Eme S Ufomba

Preliminary Matters

Service

1.    The Panel noted that the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (‘the Rules’) provide at paragraph 3(1)(b) that notice may be served on a registrant by sending it to their electronic mail address as it appears in the Register. Paragraph 6(2) of the Rules provides that “The Committee shall not fix a date for the hearing which is before the end of the period of 28 days beginning with the day on which the Committee sent the notice referred to in paragraph (1) to the registrant”.

2.    The Panel reviewed a five page Service Bundle which contained a Notice of Hearing, sent to the Registrant on 14 May 2026 via email at 2:07 PM, and an extract of the Register showing the contact details provided by the Registrant and held by the HCPC. It also received legal advice from the Legal Assessor, which it accepted and applied, and had regard to the HCPTS Practice Note ‘Service of Documents’.  

3.    The Panel noted that the Registrant was informed of the mandatory review via email on 14 May 2026. It was satisfied that the Notice of Hearing had been duly served upon the Registrant via her email address more than twenty-eight days prior to the hearing. 

4.    The Panel determined that good service of notice of the hearing had been effected. It was content that the HCPC had discharged its duty to ensure that the Registrant had been afforded an opportunity to appear before it and be heard, as set out at Article 31(15) of the Health Professions Order 2001 (‘the Order’).

Proceeding in Absence

5.    The Presenting Officer invited the Panel to proceed with the hearing in the absence of the Registrant. She set out the steps taken to make the Registrant aware of the hearing and noted that the Registrant did not request an adjournment or to be represented at the hearing.  The Registrant had however submitted to the Panel:
a.    an addendum bundle of 7 pages dated 6 July 2026; and
b.    a second addendum bundle of 10 pages dated 8 July 2026
c.    an email dated 7 July 2026 confirming that she “will not be able to attend the review hearing on 9/07/26.”

6.    The Presenting Officer also confirmed that the Registrant submitted an image of an email appearing to confirm that she had a medical appointment on 9 July 2026 but had specifically requested that this not be shown to the Panel. The Presenting Officer confirmed that the email did not contain the official letterhead of any medical facility. She submitted that the Panel was entitled to find that the Registrant had voluntarily absented herself from the proceedings and therefore that the mandatory review should proceed in her absence. 

7.    The Panel received advice from the Legal Assessor, which it accepted and applied, and had regard to the practice note provided by the HCPTS in relation to proceeding in the absence of the Registrant. It noted that the Registrant was informed that the substantive order would be reviewed prior to expiry via email 4 November 2025, and that the Registrant replied to this communication asking for details as to where to send documents she wished to submit for the Panel’s consideration. The Panel was mindful that there have been two reviews following the imposition of the substantive order already, one of which was attended by the Registrant. The Notice of Hearing of the review was issued on 14 May 2026 and the Registrant was contacted by telephone on 29 June 2026 regarding the hearing. It was at this point that she disclosed her ill-health to the HCPC but declined to share the details. The Registrant then forwarded some documents to the HCPC via an email dated 2 July 2026 in which she stated  “I am unwell but will endeavour to send the documents”.  

8.    Having determined that good service of notice of the hearing had been effected by the HCPTS, the Panel carefully considered all of the circumstances of the case to inform its assessment of the fairness to the HCPC, the public and the Registrant in respect of whether to proceed with the hearing in the absence of the Registrant. It noted that the notice of hearing specifically informed the Registrant that the hearing could proceed in her absence if proper notice was given of the hearing.

9.    The Panel was satisfied that the Registrant was aware of the date, time, location and purpose of the meeting as required by the Rules. It was also satisfied that the HCPC had taken all reasonable steps to engage the Registrant in the proceedings. The email correspondence and documentation provided to the Panel by the Registrant demonstrated that she had not disengaged from the regulatory proceedings and offered an explanation for her absence. She did not request an adjournment of the hearing or to be represented at the hearing. The Panel was mindful that the Notice of Hearing confirmed that the hearing could proceed in the absence of the Registrant.  It also provided her with links to a variety of guidance documents, including those relating to adjournments and substantive review hearings.  

10.    The Registrant was, in the Panel’s view, maintaining limited engagement with her regulator.  There was no indication that she would attend the hearing on a future date in the event that the hearing was adjourned. 

11.    In considering fairness to the HCPC and the public when making its decision whether to proceed with the hearing or not, the Panel noted that the HCPC attended the hearing and was in a position to proceed. It considered that the steps taken by the HCPC to secure the Registrant’s attendance were reasonable in all the circumstances.     

12.    The Panel gave careful consideration to the prejudice that may be caused to the Registrant by the matter proceeding in her absence but was content that it could mitigate any disadvantage as much as possible. It was mindful of the practice note issued by the HCPTS in respect of ‘Unrepresented Registrants’ and the fact that registrants should not be able to frustrate the efficient administration of regulatory matters by simply not engaging in the proceedings.  

13.    In the circumstances, the Panel determined that the public interest favoured the proceedings continuing in the absence of the Registrant. The hearing had been convened to undertake a mandatory review of an order imposed following a substantive hearing. The HCPC was in attendance and ready to proceed with the matter while the Registrant was aware of the hearing, had contributed information to it and had not requested to be represented or sought an adjournment. The Panel was satisfied that the hearing could fairly proceed in the absence of the Registrant. 

Background

14.    The Registrant is an Occupational Therapist (‘OT’) who was employed as a Band 6 OT within the rapid response team at Virgin Care between 23 March 2020 and 4 December 2020. 

15.    On 29 July 2020, the Registrant attended Service User 1’s home address to perform a functional assessment at the request of Social Services. Upon arrival, the Registrant found Service User 1 unwell and bleeding heavily from her lower body. The Registrant cleaned Service User 1, changed the blood-soaked bed mats and informed Social Services of  Service User 1’s condition. She did not seek medical attention for Service User 1. Carers later attended Service User 1 and found her in a very poor condition. They called the emergency services and paramedics transported Service User 1 to hospital. 

16.    Service User 1’s daughter complained to Virgin Care about the care provided to her mother by the Registrant. An investigation was undertaken and Virgin Care made a fitness to practise referral about the Registrant to the HCPC on 5 August 2020. 

17.    On 19 October 2021, a panel of the HCPC’s Investigating Committee found that there was a case for the Registrant to answer and referred the matter to the Conduct and Competence Committee. The Substantive Hearing took place between 17 and 21 July 2023. It found all the particulars of the Allegation and the ground of misconduct proved, and determined that the Registrant’s fitness to practice was impaired. It imposed a Suspension Order for a period of 12 months. 

18.    The substantive hearing panel determined that the misconduct was remediable but that there was a high risk of repetition due to the extremely limited evidence of insight or remediation by the Registrant. It noted that the incident was an isolated incident on 29 July 2020 during the Covid 19 pandemic but that the Registrant’s reflections related primarily to the impact of the situation upon herself rather than the safety of service users. Further, the Registrant: 

a.    had completed some online learning in relation to first aid, safeguarding vulnerable adults and emergency resuscitation; 
b.    had not acknowledged that there was a delay in Service User 1 receiving medical assessment and / or treatment; 
c.    did not appear to accept that her conduct fell below professional standards; 
d.    showed no understanding of the potential consequences of her actions on Service User 1;
e.    had been less than open and honest in her account to the panel which was not in accordance with the duty of candour required of health care professionals; and
f.    breached fundamental tenets of the OT profession and failed to acknowledge the impact of her conduct upon the wider reputation of the profession.

19.    The panel decided that the appropriate and proportionate sanction was a 12-month Suspension Order.

20.    The substantive Suspension Order was reviewed prior to expiry on 12 August 2024 in the presence of the Registrant, who was represented and gave evidence to the Panel that she accepted:

a.    the original panel’s finding that as a healthcare professional, she should have acted upon the blood loss she had observed by either calling immediately for an ambulance or by contacting a colleague for advice
b.    that she owed a duty of care to Service User 1; 
c.    she had not recognised that there had been a need for medical assessment and / or treatment in the circumstances she had faced on 29 July 2020; 
d.    she had not provided adequate care; 
e.    her actions had caused a delay in Service User 1 receiving the medical treatment which she required; 
f.    her actions would also have impacted upon Service User 1’s family;
g.    her clinical notes had been inadequate and incomplete and that she had not recorded any clinical reasoning; and
h.    her behaviour had fallen below the standards required of an occupational therapist.

21.    The Registrant provided written reflections to the first reviewing panel and explained that she had learned a lot and in future would respond properly and effectively to medical emergencies to ensure that no harm would come to a patient. She explained the steps she would take to prevent a similar situation occurring in future including: 

a.    having the contact details of a number of more senior colleagues so that she could contact them for advice should she need it; 
b.    recording every piece of information in the patient’s case notes so that there would be no doubts about what she had or had not done; and
c.    applying the SOAP (Subjective, Objective, Assessment, Plan) approach to case notes. 

22.    The Registrant also described working with colleagues in a rehabilitation setting towards a service user’s discharge and working with carers. 

23.    The first reviewing panel was satisfied that the Registrant had demonstrated some progress in her level of insight and replaced the Suspension Order with Conditions of Practice for a period of 12 months. 

24.    The second review took place on 13 August 2025 in the absence of the Registrant due to illness. The Registrant supplied the second reviewing panel with evidence of training and reflection, however it found that the Registrant remained impaired on the personal and professional components of impairment. It recognised that the Registrant had “made progress” since the last hearing and demonstrated genuine remorse and regret however her reflections “lacked depth and were basic in nature”. Further, whilst the Registrant had undertaken training, it appeared to be mandatory and not targeted to the specific failings identified by the substantive panel. It concluded that the risk of repetition remained and thus posed a risk to service users and could undermine public confidence in the regulator if a finding of impairment was not made. The second reviewing panel extended the Conditions of Practice order for a further period of 12 months. It declined the Registrant’s request to remove the prohibition on her working as a locum and provided guidance as to the steps that the Registrant could take to assist a future reviewing panel. 

Submissions

25.    The Presenting Officer reminded the Panel of the background to the regulatory concerns and referred the Panel to the HCPTS Practice Note on the Review of Article 30 Sanction Orders. She submitted that the question for the Panel is whether the Registrant’s fitness to practice remains impaired and, if so, whether the existing order remains appropriate. 

26.    The Presenting Officer submitted that the Registrant had provided insufficient evidence to discharge the persuasive burden upon her to demonstrate that her fitness to practise is no longer impaired. She submitted that the Registrant has not evidenced sufficient development in her insight since the last review and that there therefore remained a clear risk of repetition of the misconduct.  

27.    The Presenting Officer invited the Panel to consider whether public confidence in the profession and in the regulatory process would be undermined if a finding of impairment were not made, and submitted that the Registrant’s fitness to practise remains impaired on both personal and public interest grounds. 

28.    The full range of sanctions are available to the Panel, in the Presenting Officer’s submission. She referred the Panel to the HCPC’s Sanctions Policy and submitted that, given the failure by the Registrant to demonstrate evolving insight, a Suspension Order is the most appropriate and proportionate sanction. The Registrant had been afforded opportunities to address the failings identified by the Substantive Panel by the first and second reviewing panels but had not taken advantage of them. The Presenting Officer submitted that a Suspension Order is necessary and proportionate in the circumstances to protect the public and maintain confidence in the profession given that little had changed since the substantive hearing and there appeared to be an “emerging pattern” of the Registrant failing to attend the hearings. This was, in the Presenting Officer’s submission, significant as it denied the Panel the opportunity to ask questions of the Registrant. Further, she noted that there was no evidence before the Panel as to the Registrant’s plan for returning to her profession. A Suspension Order for a period of 12 months would, in the Presenting Officer’s submission, give the Registrant an opportunity to develop insight into the concerns outlined by the Substantive Panel. 

Decision    

29.    The Panel noted, accepted and applied the advice of the Legal Assessor and had careful regard to the documentation and submissions it received. It also had regard to the practice notes issued by the HCPTS and the HCPC’s Sanctions Policy. It was mindful that the purpose of the review was not to go behind the findings of previous panels but to determine whether the Registrant’s fitness to practise remains impaired, and if so, to determine what action would be appropriate to address that impairment. The key issue for the Panel to determine is what, if anything, has changed since the current order was imposed.  The factors to be taken into account include: 

a.    the steps which the Registrant has taken to address any specific failings or other issues identified in the previous decision;
b.    the degree of insight shown and whether this has changed;
c.    the steps which the Registrant has taken to maintain or improve her professional knowledge and skills; 
d.    whether any other fitness to practise issues have arisen; 

30.    The Panel must consider whether the concerns which led to a finding of impairment at a hearing in July 2023 remain. As the decision in Abrahaem v GMC [2008] EWHC 183 (Admin) indicates, in practical terms this places a “persuasive burden” on the Registrant to demonstrate that she has fully acknowledged the issues which led to the original finding and has addressed them sufficiently “through insight, application, education, supervision or other achievement...”.

31.    The Panel reminded itself that when reviewing sanctions under Article 30 of the Order, the Reviewing Panel may:

a.    confirm the order; 
b.    extend, or further extend, the duration of the order;  
c.    reduce the duration of the order; 
d.    replace the order with any other order which the Panel could have made (to run for the remaining term of the original order); or 
e.    revoke the order or revoke or vary any condition imposed by it.

32.    The decision reached by the Panel must be proportionate, striking a fair balance between interfering with the Registrant’s ability to practise and the overarching objective of public protection. In determining whether fitness to practise is currently impaired, panels must take account of a range of issues which, in essence, comprise two components: 

a.    the ‘personal’ component: the current competence, behaviour etc. of the individual registrant; and 
b.    the ‘public’ component: the need to protect service users, declare and uphold professional standards and maintain public confidence in the profession. 
The personal component includes the risk of repetition and to what extent any misconduct has been remedied. In respect of the public component the Panel has to consider public policy issues, which include the need to maintain confidence in the profession and to declare and uphold the HCPC standards of proficiency.

33.    Previous panels considering this matter had thoughtfully produced comprehensive determinations which the Panel accepted and endorsed. It was mindful that the Substantive Panel considered that the misconduct was remediable and encouraged the Registrant to provide information to assist a future reviewing panel. The first reviewing panel also provided guidance as to what may assist a future reviewing panel. The second reviewing panel suggested that the Panel would be assisted by: 

a.    “the attendance of the Registrant at the review hearing; 
b.    documentary evidence of the completion of any Continuing Professional Development undertaken and evidence of the application of that learning to future practise;
c.    a written reflective piece on the impact of the Registrant’s misconduct on Service User 1, Service User 1’s family, her own colleagues, her profession, and the wider public interest; 
d.    written, dated and signed testimonials/references regarding any employment undertaken by the Registrant.”

34.    The Panel was satisfied that, whilst the Registrant had provided evidence of training she had completed, these appeared to be courses which were required to be competed as part of an induction process, comprising across 20 and 21 April 2026:

a.    Violence Reduction Training Initial Course (January 2026);
b.    Complaints Handling; 
c.    Conflict Resolution;
d.    Countering Fraud Bribery and Corruption in the NHS;
e.    Equality, Diversity and Human Right;
f.    Fire Safety; 
g.    Food Hygiene; 
h.    Handling Medication & Avoiding Drug Errors - Level 2; 
i.    Health, Safety and Welfare; 
j.    Infection Prevention & Control inc COVID-19 Protocols Level 2; 
k.    Information Governance including Cyber Security;
l.    Lone Worker; 
m.    Moving and Handling Level 2; 
n.    Paediatric Basic Life Support; 
o.    Preventing Radicalisation; 
p.    Reducing Restraints in Health and Social Care; 
q.    Resuscitation: Adult Basic Life Support - incl safe use of AEDs; 
r.    RIDDOR;
s.    Safeguarding Adults at Risk (Level 2);
t.    Safeguarding Adults at Risk (Level 3);
u.    Safeguarding Children (Level 2);
v.    Safeguarding Children (Level 3)

35.    The Registrant supplied an updated reflective statement which confirmed that she currently works as a health care assistant at a “highly secure unit for patient with mental health issues”. Her duties include: 

a.    Taking patient out on section 17 leave and liaising with nurse in charge; 
b.    Working with detained and informal patients; 
c.    Ensuring patient are signed out in line with policy; 
d.    Facilitating escorted leave, unescorted leave and restricted leave; 
e.    Having access to section 17 leave folder and completing documentation;
f.    Ensuring that I am well versed in the care plan and risk assessment before my involvement with patients; 
g.    Liaising with police should a patient fail to return; 
h.    Participating on the ward using diverse forms of observation and therapeutic engagement method depending on the risk levels of a patient or the state of his/her mental health
i.    empathise with the patient which further involved active listening;
j.    Managing silence and responding to non-verbal cues;
k.    Supporting patient emotions and responses to acute mental health problems; 
l.    Providing 24-hour supervision of patients; and 
m.    documenting concise records after each observation and ensuring record keeping is kept up to date.

36.    The Registrant submitted in her first addendum bundle that “I assure you that the incident was a one-off occurrence in my fourteen years of unblemished practice and has been a significant learning experience. I am fully committed to upholding the highest standards of care and professionalism in my practice. Thank you for considering my reflections and the steps I have taken to improve my practice. I appreciate your time in reviewing my statement and considering the measures I have taken to improve my professional conduct. This experience has underscored the importance of continual learning and reflection in my practice as an Occupational Therapist. I am dedicated to applying these lessons to ensure the highest quality of care for my patients and to uphold the standards of our profession. I do understand that when those standards are not upheld, then the standing of the profession is damaged in the eyes of the public and trust in the HCPC is weakened. Thank you for your understanding”

37.    In her second addendum bundle the Registrant provided further evidence of training completed on 4 May 2026:

a.    Resuscitation: Neonatal Basic Life Support inc. Safe Use Of AEDs and Management Of Choking (Practical); 
b.    Resuscitation: Paediatric Basic Life Support inc. Safe Use Of AEDs and Management Of Choking (Practical); 
c.    Resuscitation: Adult Basic Life Support inc. Safe Use Of AEDs and Management Of Choking (Practical); 
d.    Moving and Handling Level 2 (Practical); 
e.    Manual Handling Practical Training
and confirmed she has been employed as a health care assistant since 11 August 2025, being unable to secure a substantive OT role due to the restrictions on her practice. She describes using transferrable skills in relation to “observation, clinical reasoning, risk identification, therapeutic communication, professional accountability, record keeping, and person-centred practice”. 

38.    The Panel observed that the Registrant’s reflective statement on the surface appeared to address some of the issues identified by the substantive panel however there was no in depth reflection, no testimonials supplied, or evidence of learning specific to those concerns being undertaken and applied by the Registrant. Additionally there were no specific examples given of how the Registrant had adapted, or would adapt, her practice to embed any learning.

39.    The Panel was satisfied that the Registrant had not yet fully remediated the identified concerns of the substantive and subsequent reviewing panels. It was mindful that the Registrant has repeatedly referenced being unwell, and was also conscious that she does not appear to have been represented in the proceedings since the first review hearing.  However, the Panel considered there to be insufficient evidence before it that the concerns identified by the previous panels have been wholly addressed. It was therefore satisfied that the Registrant remains impaired on both the personal and public aspect of impairment, and that because her insight and remediation are incomplete, there remains a risk of repetition of the misconduct. 

40.    The Panel therefore considered how to address the impairment, bearing in mind the Presenting Officer’s submission that the appropriate sanction in the circumstances is that of a Suspension Order for a period of 12 months. It carefully considered the provisions of the HCPTS Sanctions Policy and the relevant practice notes. It determined that taking no further action, mediation or imposing a caution would not be sufficient to protect the public or be in the public interest, as identified by previous panels. 

41.    The Panel considered it unfortunate that the Registrant was unable to attend the hearing as, had it been able to ask questions of her, it may have been able to satisfy itself that she had in fact improved her insight and therefore remediated her conduct. It was clear to the Panel that the Registrant was committed to her profession despite her personal challenges, but had not provided sufficient detail to enable it to consider the concerns fully remediated at this point. 

42.    The Panel noted the HCPC’s position in relation to the replacement of the Conditions of Practice order with a Suspension Order, but did not consider that the failure by the Registrant to provide the information set out by the previous reviewing panel to be sufficient to evidence a change in the risk profile which warranted the imposition of a Suspension Order. It considered that the Conditions of Practice remained sufficient to protect the public, and would still afford the Registrant a route to return to practice should she wish to do so. It determined that imposing a Suspension Order would be disproportionate in the light of the Registrant continuing to engage in the process and provide additional information, albeit not sufficient for the discharge of the original concerns identified. It noted that if the Registrant had the benefit of representation, it would be probable that she would be able to articulate her remediation to better assist the Panel. 

43.    The Panel was mindful that these proceedings relate to one serious incident in July 2020, and that the Registrant has not practiced her profession since January 2023. However, the regulatory proceedings would need to be concluded rather than extended indefinitely. A future reviewing panel would need to carefully balance the public interest in maintaining suitably qualified and experienced registered professionals on the Register against indefinitely perpetuating regulatory proceedings in the hope that a return to practise may be achieved. 

44.    Whilst mindful that these recommendations would not bind a future panel, the Panel strongly encourage the Registrant, if she wishes to return to her regulated profession, to:

a.    attend and comprehensively engage at any future review so that the Panel can explore, via questions, her insight and understanding; 
b.    undertake learning related to the concerns identified, in addition to any mandatory training undertaken in her employment, in particular record keeping (whether in a regulated role or otherwise); 
c.    evidence reflection on the knowledge gained by the Registrant from continuing professional development has been applied and / or would be applied in her future practice; 
d.    a formal reflective practice piece setting out the impact of her acts / omissions on:

i.    Service User 1; 
ii.    Service User 1’s family; 
iii.    the profession; 
iv.    the Regulation of the profession;
e.    a case study of how the Registrant has effectively worked in partnership with other health professionals.
f.    provide comprehensive and up to date references and / or testimonials from registered professionals who have worked with the Registrant, whether in a regulated role or otherwise, which specifically address the failings identified by the Substantive Panel, namely: 
i.    Record keeping; 
ii.    Working collaboratively with colleagues and other healthcare professionals;
iii.    Recognising risk; 
iv.    Clinical reasoning and risk assessment;
v.    Understanding the duty of candour.

The Registrar is directed to impose the following conditions upon the registration of Ms Eme S Ufomba for a period of 12 months. 

1.    You must not undertake employment with any locum agency or work as an independent sole practitioner.
2.    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 14 days of the Operative Date or the commencement of employment whichever is the later date. You must attend upon that supervisor as required and follow their advice and recommendations including, but not limited to, any further progress with your Personal Development Plan.
3.    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:

a.    Record keeping; 
b.    Working collaboratively with colleagues and other healthcare professionals
c.    Recognising risk; 
d.    Clinical reasoning and risk assessment 
e.    Understanding the duty of candour.

4.    Within three months of the Operative Date, you must forward a copy of your Personal Development Plan to the HCPC. 
5.    You must meet with your supervisor on a fortnightly basis to consider your progress towards achieving the aims of your Personal Development Plan. 
6.    You must allow your supervisor to provide information to the HCPC every three months from the date that you take up employment as an Occupational Therapist about your progress towards achieving the aims set out in your Personal Development Plan. 
7.    You must inform the HCPC within seven days if you take up employment as an Occupational Therapist and you must inform the HCPC within seven days if you cease employment as an Occupational Therapist.
8.    You must inform the HCPC within seven days if you take up any work requiring registration with a professional body outside the United Kingdom.
9.    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: 

a.    any patient safety incident you are involved in; 
b.    any investigation started against you; and
c.    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 prospective employer (at the time of your application).

The Order imposed today will apply from 18 August 2026.
This Order will be reviewed again before its expiry on 18 August 2027.  

Right of Appeal

You may appeal to the High Court in England and Wales against the Panel’s decision and the order it has made against you.
Under Articles 30(10) and 38 of the Health Professions Order 2001, any appeal must be made to the court not more than 28 days after the date when this notice is served on you.

History of Hearings for Eme S Ufomba