Mr Gary Bell
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Allegation
As a registered Operating Department Practitioner your fitness to practise is impaired by reason of misconduct. In that:
1. On or around 16 March 2021 you did not undertake adequate checks and/or get Service User A to complete the consent form agreeing to the procedure prior to induction of anaesthetic.
2. On or around 18 March 2021 you went to collect a Service User from a ward without the theatre collection slip.
3. On or around 25 March 2021 you attempted to escort a Service User to theatre without undertaking the relevant checks in the presence of the ward admitting nurse.
4. On or around 26 March 2021 you did not follow necessary procedure in that:
a. You did not complete the WHO safety checklist for a Service User prior to them being anaesthetised.
b. You returned a Service User to the ward without handing over to the ward nurse.
5. The matters listed in Particulars 1 – 4 constitute misconduct.
6. By reason of your misconduct your fitness to practise is impaired.
Finding
Background
1. The Registrant was employed to work as an Operating Department Practitioner (‘ODP’) at Park Hill Hospital (‘the Hospital’), which is a part of Ramsay Health Care Group, on 25 January 2021.
2. The Registrant was managed by ‘SF’, Theatre Manager, who was part of the recruitment process when he was hired to his role. The Registrant’s role predominantly involved working on the anaesthetic side of the role.
3. On 16 June 2021, the HCPC received a referral form from the Former Interim Head of Clinical Services at the Hospital, in relation to concerns about the Registrant following a local disciplinary investigation having been completed in relation to the following:
· During a shift on 16 March 2021, it came to light that a service user (“Service User A”) had not signed their consent form for surgery. It is alleged that the Registrant had collected Service User A from the ward, completed the ward handover and transferred Service User A into the anaesthetic room.
· On 18 March 2021, it is alleged that the Registrant went to collect a service user from a ward but had left the patient collection slip behind.
· On 18 March 2021, SF had a one-to-one meeting with the Registrant, with a Human Resources colleague also present. SF stated that this was so the Registrant knew the meeting was official and that SF was taking the incident on 16 March seriously, as well as the incident which had occurred earlier that day.
· Further incidents occurred on: 25 March 2021 (whereby the Registrant was about to take a service user to theatre without any handover from a ward staff member) and 26 March 2021 (whereby the Registrant returned a service user to the ward without undertaking a handover with the ward nurse).
· Also on 26 March 2021, when a service user was about to be operated on, having been anaesthetised and prepped for surgery, a check was made in respect of the World Health Organisation safety checklist. It had not been completed. It is alleged that the Registrant was responsible for ensuring the form was completed.
4. The Registrant was suspended by the Hospital on 29 March 2021, pending an investigation regarding the failure to comply with Hospital policies and procedures.
5. The Registrant resigned from the hospital on 31 March 2021. Within the resignation letter, amongst other things, the Registrant stated that he was not enjoying working at the Hospital, that the hours were not suiting him, and that he did not enjoy the ‘rush rush’ culture.
6. A Substantive Hearing panel convened between 12 – 15 May 2025 to consider the aforementioned Allegation. That panel determined that the Allegation was proved in its entirety and that the Registrant’s fitness to practise was currently impaired, citing the following reasons:
‘In relation to (a) the Panel determined that the Registrant’s conduct had in the past had the potential to place patients at unwarranted risk of harm. Whilst the Panel had no evidence before it that the Registrant’s conduct had caused direct patient harm, it took into account the evidence relating to why the policies are in place, which was primarily provided by SF, but which was echoed by all the HCPC witnesses. The Panel accepted that in not adhering to the correct pre and post theatre processes, this had the potential for a patient to have surgery they do not consent to, the risk that patients are unaccounted for in the event of a fire, the wrong patient could be taken off a ward, the wrong procedure could be carried out, and/or staff would not be aware to keep an eye on the patient if there had been complications in the theatre. In relation to the degree of harm, the Panel had no evidence to suggest that the Registrant was seeking to intentionally cause harm, but his conduct in disregarding and not following the correct procedures had the potential to affect the safe and effective delivery of care to patients.
In relation to (b), the question of whether the Registrant has in the past brought the profession into disrepute, the Panel determined that he had. A significant aspect of public interest is upholding proper standards of conduct so as not to bring the profession into disrepute. The proven facts, all of which relate to the Registrant deciding not to adhere to crucial pre and post theatre checks to ensure a safe process for patient safety, does bring the ODP profession into disrepute.
In relation to (c), in finding that the Registrant did not conduct himself in such a way as to adhere to the HCPC professional standards, the Panel determined that he had breached fundamental tenets of the profession. The Panel found that the Registrant had breached a significant number of the professional standards. These include failing to communicate effectively and work in partnership with others, both of which are core components and key principles in the ODP profession and wider healthcare sector for ensuring patient safety.
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.
The Panel kept in mind that concerns do not relate to a lack of competence on the Registrant’s behalf, rather they relate to him choosing not to follow the correct pre and post theatre processes such that it placed patients at risk of harm. The Panel recognised that the misconduct occurred over a short space of time (10 days) in an otherwise long and unblemished career as an ODP. The Panel did think that the Registrant’s conduct could be easily remediated, if he could evidence insight into why the misconduct occurred and what he would do to avoid a repetition, which would be as simple as adhering to policies that are in place to ensure patient safety, even if he didn’t feel that they were necessary.
The Panel next had regard to whether the Registrant’s misconduct has been remediated. The Panel took into account the documentary evidence provided by the Registrant including the testimonials. The Panel considered that the written evidence did not give it confidence that the Registrant understands the seriousness of his actions, nor the impact that they could have on patients, and did have on his colleagues, who were left to deal with the issues that arose primarily through the fault of the Registrant. The Panel found a lack of accountability and a strong emphasis on passing the blame to others. Whilst the Panel acknowledged that the failure to check the consent for Service User A also involved missed opportunities by others, it does not detract from the fact that the Registrant was involved and needs to take accountability for his role.
The Registrant’s written evidence does not show that he is willing to concede that what he did, in relation to the proven facts, was wrong, even though he admits some of the Particulars of the Allegation.
The Panel did not find that the Registrant had expressed any remorse, either at the time or since, and his stance of seeking to apportion blame to others has remained consistent, in his investigation interview in 2021, his written evidence in 2022, and his current evidence provided for this hearing (6 May 2025). The Panel found that the Registrant’s evidence did not demonstrate any reflection or demonstrate a genuine understanding of the impact of his actions on others, and the ODP profession. The only information about impact is relating to that which the Registrant perceives was a failing by the Hospital in relation to working hours and the alleged ‘rush rush’ culture.
Based on the above, the Panel considered that the Registrant has a lack of insight into his misconduct.
The Panel considered whether there was any evidence of remediation. The Registrant did not provide any documentary evidence of any reflection or training, nor did he mention any in his written evidence.
The Panel took into account that the bundle contained various references relating to the Registrant. The Panel noted that most of these related to the Registrant’s work prior to 2021, however there are two references post the Allegation. On 17 August 2021, the Clinical Services Theatre Manager, BMI Healthcare, emailed the HCPC to state:
‘None of these allegations have occurred whilst he has been working in our theatres at BMI …Hospital…He is an excellent ODP who works within his professional scope of practice at all times. He is a strong advocate for patient care and speaks to patients in a professional and supportive manner. He works within our polices and protocols at all time and I have never been given reason to speak to him about anything other than to thank him for the high standards of care he provides to patients and support to colleagues.’
The same person provides an undated reference which is in similar terms to the above. Although it is undated, it is listed in the index alongside other documents provided in 2021/2022.
The Panel placed some weight on the references as it is clear that the author was aware of the HCPC Allegation. However, it is not current and offers no view on what has changed to suggest that the Registrant will no longer act in the way that he did at the Hospital if he found himself in similar circumstances.
The Panel considered whether the misconduct was likely to be repeated by the Registrant. The Panel took into account all it had read and heard about the misconduct. The facts found show that the Registrant had conducted a pattern of behaviour during a 10-day period in the short time he was working at the Hospital. This behaviour ceased because he was suspended and subsequently resigned. Given its finding that the Registrant has shown no insight and has only shown at best minimal remediation, as per his good reference, the Panel concluded that a real risk of repetition remained. The Panel found that given the lack of insight, there remains a potential for the Registrant to not undertake adequate pre and post theatre checks again, if he found herself in a similar position whereby, he perceived he was working in a ‘rush rush’ environment. This in turn could have a detrimental impact on the safe and efficient care of patients.
The Panel decided that the Registrant’s fitness to practise is currently personally impaired on the grounds of his misconduct.
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.’
The Panel considered its findings in relation to misconduct. The Panel took into account that ODP’s hold privileged professional positions within the healthcare setting. It is essential that the public can trust and rely on ODP’s to carry out adequate checks to ensure patient safety and communicate and work in partnership with colleagues for the benefit of patients. The failures of the Registrant, which occurred at the Hospital, as part of his ODP role, present a serious and unacceptable risk in terms of confidence in the profession.
Based on its findings in relation to the unwarranted risk of harm, the bringing the profession into disrepute and the breaching of the fundamental tenets of the profession, the Panel concluded that public confidence would be undermined if there were to be no finding of impairment. The Panel considered that not to make a finding of current impairment of fitness to practise in relation to the misconduct would seriously undermine public trust and confidence in the profession and would fail to uphold and declare proper standards.
The Panel therefore decided on the public interest element of impairment that the Registrant’s fitness to practise is currently impaired.'
7. Having found the Registrant’s fitness to practice impaired, the substantive hearing panel determined to impose the following conditions of practice for a duration of six months:
1. “You must place yourself and remain under the indirect supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within one month of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations.
2. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice, it should demonstrate your knowledge and understanding of:
- the impact of human error on patient safety and research-based approaches to minimising risk;
- the policy and procedure for patient transfer and consent, pre and post theatre;
- the policies and procedures in your workplace and how they relate to patient safety.
3. Within two months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.
4. You must meet with workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.
5. You must allow your workplace supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.
6. Having regard to the Panel’s decisions, you must produce a reflective practice profile detailing your part in the incidents, what went wrong, your learning and the impact upon patients, colleagues, the public, your profession and the regulator. This reflective practice profile must be shared with your workplace supervisor and the HCPC at least one month prior to the HCPC review hearing.
7. You must inform the HCPC within seven days if you cease to be employed by your current employer.
8. You must inform the HCPC within seven days if you take up any other or further professional work.
9. You must inform the HCPC within seven days if you take up work requiring registration with a professional body outside the United Kingdom. You must inform the HCPC within seven days of returning to practice in the United Kingdom.
10. You must inform the HCPC within seven days of becoming aware of:
- any patient safety incident you are involved in;
- any investigation started against you; and
- any disciplinary proceedings taken against you.
11. You must inform the following parties that your registration is subject to these conditions:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application);
D. any organisation through which you are undertaking professional training.
12. You must allow the HCPC to share, as necessary, details about your performance, compliance with, and/or progress under these conditions with:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application);
D. any organisation through which you are undertaking professional training.’
Submissions and oral evidence:
Outlined below is a summary of the HCPC’s oral and written submissions and the Registrant’s oral evidence to the Panel. Neither is intended to reflect a verbatim account of what was stated to the Panel.
HCPC:
8. Ms Constantine briefly outlined the background of the case to the Panel, as the Panel had indicated at the outset of the hearing that it had read all of the papers placed before it, which included the following:
i.HCPC hearing bundle – 56 pages;
ii.HCPC addendum bundle – 7 pages;
iii.HCPC second addendum bundle – 5 pages;
iv.HCPC skeleton argument – 6 pages; and
v.HCPC service bundle – 5 pages.
9. Ms Constantine submitted that the HCPC was inviting the Panel to extend the current Conditions of Practice order for a further period of 6 months.
10. Ms Constantine also submitted that the HCPC’s position was as follows (and as set in the HCPC skeleton argument):
‘…
• The Registrant sent an email on 24 November providing an undated Personal Development Plan, an undated monthly meeting schedule and a report the meeting held on 18 November 2025.
• The documents provided can not be said to credibly address the Panel’s concerns.
• The personal development plan seems to outline goals for the Registrant’s development but does not provide any mechanisms or tools for achieving these goals, particularly within the framework of the Panel’s points of concerns.
• The schedule of meetings is self-explanatory, but it should be noted that it mentions that the meetings will be short. This raises the question of how any meaningful issues relating to the Registrant be addressed in depth.
• The report dated 18 November 2025; this was written by the Registrant referring to the prior 5 months. According to the report, these meetings consisted of the supervisor asking the Registrant if everything was ok and whether he was adhering to the correct policies and protocols. This does not address the specifics as outlined in condition 2.
• The report mentions that the supervisor commented on the Registrant’s professionalism and that nothing of further note occurred during these meetings.
• The Registrant’s submissions lack any credible evidence of remediation and fail to demonstrate conducive steps towards addressing any concerns present 6 months ago. Therefore, the risk of repetition still remains high when considering these factors.
• Furthermore, the registrant’s reflective statements fail to credibly address any of the Panel’s concerns, it is the HCPC’s position that his FTP remains impaired.
• the HCPC suggest the Registrant needs more time to address the concerns.
• the HCPC have tried to be proactive in attempting to engage with the Registrant to provide useful documentation for today’s purposes, however the level of documentation remains insufficient. It is on the Registrant to provide this documentation...’
11. Ms Constantine indicated that notwithstanding the material provided by the Registrant, the HCPC position remained that a conditions of practice order remained the appropriate order. Ms Constantine further submitted:
• the reflective statement provided by the Registrant lacks focus and fails to address the points raised by the Substantive Hearing panel. For example, it states “I know that I should follow policy and procedure” but does not specify why this is important or how this has been implemented into practice in day-to-day work;
• the reflective piece is “sparse” and lacks the level of detail and lacks true reflection and insight;
• the Registrant’s current line manager, has confirmed that he is employed by Thornbury hospital;
• the reflective piece does not demonstrate an understanding of the issues raised and does not outline why it is important to not follow certain policies and procedures; and the reflective cycle is missing; and
• furthermore, the Personal Development Plan (‘PDP’) is also insufficient. What should be included (at page 3 for example), is an overarching heading and then examples of how this has been put into practice over the 6-month period to demonstrate how the Registrant has reflected on his conduct.
Registrant:
Registrant’s oral evidence:
12. The Registrant elected to give oral evidence, under affirmation, to the Panel. In doing so, he stated the following:
i. it is just part of his everyday job to do things “correctly” and “it’s what I have already done and will do”;
ii. the only reason that the Allegation arose was owing to “two months, when I worked in a different place and we clashed and they decided to make an example of me”;
iii. for the six-month period, he has made sure that he’s done things “correctly”, “pausing before doing things”, to ensure that he isn’t missing out on paperwork. Examples include collecting the ‘World Health Organisation (‘WHO’)’ form;
iv. in his current role, he does not now have ‘collection forms’, but he speaks with patients and ensures a “proper handover” for each patient;
v. he does not understand why the referrer “decided to do what they did” and he continues to act in the “best way he knows”, and as “he has for the last 25 years”; and
vi. he is not sure how to demonstrate how he is doing his job properly, as he is unclear how to do demonstrate that he is fit to practise.
13. In response to questions from Ms Constantine, on behalf of the HCPC, the Registrant stated the following:
i. he admitted some of the Allegation, as outlined before the Substantive Hearing panel, however he disputed some aspects of the case found proven;
ii. he understands that it is important to get a consent form as it’s a legal obligation and is necessary in surgery, for example, to: determine the correct site of the operation, the correct procedure is being undertaken and that the consent is in date. If signed any longer ago than six months then he also understands the need for a new up-to-date signature. This is because the document forms part of the patient’s record and it stays with them, and documents what could go wrong, what benefits the surgery may have and what could happen;
iii. in respect of the Particular 1 of the Allegation: he went to get the patient from the ward, the nurse handed over to him. They were both in the room and they both did the checks and the patient got down to ‘Theatre’ and he has no idea how it happened, and it had never happened before that the patient had not signed the consent after the surgeon had marked the patient’s leg. At that juncture, in his view it was the surgeon’s responsibility to ensure consent and that it had been obtained, as he is not the clinician. However, he accepted that it was his job to check it had been obtained and he accepted that this had been missed and that “for whatever reason” he did not notice this;
iv. he has not changed his practice; this example was one in a million times that this has happened and he obtains patient consent “6-8 times a day” and within this process he has to check a patient’s allergies, check the wrist band and the consent form has been signed and if the surgeon has not signed it with the patient, then he is not supposed to convey the patient to Theatre;
v. he has no idea how it got to the stage that it did;
vi. he no longer, in his current role, has ‘collection slips’ and he does not understand why he would have to write a collection slip, when usual process is that a patient’s name and procedure is known to him. However, he also understands that it is important to follow the policies and procedures which are in place to ensure: that mistakes don’t happen; for patient safety; and to confirm a ‘paper trail’, so that things are documented. These measures are important because should something happen then the organisation can conduct a ‘look back’ exercise and confirm what happened;
vii. on the date in question, he went to the nurses’ station on the ward to say he has come for the patient, and there was no one there. He waited for 3-4 minutes and still no one arrived. He then got a telephone call to enquire where the patient was. At this point, under pressure from Theatre staff, he went to the patient’s room, he checked the patient in the room, without a nurse being present, and because everything was “fine”, he went to convey the patient to Theatre. At this point, the nurse in charge attended and confronted him, indicating that he had not undertaken the appropriate checks and this was embarrassing as it had taken place in front of the patient;
viii. however, he has learnt from this incident and now he waits until there is a nurse present, and he informs Theatres that he is waiting for the patient to be handed over to ensure that he does not repeat this mistake again, and in this regard, he has learnt from the situation;
ix. he understands that it is important to check the ‘WHO’ checklist to ensure that you have the correct patient, that they know what procedure they are having, any allergies, whether any ‘blocks’ are being done and to check the correct site;
x. the risks to a patient are that you could have the wrong patient, the wrong site being blocked (and he knows that this has happened previously) and if you didn’t check allergies, it could be very serious for a patient;
xi. it is important that a handover to nursing staff takes place because the nursing staff need to know: that the patient is in the room; what procedure they have had done; and anything else that is relevant to the patient’s recovery and to be able to make sure that they are “okay”; and
xii. at Page 52 of the HCPC main hearing bundle – he accepted that his personal development plan is ‘light on detail’ as outlined by Ms Constantine.
14. In response to questions from the Panel, the Registrant stated the following:
i. in respect of the ‘WHO’ pre checklist, it was done verbally, and the signature was just a confirmation of that conversation. On that occasion, it was his name and date which were not outlined on the form, not that he had not undertaken the checks;
ii. he has completed further Continuing Professional Development (‘CPD’), but he does not keep a template of reflective performance;
iii. he has not completed any further CPD related to the concerns outlined within the Allegation;
iv. he has been in his current role, at Thornbury Hospital, since March 2021;
v. his current mentor, Matthew Armstead, is registered with the HCPC as an ODP and he has worked alongside him for approximately five years;
vi. Mr Armstead is mainly located within the Theatre office, and he sees him daily;
vii. in respect of the reference provided by Mr Armstead, he was not able to confirm the exact date of the reference, but it was after the Substantive Hearing panel convened in May 2025;
viii. the reason why the reference provided by Mr Armstead was not signed was because there was no ‘hard-copy’ of the document;
ix. he accepted that the PDP was not dated and he stated that it would have been written before he went on annual leave (in August 2025) and he believed it to have been crafted in late July 2025 and was provided to the HCPC on Monday (24 November 2025);
x. he accepted that he did not provide the PDP to the HCPC within the two months outlined within the Conditions of Practice, as “he was too busy with other things”;
xi. Mr Armstead did not sign the document, but had spoken it through with him; and
xii. at page 44 of the HCPC main hearing bundle – that document was emailed to the HCPC on 26 June 2025.
Decision
15. The Panel took into account the documents furnished to it by the parties (as outlined above) and it also had regard to the Registrant’s oral evidence and the parties’ submissions.
16. The Panel considered the relevant Practice Notes issued by the HCPTS, ‘Fitness to Practise Impairment’ and ‘Review of Article 30 Sanction Orders’, together with the HCPC’s Standards of Conduct, Performance and Ethics.
17. The Panel accepted the advice of the Legal Assessor who had, amongst other things, reminded it that the purpose of the review is to consider the issue of current impairment of the Registrant. The Legal Assessor also reminded the Panel of the following:
i. the Panel could have regard to a number of factors when reviewing the Order. Namely, the previous panel’s findings, the extent to which the Registrant has engaged with the regulatory process, the scope and level of insight and the risk of repetition;
ii. the Panel could take account of a range of issues, when considering current impairment, which in essence comprises the two components:
a) the ‘personal’ component: the current competence and behaviour of the Registrant; and
b) the ‘public’ component: the need the protect the public, declare and uphold proper standards of behaviour and maintain public confidence in the profession.
iii. it is only if the Panel determines that the Registrant’s fitness to practise remains impaired, that the Panel should go on to consider sanction by applying the guidance as set out in the HCPC ‘Sanctions Policy’;
iv. the Registrant bears the “persuasive burden” of demonstrating that he has fully acknowledged the deficiencies which led to the original findings and has addressed his impairment sufficiently through ‘insight, application, education, supervision or other achievement’ Abrahaem v GMC [2008] EWHC 183; and
v. the principle of proportionality required the Panel to consider the Registrant’s interests to be balanced against the interests of the public.
18. The Panel had regard to both the personal and public elements of impairment. The Panel also had regard to the previous panel’s determination however, the Panel conducted a comprehensive review in respect of the matter before it.
19. The Panel noted that the Registrant did not attend the Substantive hearing in May 2025, but that he had attended and engaged in this review hearing. The Panel was encouraged by the Registrant’s change of position in this regard. However, in considering the Registrant’s insight into the findings of the Substantive Hearing panel, the Panel determined that the Registrant’s insight continued to be very limited.
20. In the Panel’s view, the Registrant had displayed an attitude, during the course of his oral evidence to it, which was ‘blasé’ as to the Substantive Hearing panel’s findings and the failings in his ODP practice. This view was supported by comments from the Registrant such as: “I have done things as I always have” and he was “too busy” to provide documentation to the HCPC within the required time and as outlined within the Conditions of Practice.
21. Whilst the Panel noted that the Registrant acknowledged mistakes made on his part during the course of his oral evidence to it, the Panel formed the view that the Registrant had thus far failed to take full responsibility or provide adequate reasons for them. Further, whilst the Panel was satisfied that the Registrant was able to adequately describe the processes that should be adopted in his work as an ODP, in the Panel’s view he failed to provide adequate insight into why they were not adhered to on the dates outlined within the Allegation. In this regard, the Panel was concerned, having received oral evidence from the Registrant, that his views, and seeming lack of responsibility, were matters which were ‘engrained’ in his practice as an ODP and amounted to conduct which might be described as attitudinal in nature.
22. The Panel also noted that the Registrant had been asked to provide a reflective piece specifically addressing the matters outlined within the Allegation. However, the document provided to the Panel was not dated or signed and the Panel also considered that the reflective piece did not sufficiently address the Registrant’s misconduct, nor did it outline what steps he would take to ensure that there would not be a recurrence of his conduct. Further, the Panel also considered that the Registrant’s reflective piece failed to address, in any way, the impact of his misconduct on public trust and confidence in the wider profession. Whilst the Panel acknowledged that the Registrant had sought to address this point in his oral evidence to the Panel, the Panel considered the Registrant’s insight in this respect was also limited.
23. The Panel next considered the documentary evidence provided by the Registrant in respect of his PDP. In doing so, it again noted that the document was not dated, nor was it signed by either the Registrant or his supervisor. Additionally, the Panel accepted Ms Constantine’s submission to it that the PDP was lacking in terms of its content. The Panel considered that the PDP outlined a list of ‘intentions’ and/or statements and noted, in forming this view, that there were no Specific Measurable Achievable Relevant Time-bound (‘SMART’) targets or outcomes outlined within the document. Further, the Panel determined that the document failed to outline any input from his supervisor, and when questioned on this point by the Panel, he sought to pass the blame onto his supervisor indicating that his supervisor was “not good with paperwork”. In the Panel’s view, there was a lack of responsibility displayed on the part of the Registrant for his compliance with the Conditions of Practice imposed by the Substantive Hearing panel and this further supported the Panel’s earlier findings in respect of the Registrant’s wider attitude towards his ODP practice.
24. Similarly, the Panel also noted that there was a lack of detail around his supervision session information in that the notes provided were also not signed or dated by the Registrant and/or his supervisor. Additionally, the Panel also noted in the chronology provided by the Registrant in his oral evidence to it, that two of the Registrant’s supervision sessions pre-dated the drafting of his PDP and this also concerned the Panel. In the Panel’s view, this inevitably meant that two of the supervision sessions which the Registrant claimed to have undertaken with his supervisor did not discuss his PDP.
25. Whilst the Panel did not go as far as to consider whether the Registrant had been untruthful to it in his testimony to it, the Panel also noted that it had no independent documentary evidence before it to support the Registrant’s oral and/or documentary evidence in respect of his supervision sessions with his supervisor, or the completion of his PDP and this concerned the Panel.
26. Furthermore, the Panel also noted that the Registrant had not provided any evidence of recent training or continuing professional development (‘CPD’), undertaken by him, in order to demonstrate that he had kept his knowledge and skills up-to-date and/or that he had addressed the findings of the Substantive Hearing panel.
27. Additionally, the Panel also noted that the Registrant had indicated to it, that he had been working for the same employer since he left the Hospital (approximately 4 years ago) and had been progressing well in this role. However, again, the Panel noted that the Registrant had not provided any independent testimonials or references, from his employer or others, to attest to this. In the Panel’s view, the Registrant’s current employer would be able to speak to the Registrant’s ability to deal with his adherence and/or compliance with policies within the workplace, how he was managing his work and/or whether there are any current concerns regarding his employment.
28. Given the aforementioned, the Panel considered that it could not yet be confident that the Registrant has demonstrated the required insight or that he has taken sufficient steps to remediate his failings and therefore it could also not be confident that his behaviour would not be repeated. Consequently, the Panel was not satisfied that the Registrant does not still pose an on-going risk to the public. The Panel therefore concluded that in light of the above, taking the previous panel’s findings into account, the Registrant remains impaired on the personal component.
29. The Panel then went on to consider the public component of impairment. The Panel reminded itself that part of its role was to maintain professional standards and uphold confidence in the ODP profession. Having regard to this, the Panel was satisfied that a member of the public appraised of all of the circumstances of this case, would have their confidence in the profession, and the regulator, undermined if a finding of current impairment was not made on public interest grounds. The Panel therefore determined that the Registrant is impaired on the public interest component also.
30. Accordingly, the Panel concluded that the Registrant’s fitness to practise remains impaired on both the personal and public components.
31. Having determined that the Registrant’s fitness to practise remains currently impaired, the Panel went on to consider what sanction, if any, was appropriate.
32. The Panel bore in mind that sanction is a matter for its own independent judgment and that the purpose of a sanction is not to punish the Registrant but to protect the public. Further, it reminded itself that any sanction must be proportionate, so that any order must be the least restrictive order that would protect the public interest, including public protection. The Panel considered the sanctions available to it in ascending order of severity.
33. The Panel considered the option of a Caution Order however, decided that it would not provide adequate protection for the public in view of its findings.
34. The Panel next considered a Conditions of Practice Order. The Panel had regard to paragraph 106 of the Sanctions Policy and noted that it stated that a Conditions of Practice Order was appropriate in the following circumstances:
‘A conditions of practice order is likely to be appropriate in cases where:
i. the registrant has insight;
ii. the failure or deficiency is capable of being remedied;
iii. there are no persistent or general failures which would prevent the registrant from remediating;
iv. appropriate, proportionate, realistic and verifiable conditions can be formulated;
v. the panel is confident the registrant will comply with the conditions;
vi. a reviewing panel will be able to determine whether or not those conditions have or are being met; and
vii. the registrant does not pose a risk of harm by being in restricted practice.
35. The Panel considered that i) to vii), above, applied in this case. The Panel also noted the Registrant’s sporadic engagement throughout the regulatory proceedings and that he had taken some steps towards demonstrating some insight and attempting to comply with the Conditions of Practice.
36. Consequently, having regard to all of the circumstances of this case, the Panel was of the view that the Registrant should be afforded a further opportunity to demonstrate that he is capable of safe, effective and independent practice and that he should be provided with a further opportunity to satisfy a future panel that his fitness to practise is no longer impaired.
37. The Panel considered that Conditions of Practice (outlined below), were the least restrictive that could be imposed to proportionately balance the interests of the public with those of the Registrant. The Panel carefully considered the Conditions of Practice imposed by the Substantive Hearing panel and direct that the Conditions of Practice be varied to those outlined below. The Panel considered that it was appropriate to vary the previous Conditions of Practice to address its concerns in respect of the lack of independent evidence and documentation previously provided by the Registrant.
38. The Panel considered that a further period of 6 months was appropriate, as it would provide the Registrant with sufficient time to demonstrate that his fitness to practise is no longer impaired and would afford the Registrant with an opportunity to complete the recommendations outlined below. The Panel also considered that a Conditions of Practice Order was the proportionate order to impose as it balanced the need to protect the public and the public interest, with the Registrant’s interests and would afford him with an opportunity to return to work as an ODP, albeit in a restricted manner.
39. As it is required to do, the Panel considered a Suspension Order but determined that this would be disproportionate at this time.
40. The Panel considered that a future reviewing panel would be assisted by the Registrant’s future attendance and engagement, in addition to the provision of the following documentation no less than 7 working days before the start of a future reviewing hearing:
i. signed and dated: references / testimonials from: the Registrant’s employer; and/or supervisors; and/or managers; and/or service users - addressing his progress in the workplace, with specific consideration to his adherence to workplace policies and his wider practice as an ODP; and
ii. evidence of any further steps taken to maintain his skills, including evidence of training and Continuing Professional Development (CPD).
Order
ORDER: The Registrar is directed to vary and extend the Conditions of Practice Order against the registration of Mr Gary Bell for a further period of 6 months on the expiry of the existing Order.
Conditions of Practice
1. You must place yourself and remain under the indirect supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within one month of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations.
2. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice, it should demonstrate your knowledge and understanding of:
- the policy and procedure for patient transfer and consent, pre and post theatre;
- the policies and procedures in your workplace and how they relate to patient safety.
3. Within one month you must forward a copy of your Personal Development Plan to the HCPC which must be signed and dated by your supervisor.
4. You must meet with your workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan. You must provide signed and dated meeting minutes from each of these meetings to the HCPC at least one month prior to the next review hearing.
5. You must allow your workplace supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.
6. Having regard to the Panel’s decisions, you must produce a reflective practice profile detailing your part in the incidents, what went wrong, your learning and the impact upon patients, colleagues, the public, your profession and the regulator. This reflective practice profile should also address the impact of human factors on patient safety and research-based approaches to minimising risk and must be shared with your workplace supervisor and a copy signed by your supervisor should be provided to the HCPC at least one month prior to the HCPC review hearing.
7. You must inform the HCPC within seven days if you cease to be employed by your current employer.
8. You must inform the HCPC within seven days if you take up any other or further professional work.
9. You must inform the HCPC within seven days if you take up work requiring registration with a professional body outside the United Kingdom. You must inform the HCPC within seven days of returning to practice in the United Kingdom.
10. You must inform the HCPC within seven days of becoming aware of:
- any patient safety incident you are involved in;
- any investigation started against you; and
- any disciplinary proceedings taken against you.
11. You must inform the following parties that your registration is subject to these conditions:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application);
D. any organisation through which you are undertaking professional training.
12. You must allow the HCPC to share, as necessary, details about your performance, compliance with, and/or progress under these conditions with:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application);
D. any organisation through which you are undertaking professional training.’
Notes
The Order imposed today will apply from 12 December 2025.
This Order will be reviewed again before its expiry on 12 June 2026.
Hearing History
History of Hearings for Mr Gary Bell
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 26/11/2025 | Conduct and Competence Committee | Review Hearing | Conditions of Practice |
| 12/05/2025 | Conduct and Competence Committee | Final Hearing | Conditions of Practice |