. It is possible, even when denying an Allegation, for a Registrant to evidence what could (and should) have been done differently. However, the Panel found the Registrant’s written evidence to lack sincerity, depth and breadth. Whilst he offers an apology it is not clear who that is aimed at. His evidence does not demonstrate any proper 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 proceedings have had on him personally, which is not in the Panel’s view evidence of insight. The written information from him, does not seem to have developed from his Police interview in December 2020, when his responses to the Police appear to trivialise the matters that are raised with him, and deflect onto others. He is also less than transparent in terms of his recollection of later employment, until he is directly challenged on this.

266. In finding a lack of insight, the Panel also factored in the Registrant’s failure to fully engage with the regulatory process, in that he had failed to attend the hearing and there had been no correspondence from him to the HCPC since June 2023, which is almost two years ago. This is despite the clear efforts of the HCPC, as set out in its correspondence with the Registrant, to signpost him to relevant support and encourage him to engage.

267. The Panel considered whether there was any evidence of remediation. The Registrant has not provided any up-to-date evidence of whether he is working in paid or unpaid employment. From his police interview the Panel gleans that he may, at that stage, have been working as a bus driver. He provided no direct evidential feedback in relation to his conduct and work environment. Whilst the Registrant mentioned completing some training sessions on practice obligations, he has not provided any objective evidence of this. Overall, the Panel found no evidence of remediation.

268. 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 in relation to the dishonesty show that the Registrant had conducted a pattern of behaviour, across a period of nine months, on multiple occasions. Given its finding that the Registrant has shown no insight and has not remediated the Panel concluded that the risk of repetition remains. The Panel found that given the lack of insight, there remains a potential for the Registrant to behave dishonestly again if he found himself in a similar position, which in turn could have a detrimental impact on the safety of service users and colleagues.

269. The Panel decided that on the personal component the Registrant’s fitness to practise is currently impaired.

270. 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.’

271. The Panel considered its findings in relation to misconduct. The Panel considered that ODPs hold privileged positions of trust. It is essential that the public, which includes professional colleagues, can trust ODPs. Abuse of trust by way of dishonesty, particularly given that it occurred as part of the Registrant’s ODP role, is a serious and unacceptable risk in terms of confidence in the profession.

272. The Panel concluded that given the nature of the Allegation and the facts found proved, the public confidence in the profession and how it is regulated would be undermined if there were to be no finding of impairment.

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

Decision on Sanction
274. Mr Kerruish-Jones referred the Panel to the HCPC Sanctions Policy (2019).

275. Mr Kerruish-Jones submitted that in terms of mitigating factors; the Registrant was of previous good character.

276. In terms of aggravating factors, Mr Kerruish-Jones submitted that the Panel’s findings show that the Registrant’s misconduct was serious and involved repetition of concerns. He referred the Panel to paragraphs 56 – 58 of the Sanctions Policy in relation to dishonesty.

277. Mr Kerruish-Jones submitted that the dishonesty occurred on multiple occasions, over multiple months.

278. Mr Kerruish-Jones referred the Panel to its decision in relation to insight, remediation and the risk of repetition, all of which are factors to take into account when considering the proportionate sanction.

279. 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. The Legal Assessor reminded the Panel that its primary function at this stage is to protect the public, while deciding what, if any, sanction is proportionate, taking into account the wider public interest and the interests of the Registrant.

280. The Legal Assessor also referred to the following HCPTS Practice Notes:
-Making decisions on a Registrant’s state of mind.
-Drafting fitness to practise decisions.

281. In respect of the Panel’s findings of dishonesty, the Legal Assessor drew the Panel’s attention to paragraphs 56 - 58 of the Sanctions Policy and reminded the Panel that the case law in relation to dishonesty makes plain that a finding of dishonesty will always be considered to be serious and to risk serious consequences. However, a more nuanced approach should be taken to dishonesty, and dishonest conduct can take various forms; some criminal, some not; some destroying trust instantly, others merely undermining it to a greater or lesser extent. Not all cases of proven dishonesty will lead to strike off.

Panel’s decision
282. 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.

283. The Panel identified the following aggravating factors:
• The dishonesty was not a single act, it was persistent and repeated, and the Registrant was solely responsible for it. The dishonesty occurred over a nine-month period, and it resulted in potential risk of harm to service users and colleagues. The Registrant did not make any admission to the dishonesty, and it only stopped when the Hospital began its investigation and prevented the Registrant from undertaking any more shifts.
• The dishonest actions occurred within the work setting as part of the Registrant conducting his ODP role.
• The Registrant has taken no steps to address the concerns that have been raised about his conduct. Although the Registrant did provide some written evidence to the HCPC in 2023, the Panel found that this lacked sincerity and was superficial. It does not demonstrate any genuine reflection or understanding that the Registrant acknowledges what went wrong and how he can prevent a recurrence. It also demonstrated little evidence of the impact of the misconduct on his colleagues, the public and the ODP profession. There was no examination of his own character and in part it appears that the Registrant has cut and paste the reflection from an external source. The Panel therefore found that the Registrant has no insight into the proved facts, has not demonstrated any remorse for his actions, or undertaken any remediation. These are all aggravating features.
• The Registrant has failed to fully engage with the HCPC by not attending the hearing to respond to the serious Allegation that was raised against him.

284. The Panel identified the following mitigating factors:
• There have been no previous regulatory matters raised against the Registrant who had been in ODP practice for approximately sixteen years, at the time of the Allegation.

285. 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.

286. Due to the serious nature of the misconduct found in this case (dishonesty), the Panel considered that taking no further action or mediation would not be appropriate.

287. The Panel next considered whether a Caution Order would be appropriate. The Panel considered that a Caution Order would not be in accordance with the HCPC Sanctions Policy which states: ‘A caution order is likely to be an appropriate sanction for cases in which: the issue is isolated, limited, or relatively minor in nature.’ The Registrant’s misconduct was not isolated, it was not limited, nor was it relatively minor in nature. It involved dishonestly amending/obliterating the Controlled Drugs Register, a document which is utilised for the purpose of patient safety and compliance with the Misuse of Drugs legislation. The HCPC Sanctions Policy also states that a Caution Order is likely to be an appropriate sanction for cases in which there is: ‘a low risk of repetition; the registrant has shown good insight, and the registrant has undertaken appropriate remediation’. The Panel considered its earlier decision on impairment and kept in mind it had not found a low risk of repetition, it had not found the Registrant to have good insight, nor did it find that he had remediated. In the circumstances the Panel considered that the Registrant’s misconduct was too serious for a Caution Order and such a disposal would be contrary to the Sanctions Policy.

288. The Panel next considered whether to impose a Conditions of Practice Order. The Panel took into account the Sanctions Guidance which notes that:
‘Conditions will only be effective in cases where the registrant is genuinely committed to resolving the concerns raised and the panel is confident they will do so. Therefore, conditions of practice are unlikely to be suitable in cases in which the registrant has failed to engage with the fitness to practise process or where there are serious or persistent failings.

Conditions are also less likely to be appropriate in more serious cases, for example those involving:
• dishonesty.’

289. The Panel found that the Registrant has not shown insight and that he has not engaged in the fitness to practice hearing process. Further, he has had serious misconduct findings made against him by the Panel, including repeated and persistent dishonesty. The Panel found that the Registrant’s conduct was not minor, rather that it was particularly serious given the potential impact it had on colleagues and could have had on service users.

290. The Panel kept in mind its decision on impairment, and that it found that there is a risk that the dishonest conduct will be repeated given the lack of insight and remediation. Taking all these factors into account, the Panel found that a Conditions of Practice Order would not be sufficient to address and safeguard members of the public from the risks of the dishonesty aspects of the Registrant’s misconduct.

291. The Panel next considered a Suspension Order. The HCPC Sanctions Policy states:

‘A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register.’

292. The Panel was mindful that it had found a lack of insight from the Registrant and found a risk of repetition. Whilst the Panel had concluded that the misconduct is capable of being remediated, it had no evidence from the Registrant to indicate that he is likely to be able to resolve or remedy his failings. He has not corresponded with the HCPC for almost two years and he has not engaged in the fitness to practice hearing process.

293. The Panel reminded itself, as per paragraphs 56 – 58 of the Sanctions Policy, that there are different forms, and different degrees, of dishonesty, which need to be considered in an appropriately nuanced way when considering sanction. Taking a nuanced approach, the Panel considered the degree of dishonesty to be at the high end. The Panel found the dishonesty in this case occurred on multiple occasions, took place over a nine-month period, involved the Registrant taking an active role, in which he consequently implicated his colleagues. His misconduct was not an uncharacteristic lapse in a front-line challenging clinical situation, rather it was a deliberate and persistent action.

294. The Panel took into account that ODPs hold positions of trust, and the role often requires them to engage with vulnerable people, who are about to undergo surgery under general anaesthetic. Dishonesty is therefore likely to threaten public confidence in ODPs. The public (which includes colleagues) must be able to trust and rely on the honesty and integrity of ODPs when performing their duties.

295. The Panel considered that the misconduct in this case was such that the requirements of public protection and the wider public interest would not be adequately served by imposing a Suspension Order.
296. The Panel, having decided a Suspension Order did not protect the public nor meet the wider public interest, decided that the proportionate order was a Striking Off Order.

297. The Panel took into account the Sanctions Policy and noted that a Striking Off Order is a sanction of last resort and should be reserved for those categories of cases where there is no other means of protecting the public and the wider public interest. The Panel decided that the Registrant’s case falls into this category because of the persistent nature of the dishonest conduct and the ongoing risk of repetition. These factors combined with the Registrant’s lack of insight and apparent unwillingness to resolve matters led the Panel to conclude that any lesser sanction would undermine public trust and confidence in the profession and would be insufficient to protect the public.

298. 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 Striking Off Order may have upon the Registrant but concluded that these considerations are significantly outweighed by the Panel’s duty to give priority to public protection and the wider public interest.

299. The Panel concluded that the appropriate and proportionate order is a Striking Off Order.

The Registrar is directed to strike the name of Philip Welburn from the Register on the date this order comes into effect.

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

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

Interim Order
1. Having handed down the decision, the Panel enquired with Mr Kerruish-Jones whether the HCPC would be applying for an Interim Order to cover the appeal period. Mr Kerruish-Jones said that the HCPC would not be applying for an Interim Order.

2. The Panel heard and accepted the advice of the Legal Assessor that it has the power to make an Interim Order if it considers it is necessary for public protection or otherwise in the public interest. The Panel was referred to the Sanctions Policy and the HCPTS Practice Note on Interim Orders.

3. Mr Kerruish-Jones told the Panel that the Registrant had been subject to an Interim Order from April 2021, which was reviewed on ten occasions and extended by the High Court on three occasions. The Interim Order expired on 22 December 2024.

4. The Legal Assessor advised the Panel that as the Registrant was not present it had, in accordance with the HCPTS Practice Note, first to decide whether to proceed in the absence of the Registrant.

Decision
5. The Panel decided that it was appropriate to consider whether to make an Interim Order 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 13 January 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.

6. 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 whether to make an Interim Order today, even if that meant it was conducted in the absence of the Registrant.

7. The Panel acknowledged that the Registrant has not been subject to any restrictions during the last six months, however, the Panel has now made findings of fact which involve serious dishonesty. The Panel made an Interim Suspension 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 necessary in light of the risks to the public identified in the substantive decision. The Panel considered 18 months was appropriate and proportionate given the length an appeal may take to be decided by the High Court, if an appeal is made.

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 18 months.

Matters arising after hand down of decision
1. The Panel handed down the decision in relation to sanction and Interim Order on 29 May 2025.

2. On 30 May 2025, an email was received from Mr Kerruish-Jones to inform the Panel that he had spotted a factual error which was based on his submission in relation to the Interim Order. Although he had submitted to the Panel that the Interim Order had lapsed in December 2024, in fact, the Registrant was made subject to a further Interim Order by the High Court which was due to expire on 22 June 2025.

3. The Panel concluded that the new information did not have any impact on its decision to impose the Interim Order which it made on 29 May 2025. The Panel remained satisfied that whatever the position pre final hearing, it had now made findings of fact which involve serious dishonesty. Further, it had found both personal and public impairment and a risk of repetition. Therefore, an Interim Suspension Order to cover the appeal period is necessary to protect the public and is otherwise in the public interest.

History of Hearings for Philip Welburn

Date	Panel	Hearing type	Outcomes / Status
19/05/2025	Conduct and Competence Committee	Final Hearing	Struck off