Grahame C Mann

Preliminary Matters

Conducting part of the hearing in private.

1. At the commencement of the hearing, the Panel was informed that during the hearing there would be mention of matters relating to the Registrant’s health. Both the Presenting Officer and Ms Shah on behalf of the Registrant submitted that it would be appropriate for the Panel to make a direction that any mention of the Registrant’s health should be given during a private session of the hearing
2. Having taken advice from the Legal Assessor, the Panel agreed to the direction sought, concluding that it would be necessary for those parts of the hearing when the Registrant’s health would be discussed to be conducted in private in order to protect his private life.

   The Registrant’s response to the Allegation and the Panel’s desire to hear the evidence of HCPC witnesses.

3. When the Registrant was given the opportunity to respond to the Allegation, Particulars 1 and 2 were admitted, and the allegation advanced by Particular 3 that those factual particulars amounted to misconduct, were all admitted. In the relation to Particular 4 of the Allegation, it was stated on behalf of the Registrant that the decision on whether the Registrant’s fitness to practise is impaired was one for the Panel’s judgement.
4. The hearing bundle provided by the HCPC contained three witness statements (with associated documentary exhibits). On behalf of the Registrant, Ms Shah informed the Panel that the Registrant accepted the contents of all three witness statements. She stated that she did not require the witnesses to be called to give oral evidence but would be content for the evidence of the witnesses to be provided by the terms of their respective witness statements. On behalf of the HCPC, the Presenting Officer stated that he did not have additional matters he wished to address through oral evidence by the witnesses. It followed that the position of the parties was that they did not require the witnesses to give oral evidence.
5. The Panel retired to consider whether it wished the witnesses to give evidence. The conclusion reached by the Panel was that the Registrant’s admission of Particulars 1 and 2 established what had occurred. However, the Panel considered it to be necessary for the witnesses to be called to deal with contextual matters relating to the two incidents, and, in particular, any evidence the witnesses might be able give that might bear upon the issues of why and how the two incidents occurred.
6.  Accordingly, the three witnesses were called by the HCPC. The witnesses, and a short summary of the evidence they gave, will be provided when the Panel explains its decisions on the factual elements of the case.

   Background

7. The Registrant is registered in the Chiropodists and Podiatrists part of the HCPC Register. His registration is annotated to record the fact that he is a Podiatrist practising Podiatric Surgery.
8. At the time relevant to the Allegation, the Registrant had “practising privileges” with an organisation named Epsomedical. Epsomedical operated clinics where podiatric surgery was carried out.
9. On 4 January 2023, the Registrant informed the HCPC of two incidents he described as “never events” that had occurred within the space of three months. Epsomedical made a referral to the HCPC concerning the Registrant the following day.
10. The first incident (involving Patient A and the subject of Particular 1) occurred on 7 October 2022. The Registrant performed a great toe joint replacement and inserted an implant with the incorrect laterality.
11. The second incident (involving Patient B and the subject of Particular 2) occurred on 2 December 2022, when the Registrant undertook a left foot lesser toe implant. On this occasion, the Registrant completed the surgery by leaving in the patient’s toe a trial size implant rather than the intended permanent implant.
12. On 20 December 2022, Epsomedical suspended the Registrant’s practising privileges. On 13 January 2023, the Registrant notified Epsomedical that he had decided to permanently cease surgical practice with immediate effect, and on 26 January 2023 the organisation permanently withdrew the Registrant’s practising privileges

    Decision on Facts

13. The witnesses whose witness statements were included in the HCPC’s hearing bundle, and from whom the Panel stated at the commencement of the case it wished to hear evidence, were:
    • Ms HK, Epsomedical’s Compliance Director, who investigated both incidents.
    • Ms MP, who was employed by Epsomedical as a Theatre Nurse Practitioner, who was the scrub practitioner assisting the Registrant on 7 October 2022, when the incident concerning Patient A occurred.
    • Ms MJ, who was also employed by Epsomedical as a Theatre Nurse Practitioner, who was the scrub practitioner assisting the Registrant on 2 December 2022, when the incident concerning patient B occurred.
14. The Registrant produced a witness statement and various documents in support of his case. Included in the documents he provided were testimonials, documents related to his health, and training certificates. The Registrant also gave evidence before the hearing.
15.  In view of the fact that the Registrant admitted the factual particulars and there were no disputed issues arising from the evidence, the Panel will confine its explanation of the evidence given to those issues it is necessary to refer to explain the decisions made by the Panel.
16. It was clear from the evidence of Ms HK that the Registrant fully cooperated in the Epsomedical investigations, was accepting of blame (in relation to the 7 October 2022, incident to the extent that Ms HK thought that his acceptance did not recognise the contribution made by others to what went wrong) and expressed remorse. She confirmed the summary already given of the cessation of the Registrant’s practice as a Podiatric Surgeon with Epsomedical. The incident on 2 December 2022 occurred during the first surgical undertaken by the Registrant after he return to work following a period of sickness absence. Ms HK also explained to the Panel the methodology of an audit she conducted following the first incident. By examining the recorded details of the surgical procedures undertaken by the Registrant and the records of materials used during those procedures, she was able to confirm that he had not, before 7 October 2022, used an incorrect implant in undertaking surgery.
17. Ms MP confirmed that she was acting as scrub practitioner on 7 October 2022, but also confirmed that it was another practitioner, Ms JT, who obtained the implant from the cupboard and presented it to the Registrant in the package for him to confirm that it was the correct item. Ms MP accepted that she did not herself check that it was the correct item as she acknowledged she should have done, merely relying on the interaction between Ms JT and the Registrant. 
18. Ms MJ confirmed that she was acting as scrub practitioner on 2 December 2022. She told the Panel that she twice stated to the Registrant that the implant was the trial size implant, but that the procedure was nevertheless completed by the Registrant with the trial size implant in situ.
19. In his evidence, the Registrant repeated the admissions he had consistently made from the time the incidents occurred. The Panel was satisfied that his acceptance of wrongdoing, his remorse and apologies were both genuine and unqualified. The Registrant very clearly stated that he did not have a recollection of Ms MJ drawing his attention to the fact that he was proposing to conclude the surgery with the trial size implant in place, but he was equally clear that, given that it was Ms MJ’s evidence that she did say that, he accepted that she had.
20. The Panel accepted the advice of the Legal Assessor in relation to the finding of facts. Accordingly, the Panel accepted that it could find the specific facts alleged by the particulars to be proven on the basis of the Registrant’s admissions of them. To the extent that the Panel considered it necessary to make other contextual factual findings, it was necessary to remember that the HCPC carried the burden of proving matters on the balance of probabilities, and of the care that should be taken in assessing hearsay evidence. The Panel confirms that it applied this guidance in reaching the decisions it has.
21. In relation to the specific contentions advanced by Particulars 1 and 2, the Panel was satisfied that the evidence it received was entirely consistent with the admissions made by the Registrant at the commencement of the case. The Panel found both Particulars 1 and 2 to be proven.
22. As to why the incidents reflected in Particulars 1 and 2 occurred, the Panel sought to reach an understanding based on the evidence it received.
    • So far as Particular 1 is concerned, until approximately a year before the incident, implants of different lateralities were not used. There then became available left and right implants and the Registrant had previously used implants of different lateralities. He should, therefore, have correctly identified that the appropriate implant was being presented to him, and he did not do so. When asked whether the health issue that is suggested to have been a significant factor in the later incident were relevant on 7 October 2022, the Registrant did not go beyond saying that it could have been.
    • With regard to Particular 2, the Panel accepted the evidence of Ms MJ that she did draw to the attention of the Registrant on two occasions the fact that he was using the trial size implant. The evidence received by the Panel does not support (or even suggest) the proposition that the Registrant chose deliberately to ignore Ms MJ’s warnings. For that reason, the Panel is not able to conclude that there was any reason other than lack of concentration on the part of the Registrant for Ms MJ’s clear warnings not being heeded.

    Decision on Misconduct

23.  It has already been recorded that at the commencement of the hearing, the Registrant admitted misconduct. However, the Panel took the view that it was necessary for it to exercise its independent judgement as to whether, and, if so, why, misconduct was established. Without that independent judgement being made by the Panel, it would not be possible for a robust decision as to whether the Registrant’s fitness to practise is currently impaired.
24.  The Panel accepted the advice it received from the Legal Assessor in relation to a finding of misconduct. Accordingly, it began by assessing whether there had been acts and omissions on the part of the Registrant that fell short of what would be proper in the circumstances, the falling short being identified by reference to the standards required by the HCPC. The Panel accepted that a breach, or even multiple breaches, of standards should not be taken automatically to result in a finding of misconduct. It is required to assess the seriousness of the fallings short, only finding misconduct if they are decided to be serious.
25.  The Panel began its decision on misconduct by reviewing the HCPC’s Standards of conduct, performance and ethics that were in force between January 2016 and September 2024. The conclusion of the Panel was that the incidents that occurred on 7 October 2022, and 2 December 2022, demonstrated breaches of the following standards:
    • Standard 2.6, which requires relevant information to be shared with colleagues involved in the care and treatment of service users.
    • Standard 6.1, which requires that all reasonable steps must be taken to reduce the risk of harm to service users.
    • Standards 6.2, which requires all registrants not to do anything, or allow someone else to do anything, that could put the health or safety of a service user at unacceptable risk.
26. Having identified breaches of these standards, the Panel assessed the seriousness of the fallings short from expected standards of performance.
27. The Panel was of the clear view that of the two incidents, for three distinct reasons, the incident on 2 December 2022 was the more serious. First, it occurred less than two months after the earlier incident, and therefore at a time when it would have been expected that the Registrant would have been especially vigilant in the conduct of his professional duties. Secondly, whereas other professionals who had their own responsibilities were involved in the earlier incident, on 2 December 2022, not only were there no other people contributing to what occurred, but an incorrect implant was used despite Ms MJ twice stating that it was not correct. Thirdly, Patient B suffered actual harm, in that he had to undergo corrective surgery.
28.  The Panel’s finding that the 2 December 2022 incident was the more serious of the two does not mean that the Panel takes the view that the incident on 7 October 2022 was insignificant. It is true that on 7 October 2022 there were two other professionals who each had their own responsibilities to ensure that the correct implant was used. However, as the surgeon, the ultimate responsibility was that of the Registrant, and the insertion of the implant with the incorrect laterality means that he failed to discharge that responsibility. Secondly, unlike Patient B, Patient A was not required to undergo corrective surgery, and the view has been taken that Patient A did not suffer any tangible harm. However, as Ms Shah correctly recognised in her submissions on behalf of the Registrant on the issue of impairment of fitness to practise, it was pure luck that Patient A did not suffer harm.
29. When the Panel stood back and considered the seriousness of the two incidents when viewed together, it concluded that they crossed the high threshold properly to be categorised as misconduct.

    Decision on Impairment

30. The Panel received oral submissions from the parties on current impairment of fitness to practise.
31. On behalf of the HCPC, the Presenting Officer drew the Panel’s attention to the three overarching objectives of the HCPC. He submitted that the Registrant’s fitness to practise was impaired in the period in 2022 when the incidents occurred and remains impaired. He submitted that two never events occurred within a very short period of time, and that they were stark errors that were not easily remediable. It was also submitted that both incidents involved a degree of lack of communication, over-familiarity, and complacency on the part of the Registrant. The HCPC’s submission is that a finding of current impairment of fitness to practise should be made.
32. On behalf of the Registrant, Ms Shah reminded the Panel of the positive testimonial evidence that had been provided and of the fact that he had an unblemished record until 2022. She submitted that until the time of the two incidents relevant to this case, the Registrant had practised as a highly competent surgeon. With regard to the evidence relating to the Registrant’s health that had been received by the Panel, she submitted that it can take a while for people to appreciate the effects of ill health. She also asked the Panel to have regard to the Registrant’s response to the matter as he had taken full responsibility, had not attempted to shift blame onto others, and had demonstrated full insight. These factors, coupled with the Registrant’s decision to cease practising as a Podiatric Surgeon and the fact that, were he to ever consider returning to that area of work, he would have to undergo re-training, should lead the Panel to conclude that it is not necessary to impose safeguards.
33. The Panel accepted the advice of the Legal Assessor in relation to impairment of fitness to practise. Accordingly, the Panel paid close attention to the HCPTS Practice Note, “Fitness to Practise Impairment” issued in August 2025. Following the guidance contained in that document meant that the Panel addressed the personal and public components of impairment of fitness to practise separately.
34. With regard to the personal component, the Panel acknowledged that it is very largely concerned with the likelihood of repetition of unacceptable conduct. The Panel considered that the following factors were relevant to this issue:
    • The Registrant had expressed genuine remorse. The Panel accepted that it is possible to express remorse for past failings without having the degree of insight that would be required to say that a recurrence is unlikely.
    • The Registrant does not have any positive explanation for the incident that occurred on 7 October 2022, apart from postulating that it was the result of complacency.
    • The Registrant has a clearer understanding of why the incident on 2 December 2022 occurred, and as a result has ceased to undertake surgery.
    • The Registrant has not only ceased to undertake surgery, but has also stated that he does not intend return to practise surgery in the future. The Panel accepted that this intention is genuine.
    • Further, in the event that at some time in the future the Registrant changes his mind about wishing to return to undertake podiatric surgery, the Panel is satisfied that there would be a need for him to undertake significant professional updating to do so.
    • There is no suggestion that the Registrant’s ability to practise safely and effectively in other, non-surgical, areas of Podiatric practice is adversely affected.
35. With the factors just identified in mind, the Panel assessed the likelihood of the Registrant repeating behaviour of the type that has been considered by the Panel. The Panel is satisfied that there is no realistic prospect of the Registrant seeking to return to undertake podiatric surgery. This is a judgement that is based not only on the Panel’s assessment of his integrity as demonstrated since the relevant events, but also by a recognition of the hurdles the Registrant would have to clear to return to that work in the (in the view of the Panel, highly unlikely) event of him changing his mind. The fact that the Panel is satisfied that three is no realistic prospect that the Registrant will return to practise surgery has the consequence that there is no significant risk of matters being repeated.
36.  For the reason just explained the Panel finds that upon consideration of the personal component, the Registrant’s fitness to practise is not currently impaired.
37. The Panel went on to consider the public component of impairment of fitness to practise. In doing so it addressed the three elements identified in the Practice Note, namely, (i) protection of service users from the risk of ongoing or future harm, (ii) the maintenance of professional standards, and, (iii) maintaining public confidence in the Registrant’s profession.
38. The finding already explained in relation to the personal component answers the first element, protection of service users. The finding that there is not a sufficient likelihood of repetition to justify a finding of personal component impairment of fitness to practise has resulted in the Panel concluding that the need to protect service users is not a factor requiring a finding of public component impairment of fitness to practise.
39. However, the answer to the question whether service users require protection from the risk of ongoing or future risk of harm does not answer the question whether a finding of impairment of fitness to practise is required to mark a departure from professional standards or to maintain a proper degree of public confidence in the profession of Podiatry. It is not necessary for the Panel to repeat at this point in its determination all that has already been stated about the seriousness of the findings made. It is sufficient to record that on two occasions within two months of one another incorrect implants were used in surgery. One of the patients (Patient B) suffered actual harm by being required to undergo remedial surgery. As has already been stated, it was simply chance that Patient A does not appear to have suffered actual harm. In the judgement of the Panel these are sufficiently serious breaches to require a finding of current impairment of fitness to practise to mark a departure from proper professional standards. Furthermore, informed and fair-minded members of the public would be likely to have their confidence undermined in the profession of Podiatry, as well as in the regulation of that profession, were there to be no finding of impairment of fitness to practise.
40. For these reasons, the Panel finds that the Registrant’s current fitness to practise is impaired by reference to the public component.
41. The finding of current impairment of fitness to practise has the consequence that the allegation is well founded. Accordingly, it is necessary for the Panel to go on to consider the issue of sanction.

    Decision on Sanction

42. After the Panel handed down its written determination explaining its reasons for finding that the Allegation is well founded, it allowed the parties time to consider the document before receiving submissions on sanction.
43. On behalf of the HCPC, the Presenting Officer stated that the HCPC’s position was one of neutrality. He urged the Panel to recall that any sanction decided upon should protect the public and be proportional. In identifying mitigating factors, the Presenting Officer referred to the remorse expressed by the Registrant, the fact that he had shown some insight in his shortcomings, and the length of his career before the first event occurred. As aggravating factors, he submitted that the breaches of fundamental elements of the Standards of conduct, performance and ethics, the fact that the case concerns two incidents, the harm to Patient B who required corrective surgery and the potential for Patient A to suffer harm, were all matters to be kept in mind. The Presenting Officer submitted that any sanction below a Conditions of Practice Order would be unlikely to be appropriate, and, in particular in relation to a Caution Order, the issues, being two in number, were not isolated and were not minor in nature. Finally, the Presenting Officer reminded the Panel of the fact that the Registrant had been subject to an interim Conditions of Practice Order.
44. On behalf of the Registrant, Ms Shah also reminded the Panel of the proper approach to the imposition of a sanction. It should not be imposed to punish for past mistakes and should be the least restrictive required. She submitted that for the Panel’s sanction decision to be consistent with its decisions leading to the finding that the Allegation is well founded, it should not be imposed to address risks going forward. She submitted that the present case could properly be considered to be one of those rare cases in which it would be appropriate to take no action. This was advanced on the basis that considerations of marking proper professional standards and maintaining public confidence in the profession would be satisfactorily addressed by the Panel’s finding of misconduct and impairment of fitness to practise. In the event that the Panel did not accept her submissions that there should be no order, Ms Shaw urged the Panel to impose a Caution Order for 1 year.
45. The Panel accepted the advice received from the Legal Assessor on sanction. Accordingly, the Panel accepted that a sanction must not be imposed to punish the Registrant. A sanction should only be imposed to the extent that if it is required to protect the public, to maintain public confidence in the profession, or to mark a departure from proper professional standards. It must first be decided whether the case requires the imposition of any sanction at all. If a sanction is required, then the available sanctions must be considered in an ascending order of seriousness. The Panel confirms that it applied this approach in reaching its decision.
46. A Panel making a sanction decision is expected to identify the aggravating and mitigating factors it considers to be appropriate to take into account.
47. The Registrant’s shortcomings were serious. In the view of the Panel, being already serious, the shortcomings were not further aggravated save that there were two incidents in a short period of time.
48. Some of the mitigating factors have already been referred to in the summary of the Presenting Officer’s submissions. In addition to remorse, insight and otherwise unblemished career, the Panel considers that the full engagement by the Registrant in both the Epsomedical investigations and the HCPC’s fitness to practise process reflect credit on him, quite apart from the fact that he made unequivocal admissions in both.
49. The Registrant’s breaches were serious for the reasons already fully explained. For the purposes of the sanction decision it is important to repeat what has already been stated in the Panel’s decision on impairment of fitness to practise, namely that this is a case in which there is no significant risk of repetition. For that reason, the sanction decision is not required to include an element of future protection. That said, for the reasons also already explained, the Panel is satisfied that the issues of the marking of departures from proper professional standards and the maintenance of public protection are factors that are required to be kept in mind.
50. When the Panel asked itself the question whether this is a case in which it would be appropriate to make no order, the Panel answered that question by deciding that it would not. A sanction is required.
51. The Panel next considered a Caution Order, and in that context had regard to paragraph 101 of the Sanctions Policy. That paragraph is in the following terms:
    ‘A Caution Order is likely to be an appropriate sanction for cases in which:
    • the issue is isolated, limited, or relatively minor in nature;
    • there is a low risk of repetition;
    • the registrant has shown good insight; and
    • the registrant has undertaken appropriate remediation.’
52. With regard to the four bulleted points in paragraph 101, the Panel was satisfied that they are met in the present case; there is a very low risk of repetition, the Registrant has shown good insight, and he has taken the most appropriate remedial action possible by ceasing to undertake professional work of the type in which the shortcomings occurred. In relation to the first bullet point, it could be argued that the findings represent issues that were isolated in the sense that there is no suggestion of a larger pattern, and they were limited in the sense that they were two in number over a short period of time. However, on no basis could they be said to be relatively minor.
53. The Panel noted that the isolated, limited and relatively minor in nature are linked by the word “or”, but nevertheless the fact that the issues in the present case could not be described as relatively minor underlined the importance of the requirement to consider the next most restrictive sanction available.
54. When the Panel addressed the question whether it should impose a Conditions of Practice Order, it was conscious of the fact that the Registrant has been subject to an interim Conditions of Practice Order for a period of approximately 2 years and 6 months. However, the decision to impose a restriction on the Registrant undertaking podiatric surgery by an interim order would have been taken when the panel imposing the order did not have the ability the present Panel has had to assess whether it was necessary to impose that restriction. As has already been stated, the present Panel is satisfied that the Registrant has made the decision to cease undertaking surgery. The Panel has concluded that it is not necessary to impose that restriction by way of a substantive Conditions of Practice Order. That being the case, it concluded that a Conditions of Practice Order would be both unnecessary and disproportionate.
55. In view of the fact that the Panel’s findings have the consequence that a Conditions of Practice Order would not be appropriate, the Panel considered one further sanction, namely a Suspension Order. In circumstances where the Registrant is practising safely and effectively in some areas of Podiatry and it is not necessary to restrict him from practising in other areas of Podiatry, to suspend him from all practice would be wholly disproportionate.
56. Having concluded that neither a Conditions of Practice Order nor a Suspension Order would be either appropriate or proportionate, the Panel returned to its consideration of a Caution Order. The Panel asked itself whether a Caution Order for a significant period would satisfactorily address the required sanction issues, namely marking the departure from proper professional standards, and the maintenance of a proper degree of public confidence in the profession of Podiatry. For that reason the Panel concluded that a Caution Order should be imposed, and that, in the particular circumstances of the present case, that is the appropriate outcome despite the fact that the issues cannot properly be described as “relatively minor in nature”. The Panel decided that Caution Order should be for a period of 3 years, that period striking a proper balance between, on the one hand, the seriousness of the issues involved, with, on the other hand, the fact that the incidents occurred very nearly three years ago and the fact that the Registrant has been subject to an interim order for most of the intervening period.
57. The Panel was also satisfied that when viewed from the standpoint of the Registrant, a Caution Order for a period of 3 years represents a proportionate response as no lesser sanction would address the matters the Panel is satisfied are required to be addressed by the imposition of a sanction.

Order: The Registrar is directed to annotate the register entry of Grahame Mann with a caution which is to remain on the Register for a period of 3 years from 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.

History of Hearings for Grahame C Mann