Troy Butler

Preliminary Matters

Application to amend

1.          On behalf of the HCPC Mr Barnfield made an application to amend the Allegation (as indicated by the striking through and additions highlighted below) to read as follows:

As a registered Operating department practitioner (ODP36928) your fitness to practise is impaired by reason of misconduct. In that:

1.     On or around 18 19 April 2023, you self-administered anaesthetic gas, namely Sevoflurane Vaporiser, while at work.

2.     Your actions as detailed in Particular 1 constitute misconduct.

3.     By reason of your misconduct your fitness to practise is impaired.

2.          On behalf of the Registrant Ms Yeghikian did not oppose the application.

3.          The Panel had regard to the submissions on behalf of the HCPC and accepted the advice of the Legal Assessor. The Panel was satisfied that the proposed amendment did not materially prejudice the Registrant and better reflected the evidence in the case. The Panel therefore granted the application to amend.

Background

4.          The Registrant is registered with the HCPC as an Operating Department Practitioner (ODP) and was employed as a Band 5 ODP in the Main Theatre Department at Doncaster and Bassetlaw Teaching Hospital (“the Hospital”) since he qualified, having previously worked at the Hospital as a Band 2 ODP from approximately August 2016. He worked within the Hospital’s Emergency team and Resuscitation team. He was responsible for responding to cardiac arrests across the Hospital and worked within the Anaesthetic Department, including assisting anaesthetists, checking in patients and preparing patients for surgery.

5.          On 19 April 2023, colleagues of the Registrant were required to set up for emergency theatre, following contact from A&E at about 1am. The Registrant’s colleagues could not find the Registrant and he did not respond to being bleeped. Persons 2 and 3 found the Registrant asleep on a trolley with a sheet over him in Theatre Room at approximately 2.20am. The anaesthetic circuit was in the Registrant’s hands with the end near his mouth, whilst he was asleep. He had self-administered anaesthetic gas during an unpaid rest break during a night shift.

6.          Persons 2 and 3 switched on the lights, clapped loudly and shouted at the Registrant until he woke up after at least one minute. He was initially startled and appeared dazed; it took approximately 30-60 minutes for him to return to fully acting normally. Under supervision from a senior practitioner (Person 4), he was able to finish his shift. The patient in theatre was safely anaesthetised and operated on.

7.          At around 8.30 am the Registrant was asked by the Divisional Nurse about the incident and what his intentions were. The Registrant explained that he was desperate for sleep [redacted] which had led to him working long hours with an agency. The Registrant accepted that he had self-administered anaesthetic gas. He expressed his deep regret for his “ridiculous decision” to turn on the anaesthetic gas. He said he had a small amount but could not sleep so turned it up some more.

8.          The Registrant was placed under supervision at work until further notice and did not work “unsociable” hours for approximately three to four weeks.

9.          On 20 April 2023 the Divisional Nurse made a referral to the HCPC which resulted in these proceedings.

10.       The Registrant has continued to be employed as an ODP at the Hospital without restriction.

Decision on Facts

11.       At the outset of the hearing, the Registrant admitted Particular 1 of the Allegation and the Panel Chair announced that the facts were proved by way of admission without the need for further evidence.

Decision on Grounds

12.       The Panel went on to consider whether the facts found proved amounted to misconduct, as alleged in Particular 2 of the Allegation.

13.       The Registrant admitted misconduct at the outset of the hearing.

14.       The Panel was mindful that this was a matter for the Panel’s professional judgement, there being no standard or burden of proof.

15.       The Panel took into account that misconduct was defined in Roylance v General Medical Council (no 2) [2001] 1 AC 311 as:
“a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a (medical) practitioner in the particular circumstances”.

16.       The Panel found that the Registrant had been in breach of the following standards in the HCPC Standards of Conduct, Performance, and Ethics (2016):

6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.

6.2 You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.

9.1 You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.

17.       The Panel concluded that the Registrant’s conduct fell seriously short of the standards to be expected of him in the circumstances and thereby constituted misconduct.

Decision on Impairment

18.       The Registrant denied that his fitness to practise is currently impaired by reason of his misconduct, as alleged in Particular 3 of the Allegation.

19.       The Registrant provided a reflective statement and gave oral evidence on oath to the Panel.

20.       By way of explanation of his misconduct, the Registrant told the Panel that at the time of the incident he had been overworking. In addition to his contracted employment, he was undertaking agency work and occasional work in a bar. He was habitually working 70 hours a week. [redacted] On the night in question, he had reached breaking point and was desperate to have some sleep. On impulse, he self-administered a small amount of anaesthetic gas to get some sleep.

21.        In answer to questions from the Panel about his understanding of the consequences of his action, the Registrant acknowledged that his behaviour was stupid and selfish. He said that he had put everyone at risk: patients, colleagues and the public. He said that he realised that, by incapacitating himself, he could have left his team at the Hospital under-staffed and potentially unable to deal with any emergency cases which might have arisen, thereby putting the lives of patients at risk. He said that his conduct had diminished the high regard in which his profession was held by the public and that his behaviour had been deplorable. He said that his own parents were ashamed of him.

22.        The Registrant stated that he had taken steps to ensure that he would never behave in such a way again. [redacted] He had consciously reduced his workload: he had given up agency work and since February 2025 had only worked for the Hospital at Doncaster. The only additional paid work which he now undertook was bank work via NHS Professionals at the Hospital.

23.        The Registrant said that since the incident he [redacted] no longer over-stretched himself. [redacted] had improved his work-life balance by taking exercise and having some social life outside work.

24.        He said that he now realised the importance of being open and talking about the stresses and worries in his life with his family and his manager at work, rather than bottling them up as he done previously. He said that, if he became over-tired in future, he would talk to his manager and, if necessary, take time off work rather than carrying on regardless.

25.       The Registrant provided a number of supportive testimonials from professional colleagues, all of whom were aware of the Allegation but spoke highly of the Registrant as a colleague and of his diligence and professionalism as an ODP.

26.       The Panel took account of the Registrant’s evidence and carefully considered the submissions on behalf of the HCPC and the Registrant respectively.

27.       The Panel also had regard to the HCPTS Practice Note on “Finding that Fitness to Practise is Impaired” and accepted the advice of the Legal Assessor.

28.       In determining whether the Registrant’s fitness to practise is impaired, the Panel took into account both the personal and public components of impairment. The personal component relates to the Registrant’s own practice as an ODP, including any evidence of insight and remorse and efforts towards remediation. The public component includes the need to protect service users, declare and uphold proper standards of behaviour on the part of registrants and maintain public confidence in the profession and the Regulator.

29.       With regard to the personal component, the Panel accepted the Registrant’s expressions of remorse to be entirely genuine. He candidly admitted that his conduct in self-administering the anaesthetic on duty was selfish and stupid. He acknowledged that he thereby put himself, patients and colleagues at risk of harm and that his conduct could have damaged the reputation of the Hospital where he worked and the profession at large.

30.       The Panel was satisfied that the Registrant has good insight into the causes and consequences of his misconduct and that he has made adjustments to his working life and personal circumstances so as to avoid any repetition. [redacted]

31.       The Panel accepted that this was an isolated incident arising from the strains and pressures in Registrant’s life at the time. Having regard to the Registrant’s remorse, insight and the practical steps which he taken since the incident to improve his work-life balance, the Panel considered that there was a low likelihood that he would repeat such misconduct in the future.

32.       Accordingly, the Panel found that the Registrant’s fitness to practise is not currently impaired having regard to the personal component.

33.       With regard to the public component, the Panel was satisfied that the Registrant does not pose a risk to the public; on the contrary, he is, by all accounts, a good and competent practitioner, whose continued practice as an ODP is of benefit to the public. However, the Panel considered that the Registrant’s misconduct in self-administering an anaesthetic gas whilst on duty and thereby putting himself, patients and colleagues at risk, was such a serious departure from professional standards as to require a finding of current impairment as a deterrent to others, to uphold proper professional standards and to maintain public confidence in the profession and the HCPC as its Regulator. In the Panel’s judgement, public confidence in the profession and the regulatory process would be undermined if there were no finding of current impairment.

34.       Accordingly, the Panel found that the Registrant’s fitness to practise is impaired on public interest grounds. 
 
 
Decision on Sanction
 

35.       The Panel carefully considered the submissions on behalf of the HCPC and the Registrant respectively.

36.       The Panel had regard to the HCPC’s Sanctions Guidance and accepted the advice of the Legal Assessor.

37.       Having decided that the Registrant does not pose a risk to the public, in determining what sanction, if any, to impose, the Panel considered how best to address the wider public interest in upholding proper standards of conduct and maintaining public confidence in the profession and the regulatory process. The Panel also applied the principle of proportionality, balancing the interests of the Registrant with those of the public, and considered the available sanctions in ascending order of seriousness.

38.       The aggravating factor in this case is that the Registrant’s misconduct in self-administering anaesthetic gas whilst on duty gave rise to a significant risk of harm to patients, colleagues and himself.

39.       The mitigating factors are that the Registrant has shown unqualified remorse, he has full insight into the causes and consequences of his misconduct and has taken appropriate steps to ensure that it will not be repeated. The Panel also noted that, since May 2023, the Registrant has continued to be employed without restriction by the same employer and has throughout that time performed his role as an ODP in a professional and competent manner, as confirmed by the numerous testimonials provided by his professional colleagues.

40.       The Registrant’s misconduct was too serious for the Panel to take no further action. The Panel considered that some mark should be placed on his registration to send a message to the public and the profession that his conduct in self-administering anaesthetic gas whilst on duty was unsafe, inexcusable and unacceptable.

41.       The Panel carefully considered the indicative features for imposing a Caution Order and decided that they apply to a large extent in this case. In particular, this was an isolated incident of misconduct which is very unlikely to be repeated. It did not involve the Registrant’s clinical practice which appears to be of a high standard and it is in the public interest that he should continue to practise as an ODP without restriction.

42.       In deciding the length of a Caution Order, the Panel sought to balance the need to send a sufficiently robust message by way of a deterrent against such misconduct to the profession with fairness to the Registrant.

43.       In all the circumstances, the Panel considered that the appropriate and proportionate sanction was a Caution Order for a period of 12 months.

44.       For the sake of completeness, the Panel did not consider that a Conditions of Practice Order would be relevant or appropriate as there were no concerns about the Registrant’s clinical competence. The Panel considered that a Suspension Order would be disproportionate.

ORDER: That the Registrar is directed to annotate the register entry of Troy Butler with a caution which is to remain on the register for a period of 1 year from the date this order comes into effect.

This Order will come into effect on 16 December 2025, if no appeal is made.

History of Hearings for Troy Butler