Tony Quane

Preliminary Matters:

Amendment

1.    On behalf of the HCPC Mr Slack applied to amend particular 1 of the Allegation, to correct the typographical error from ‘pocked’ to ‘pocket’. Ms Scrivens did not oppose the application. The Panel received advice from the Legal Assessor, which it accepted.

2.    The Panel granted the application, because the amendment would correct an obvious typographical error and there was no prejudice to the Registrant in making that amendment.

Privacy application 

3.    Ms Scrivens applied for parts of the hearing to be conducted in private insofar as they would concern aspects of the Registrant’s private life, namely health and family matters. Ms Scrivens asked for the entirety of the Registrant’s evidence to be given in private, because of the risk that he would refer to private matters, without identifying that he would be doing so for the purposes of the transcript. 

4.    Mr Slack did not oppose the application. The Panel received advice from the Legal Assessor, which it accepted. 

5.    The Panel decided to grant the application under rule 10(1)(a) of the HCPC (Conduct and Competence Committee) (Procedure) Rules 2003 in order to protect the private life of the Registrant. However, it decided not to make a direction as sought by Ms Scrivens, as the concern she identified related to evidence that would not be exclusively private in nature. If private matters were raised, these could be sufficiently addressed by a suitable direction to the transcriber given after the event should that be necessary, there being no members of the public present. Should a member of the public attend the hearing, the Panel would review the arrangements.

Background:

6.    On 11 February 2022, concerns were raised in relation to the Registrant’s handling of controlled drugs after a colleague witnessed vials or ampoules of Midazolam fall out of the Registrant’s coat, which was hanging up in the changing room at the hospital where he was working. A “dirty” (i.e used) needleless syringe was also subsequently found in the pocket of his jacket.

7.    An investigation was carried out by the Registrant’s employer, Transform Hospital Group Ltd. (‘Transform Hospital Group’), which included obtaining a statement from the Registrant and interviewing him. 

8.    During that investigation the Registrant accepted that he had put the ampoules of Midazolam in one of the pockets of his “theatre blues” having spotted them whilst re-stocking. The Registrant stated that he had been distracted by an urgent personal phone call, and he had decided to take these items home and to deal with them on his return to work. The Registrant acknowledged that Midazolam should be kept locked away.

9.    A written referral to the HCPC dated 30 March 2022 concerning those matters was made by Transform Hospital Group.  

Decision on Facts:

10.    After Mr Slack had opened the case, the Registrant was asked which of the particulars of the Amended Allegation he admitted or denied. 

11.    The Registrant admitted the HCPC’s factual case set out in particular 1. He made clear that he did so on the basis that he had in his pocket two vials or ampoules of Midazolam, without authorisation and also contrary to the correct procedure for handling, storing and disposing of controlled drugs. Particulars 2 and 3 of the Amended Allegation were denied.

12.    The Panel was satisfied that it was proper for it to accept the Registrant’s admission of particular 1 in view of responses to questions asked of him by the Legal Assessor (with the permission of Ms Scrivens). Those responses showed that the admission was unequivocal and that the Registrant understood both the amended Allegation and the potential implications of making the admission. The Registrant’s answers showed that he had made the admission because he genuinely accepted the truth of the facts alleged in particular 1, and not for expediency or for some other inappropriate reason.

13.    Having received advice from the Legal Assessor which the Panel accepted, the Chair announced its decision to accept the admission and its further decision that particular 1 of the Amended Allegation was proved by admission.

Decisions on the Admission of Evidence:

14.    Mr Slack applied for two witness statements to be admitted into evidence from the following witnesses –

•    AA (Operating Department Practitioner) dated 19 October 2023;

•    JD (former Human Resources Manager of Transform Hospital Group) dated 29 July 2024.

15.    In the light of the admission made by the Registrant to particular 1, Mr Slack did not propose to call either witness to give evidence, and Ms Scrivens did not seek to cross-examine either witness. Mr Slack also made a ‘hearsay application’ in respect of JD’s evidence as her evidence consisted of the production of documents generated by the internal investigation conducted by Transform Hospital Group, which had been conducted by another colleague. Mr Slack submitted that it would be fair for the hearsay evidence to be admitted and Ms Scrivens stated that she did not oppose the application. 

16.    Having received legal advice that it accepted, the Panel determined that it would be fair to admit the hearsay evidence. Its reasons for that decision were as follows. The hearsay evidence is relevant to particular 1 but is neither sole nor decisive as to its proof in view of the Registrant’s admissions and the facts announced as proved. Other aspects of the hearsay evidence are contextual and as such relevant to the issues of misconduct and current impairment (should the latter arise) and their admission into evidence had not been opposed by Ms Scrivens on behalf of the Registrant.

17.    In those circumstances, the Panel decided to receive both witness statements into evidence. The Panel considered that no questions from it of either witness were necessary in the circumstances.   

Decision on Grounds:

18.    The Panel considered the statutory ground of misconduct. 

19.    The Panel heard oral evidence from the Registrant on both misconduct and impairment, having indicated to the parties its decision to receive submissions and legal advice on misconduct first, and to hand down its decision on misconduct with reasons before proceeding further. 

20.    The Registrant’s oral evidence was based on his signed witness statement dated 17 April 2026. The Registrant was cross-examined on matters relating to current impairment. He also responded to questions from the Panel. 

21.    The Panel then received submissions from Mr Slack on behalf of the HCPC and from Ms Scrivens on behalf of the Registrant. The Panel retired in the afternoon of the first day of the hearing to make its decision on statutory grounds having received advice from the Legal Assessor. 

22.    Mr Slack submitted that the facts admitted and found proved constituted statutory misconduct in view of what he submitted to have been the resulting breaches of relevant professional standards, breaches which he submitted to be of sufficient seriousness as to establish the statutory ground. He referred the Panel to HCPC Standards of conduct, performance and ethics 6.1 and 9.1 and HCPC Standards of proficiency for Operating Department Practitioners 15.1 and 15.3 (which were relevant at the time). 

23.    Ms Scrivens referred to the admissions made by the Registrant almost immediately following the events the subject of particular 1. She submitted that there had never been an intention on the part of the Registrant to permanently remove the two vials or ampoules and he had done so in view of a number of extenuating distressing personal circumstances, notably a phone call that he had received concerning his daughter. That call had led to his inadvertent mishandling of the Midazolam, a one-off event that had not been repeated since. In those circumstances, Ms Scrivens submitted that the Registrant’s actions did not amount to statutory misconduct.  

24.    In making its decision on statutory grounds, the Panel took into account all the evidence before it, including the facts proved by the Registrant’s admissions. The Panel also bore in mind all the submissions made on behalf of each party and the advice from the Legal Assessor, which it accepted.

25.    The circumstances of the Registrant’s conduct were not in dispute. They were as follows. On 9 January 2022, the Registrant was working as an Operating Department Practitioner at Burcot Hall Hospital employed by Transform Hospital Group. He had worked there since 2006. Towards the end of the working day on 9 February 2022, the Registrant checked the anaesthetic trolley to ensure that there was sufficient stock for the operating theatre for the next day. He noticed that there were two loose ampoules of Midazolam, which is used for sedation to calm children and nervous adults before they come to the operating theatre. Midazolam is a controlled drug as specified by the Misuse of Drugs Act 1971, Schedule 2, Part 3.  

26.    The Registrant picked up the ampoules and put them in one of the pockets of his “theatre blues” with the intention of putting them in the drug cupboard. However not long afterwards, he received a phone call from his daughter who was crying hysterically. The Registrant felt extremely concerned for his daughter’s wellbeing. 

27.    In his haste to see his daughter that day and feeling very stressed, the Registrant did not lock the two ampoules in the drug cupboard but put them in one of the pockets of his coat and took them home, intending to put them in the drug cupboard during his next shift, which was on 11 February 2022. He put the ampoules into his coat pocket with a used (needleless) syringe that he had also seen and collected when tidying up for the day, intending to put it into a sharps bin but omitting to do so.

28.    On his return to work on 11 February 2022, the Registrant did not secure the ampoules (and dispose of the syringe) because he was in a rush not to be late, as his time - keeping was being monitored at the time. At approximately 14:00 hours that day, AA, a colleague of the Registrant working as an Operating Department Practitioner, went into the male changing rooms to obtain his wallet to pay for his lunch. He inadvertently brushed past the Registrant’s coat and the two ampoules, which were labelled as Midazolam, fell out of one of the pockets. AA picked up the ampoules, took a photograph of them, and left the ampoules with a note in the office of the Theatre Manager, MS.

29.    MS investigated the matter later that afternoon. He went to the changing room and searched the Registrant’s coat where he found the syringe. He took the matter up with the Registrant that day, interviewing him with a colleague. The Registrant initially asked how they knew it was his coat before admitting that the ampoules had been in his coat.     

30.    Such were the circumstances in which the Registrant came to have the two ampoules of Midazolam in his pocket. He did not seek or obtain authorisation from his employer to deal with the two ampoules as he did. Further, in failing promptly to secure the ampoules in the drug cupboard and taking them off the hospital premises to his home, the Registrant acted in breach of his employer’s written procedure contained in Transform Hospital Group’s Controlled Drug Policy and Standard Operating Procedures. Paragraph 7.5 of that procedure required that, ‘CDs must be stored in a locked cupboard that is permanently fixed to the wall or floor’. The Registrant knew at the time that the procedures required him to put the ampoules in the drugs cupboard and not to take them home. 

31.    A definition of misconduct was given in the case of Roylance v GMC [2000] 1AC 311, PC where Lord Clyde stated at p. 330, - 

‘Misconduct is 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. The misconduct is qualified in two respects. First, it is qualified by the word ‘professional’ which links the conduct to the profession of medicine. Secondly, the misconduct is qualified by the word ‘serious’. It is not any professional misconduct which will qualify. The professional misconduct must be serious …..’

As to the necessary element of seriousness, in Nandi v GMC [2004] EWHC 2317 (Admin) Collins J. stated, -

‘The adjective "serious” must be given its proper weight, and in other contexts there has been reference to conduct which would be regarded as deplorable by fellow practitioners.’

32.    Although the circumstances of the conduct may be taken into account, matters of personal mitigation are not relevant at this stage: see R (Campbell) v GMC [2005] 1 WLR 3488, CA at [46] where Judge LJ giving the judgment of the Court of Appeal stated, -

‘(3) … [fitness to practise committees] can, if they think it right to do, consider the circumstances in which the practitioner found himself when committing the relevant misconduct, they should always be alert to the possibility that such circumstances may be more properly relevant to the question of penalty rather than to the question whether the professional misconduct was serious; in particular committees should not use personal mitigation to downgrade what would otherwise amount to serious professional misconduct to some lesser form of misconduct.’

33.    In assessing the question of misconduct, the Panel first considered the professional standards in place at the time. The HCPC’s Standards of conduct, performance and ethics stated as follows: -  

‘6. Manage Risk

Identify and Manage Risk

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. Be honest and trustworthy

Personal and professional behaviour

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

34.    The Panel considered that in view of the circumstances in which the Registrant engaged in the conduct set out in particular 1 of the Allegation, the Registrant failed to comply with each of standards 6.1 and 6.2. By failing to place the ampoules of Midazolam, a controlled drug, in a locked hospital drug cupboard and, instead, taking them home and then leaving them in his coat, the Registrant failed to reduce the risk of harm to service users. The service users are those members of the public who could have accessed the Midazolam because it had been left unsecured. The Panel noted that the two ampoules contained a total of 20 mg of Midazolam which is a significant amount of sedative. 

35.    In doing so, the Registrant placed service users at unacceptable risk of harm. The Panel also considered that the Registrant’s actions exposed colleagues to the risk of investigation and resulting blame for misplacing or misappropriating controlled drugs.

36.    The Panel did not consider ‘the extenuating circumstances’ relied on by Ms Scrivens to have justified the risk that the Registrant created by his actions for the purposes of either standards 6.1 or 6.2.      

37.    The Panel also decided that the Registrant’s actions amount to a failure to comply with standard 9.1, being conduct that breached the public’s trust and confidence in the Registrant and his profession. Members of the public and colleagues would expect the Registrant, who occupied a trusted position to handle controlled drugs properly, to comply with the handling and storage requirements for controlled drugs used for the purpose of his profession. That he did not do so constituted a breach of the trust and confidence reposed in him and his profession.                  

38.    The HCPC’s Standards of proficiency for Operating Department Practitioners applicable at the time stated as follows: - 

15 understand the need to establish and maintain a safe practice environment 

15.1 - understand the need to maintain the safety of both service users and those involved in their care

15.3 - be aware of applicable health and safety legislation, and any relevant safety policies and procedures in force in the workplace, such as incident reporting, and be able to act in accordance with these.   

39.    The Panel decided that paragraph 15.1 did not apply, because the Panel was satisfied that the Registrant did understand the requirements in question. However, in the Panel’s view the Registrant did fail to comply with paragraph 15.3 in view of his inability at the time to observe his employer’s safety procedure as set out in paragraph 7.5 of the Controlled Drug Policy and Standard Operating Procedures of Transform Hospital Group.

40.    In assessing the seriousness of the Registrant’s conduct and in particular his departures from those professional standards, the Panel has given little weight at this stage to the extenuating circumstances relied on by Ms Scrivens on his behalf as they amount to matters of personal mitigation. 

41.    The Panel has concluded that by his actions in mishandling and failing to the secure the two ampoules of Midazolam, the Registrant broke the trust and confidence placed in him as a registered Operating Department Practitioner to handle and store controlled drugs safely and in compliance with his employer’s procedures and professional standards. Those actions brought the profession into disrepute and exposed colleagues and members of the public to unacceptable risk. 

42.    The Panel has concluded that in all the circumstances the Registrant’s failures to comply with the professional standards would be regarded by fellow practitioners as deplorable and that his actions in respect of the facts proved under particular 1 of the Allegation were serious and fell far short of what was proper in the circumstances. 

43.    Therefore, the statutory ground of misconduct has been established.       

Decision on Impairment: 

44.    Following the announcement of the Panel’s decision on misconduct, the parties were provided with its written reasons for that decision. The Panel then heard submissions on behalf of the parties on the issue of current impairment.

45.    On behalf of the HCPC Mr Slack referred the Panel to the guidance set out in the Practice Note, Fitness to Practise Impairment, August 2025 (‘the Practice Note’) and to case law. He submitted that in view of the Panel’s decision on misconduct, the Registrant had placed service users at risk, had brought the profession into disrepute and had breached one of the fundamental tenets of the profession. He also referred to the admissions made by the Registrant and to his lengthy reflections. Mr Slack informed the Panel that the HCPC remained neutral on the issue of current impairment.

46.    For the Registrant, Ms Scrivens referred to relevant case law and reminded the Panel that not all misconduct results in impaired fitness to practise. She submitted that the Registrant had admitted his conduct from the outset and had reflected and accepted that it was wrong. He had learned from his error of judgment. There had been no repetition of the misconduct in the period of four years since. Ms Scrivens drew attention to the testimonial evidence from his line manager (among others) who had attested to his good practice in all areas. 

47.    Ms Scrivens referred also to testimonials from senior members of the medical profession who have been working with the Registrant. Their testimonials praised his professional abilities and reliability as a practitioner, observing protocols and guidelines making patient safety his priority. Ms Scrivens also referred to the many positive reviews of his work from patients which had earned him the nickname with colleagues “5 star Tony”. The interim conditions of practice order imposed on 12 August 2022 had been revoked on 10 May 2023 and there were no longer any public protection issues arising from the misconduct, she submitted. Ms Scrivens informed the Panel that the Registrant had 25 years of post-qualification experience and with the exception of the events of this case has an unblemished fitness to practise and disciplinary record. Ms Scrivens submitted that the Registrant understood the effect his actions had on the reputation of the profession and on public confidence in it. She submitted that the Registrant’s fitness to practise is not impaired.     

48.    The Panel heard advice from the Legal Assessor, which it accepted.

49.    In its decision-making the Panel has taken into account the guidance set out in the Practice Note and passages from the judgment in CHRE v NMC & Grant [2011] EWHC 927 (Admin) at [66] – [76]. 

50.    The Panel first considered the ‘personal’ component of the Practice Note as set out in paragraphs 25 – 31 of the Practice Note, in order to form a view about the Registrant’s current fitness to practise. The key considerations are the following: -

a)    Are the acts remediable?
b)    Has the Registrant taken remedial action?
c)    Are those acts likely to be repeated?

51.    The Panel considered that the misconduct was in principle capable of remediation. This could be achieved by a careful reading of necessary policies and procedures for the handling and storage of controlled drugs and by addressing the mental health issues and poor decision-making that the Panel considers lay behind the misconduct. This is not a case that involves serious attitudinal or behavioural issues, which may be more difficult to remediate. 

52.    The Registrant has shown substantial insight. From the outset during his former employer’s investigation, he admitted his conduct and accepted that he should not have acted as he did. In his evidence to the Panel and his written reflections, the Registrant acknowledged that what he did was ‘fundamentally wrong’ and expressed his ‘bitter regret’ for what he did. He accepted that his behaviour was a breach of the workplace procedures and that his conduct fell below the professional standards required of him.

53.    In those reflections and his evidence to the Panel, the Registrant has shown that he understands how and why the misconduct occurred. In his reflections dated 20 April 2026, the Registrant stated: -

‘Regarding my personal circumstances … I have learnt one major lesson and that is to always seek help if I need it. I would always go to my GP if I feel that is needed. I would also seek help from other sources such has [S]pectrum which is provided by [Enhance Medical Group, the Registrant’s current employer] for it’s staff’s welfare. I recently suffered a bereavement whilst I was at work and received a lot of support from the management offering me contact details for spectrum and allowing me as time has I needed to deal with it. It is an on going issue that I know I can handle with the support of others and importantly the love and support of my family who are the most important part of my life.’ 

54.    These reflections are important, because they address what the Panel considers were the root causes of the misconduct. At the time, the Registrant was experiencing great personal stress. The Registrant also described, in both his oral and written evidence, how at the time he could not speak to his wife or to anyone at work about important aspects of the stresses he was experiencing. 

55.    As a result, the Panel considers that the Registrant was overwhelmed when he took the phone call from his daughter on 9 February 2022. As a result of being overwhelmed from the phone call, the Panel considers that the Registrant made what was an error of judgment in not placing the two ampoules in a locked drugs cupboard but taking them home instead. 

56.    The Registrant has, to the Panel’s satisfaction addressed the root cause of the misconduct. He explained in his oral evidence that at the time of this incident he had tended to hide his difficulties or push things into the background, thinking he could control them himself. He now realises that the best thing to do is to tell people and as evidenced above, in the case of a recent bereavement, he now has the support network he needs, to ensure that he manages stress appropriately so that the misconduct is not repeated.  

57.    In his evidence, the Registrant showed that he understood the harm to public confidence in the profession resulting from his misconduct. In his witness statement the Registrant stated “I also realise the seriousness of me taking the drugs out of the building particularly if they then fell into the hands of a third party”. He also showed in his evidence his understanding that trust is essential to working effectively with colleagues, that he had let them down by what he had done, and that letting people down impacts negatively on the reputation of the profession. 

58.    The Panel has paid particular regard to the contents of the two written testimonials dated 17 April 2026 from his current line manager and from the Director of Governance and Compliance of Enhance Medical Group. The Panel accepts that the Registrant has been complying with the policies and procedures for controlled drugs of Enhance Medical Group, for whom he has worked as an Operating Department Practitioner since 25 April 2022 and to whom he made a prompt disclosure of the allegations made against him in this case. 

59.    In considering the adequacy of the Registrant’s remediation of the misconduct, the Panel has also taken into account the high standard of his work as an Operating Department Practitioner for Enhance Medical Group since April 2022, as evidenced by the testimonials. 

60.    The Panel noted the Registrant’s evidence that he was previously subject to an interim conditions of practice order imposed in August 2022. This was imposed on all three of the statutory grounds, required supervision of the Registrant’s work and required that the Registrant engage with his GP or other relevant medical practitioner. The Panel noted that the interim order was revoked on 10 May 2023 at a hearing which considered reports from the Registrant’s managers and his GP. Revocation of the interim order indicates that the Registrant was considered to no longer pose a risk to service users, colleagues or other members of the public. 

61.    There has been no repetition of the misconduct since revocation of the interim order and none since 11 February 2022. The Panel accepts that this was an isolated incident in the Registrant’s career of approximately 25 years as an Operating Department Practitioner.  

62.    In his evidence to the Panel, the Registrant stated that he understands that it is a privilege to work as an Operating Department Practitioner and that he wishes to work for his current employer until retirement. The Panel also noted the Registrant’s commitment to sound practice, as expressed in his reflections of 9 February 2025, namely –

‘I will work incredibly hard to maintain my good conduct. I am aware of what you expect of me has an ODP …. I am working in a place where I am respected [by] my colleagues including fellow ODP’s nurses, anaesthetist and surgeon’s. I will turn 60 on the 3rd March and see myself ending my career where I am. I would finally like to say this was a very wrong thing I did but was a one-off incident in an otherwise good career.’

63.    The Panel has concluded that in all these circumstances, the Registrant has shown insight, taken remedial action and there is a very low risk of him repeating the misconduct.

64.    For those reasons, the Panel has decided that the Registrant’s fitness to practise is not impaired by reference to the personal component.

65.    The Panel next considered whether or not the Registrant’s fitness to practise is impaired by reference to ‘the public component.’ The Practice Note provides the following guidance, -

‘32…, Panels must consider the three elements of the public component. The first element of the public component - the need to protect service users - overlaps with the personal component. A registrant who has insight and is unlikely to repeat past acts or omissions may not present an ongoing/ future risk to service users. 

33.The other two elements of the public component are maintaining professional standards and public confidence in the profession concerned. The HCPC has set out the standards it expects of registrants and panels should refer to those Standards and the importance of upholding them at the impairment decision-making stage. Panels should consider the need for the public to have confidence in the registrants who treat them. The public is entitled to expect registrants to be professionally competent and act with decency, honesty and integrity. The public should also be able to rely on the regulatory process to be robust, fair and transparent. 

34.The key question to be answered here is, given the nature of the allegation and the facts found proved, would public confidence in the profession and how it is regulated be undermined if there were to be no finding of impairment?’   

66.    As to the first element of the public component, the Panel has concluded that the Registrant has insight and is unlikely to repeat the misconduct and does not present an ongoing or future risk to service users.

67.    In order to make the required assessment of the other two elements of the public component, it is necessary to give due weight to the seriousness of the misconduct.

68.    The Panel refers to, and repeats, its findings on misconduct. It has borne in mind that the Registrant’s misconduct was a serious departure from expected professional conduct and standards. By taking the ampoules of Midazolam off the hospital premises instead of securing them there in a locked drugs cupboard, the Registrant created a risk to service users for nearly two days. The ampoules could have fallen from his coat anywhere, exposing members of the public to a risk of harm. As the Registrant himself put it in his oral evidence, Midazolam can cause harm if it is not handled correctly. 

69.    The Registrant’s misconduct also caused a potential risk to the delivery of safe and effective care had there been a shortage of Midazolam at the hospital on 10 February 2022, i.e. the day after he took the drugs home, due to his failure to lock the ampoules in a hospital drugs cupboard.

70.    Accordingly, the Registrant did place service users at unwarranted risk of harm.

71.    By mishandling the Midazolam, the Registrant also breached the trust and confidence placed in him as an Operating Department Practitioner and as a result he brought the profession into disrepute. The Panel considers that this conduct created a significant adverse impact on public confidence in the profession. 

72.    In reaching its conclusions on the public component of impairment, the Panel has assessed the seriousness of the misconduct measured against the need to maintain public confidence in the profession and to uphold professional standards.

73.    Even though the risk of a repetition of the misconduct is low and despite all the matters submitted by Ms Scrivens on behalf of the Registrant, the Panel has concluded that the Registrant’s breach of the trust and confidence placed in him as a practitioner and the unwarranted risk of harm to which he exposed members of the public require a finding of current impaired fitness to practise by reference to the public component.

74.    In those circumstances, a finding of impaired fitness to practise is necessary to maintain public confidence in the profession and its regulation. Such a finding is also required to uphold professional standards and thereby provide a deterrent effect to other members of the profession who might consider it acceptable to act as the Registrant did.

75.    For those reasons, the Panel has concluded that the Registrant’s fitness to practise is currently impaired on the public component.

Decision on Sanction:

76.    The Panel received no further evidence at this stage of the hearing. The Panel received oral submissions from Mr Slack on behalf of the HCPC and Ms Scrivens on behalf of the Registrant. 

77.    Mr Slack based his submissions on the HCPC Sanctions Policy, 2 March 2026 (‘the Sanctions Policy’). He submitted that there were no aggravating factors and that there were mitigating factors which he would leave to Ms Scrivens to place before the Panel. Mr Slack advocated no particular sanction. 

78.    Ms Scrivens submitted that there are no aggravating factors but numerous mitigating factors. This had been a one-off incident in 25 years of registered practice which had been brought about by a unique set of circumstances, involving a family emergency. There had been no intention of the Registrant to permanently deprive his employers of the ampoules of Midazolam, no patient had been put at risk and no harm arose from incident. The Registrant had apologised at the time to his employer and has apologised since on numerous occasions in these proceedings, and before the Panel. Ms Scrivens submitted that the Registrant had been honest and transparent from the outset and had reflected on his misconduct at the time and more recently. His insight was evident from his written reflections and from the evidence he gave to the Panel. The misconduct had been fully remediated and there has been no repetition of it.  Ms Scrivens submitted that the Registrant is managing his health much better than he did at the time. There were no deep-seated harmful or attitudinal problems. 

79.    Ms Scrivens submitted that the Registrant had been with his current employer since April 2022. The recent reports from his line manager and the Head of Governance and Compliance speak highly of him, particularly as to him being fully compliant with the employer’s own policies and with professional standards generally. There had been no previous regulatory or other proceedings against the Registrant. 

80.    Ms Scrivens submitted that a sanction of any kind would be disproportionate. The Registrant posed no risk to the public. A reasonably informed member of the profession would not be concerned to learn that the Registrant was practising unrestricted in view of the unique circumstances of this case.    

81.    In making its decision on the issue of sanction, the Panel has taken into account its findings in the case to this stage, the evidence so far as relevant to the issue of sanction, all the submissions for the parties and the advice given by the Legal Assessor at this stage, which it accepted.

82.    The Sanctions Policy identifies the purposes of sanctions as follows: 

‘13. The primary function of any sanction is to protect the public. This includes consideration of: 

•    any risks the registrant might pose to those who use or need their services; 
•    the deterrent effect on other registrants; 
•    public confidence in the profession …; and 
•    public confidence in the regulatory process.’

83.    In assessing the seriousness of the misconduct, the Panel is required to take into account and appropriately weigh the mitigating and aggravating features of the misconduct as set out in the relevant paragraphs of the Sanctions Policy. 

84.    The Panel considered the following to be mitigating factors in the case. The misconduct was an isolated act borne out of exceptional personal circumstances. The Registrant has shown good insight into his actions, has fully remediated them and the risk of repetition is low. The Registrant has expressed genuine and consistent remorse for his conduct during the investigation conducted by his then employer, during these proceedings and in his evidence to the Panel.             

85.    The Panel considered the following to be an aggravating factor in the case. The misconduct did create a risk of harm to service users. 

86.    The Panel approached the question of sanction by first considering the least restrictive outcome available.

87.    Despite the matters drawn to its attention by Ms Scrivens, the Panel considered the case to be too serious to justify ‘no action’. 

88.    Paragraph 145 of the Sanctions Policy states as follows: -

‘In any case in which the panel considers taking no action to be the appropriate and proportionate outcome, it must provide clear reasons to explain this decision. In particular, it must set out why it has concluded that there is no risk to the public, or to public confidence in the profession, in taking no action.’

89.    In view of its findings on misconduct and current impairment, the Panel considers that some action is required so as to maintain public confidence in the profession and to uphold professional standards.

90.    The Panel next considered a caution order, which may be from one to five years. The Sanctions Policy states the following, namely: -

‘147. 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. 

148. A caution order should be considered in cases where the nature of the allegations means that there is no risk to public protection that has to be addressed by a more restrictive sanction or that meaningful practice restrictions cannot be imposed, but a suspension order would be disproportionate.

…

150. The panel can impose a caution order for any period between one and five years. The panel should take the minimum action required to protect the public and public confidence in the profession, so should begin by considering whether or not a caution order of one year would be sufficient to achieve this. It should only consider imposing a caution order for a longer period where one year is insufficient.’

91.    In view of the findings it has made, the misconduct was ‘isolated’, the Registrant has shown good insight, has undertaken appropriate remediation and the risk of repetition is low. Therefore, this is a case where a caution may be appropriate.

92.    In reaching its decision on sanction, the Panel has considered whether conditions of practice would be an appropriate outcome. However, in view of the adequacy of the Registrant’s remediation and the low risk of repetition, conditions of practice (which are generally directed at practical remedial action) would not address the reasons for the impairment, which relate solely to the wider public interest. Therefore, conditions of practice would be both disproportionate as well as inappropriate.      

93.    In view of 148 of the Sanctions Policy and the unsuitability of conditions of practice, the Panel has considered whether a suspension order would be disproportionate. 

94.    The Panel notes that a suspension of a short period or even up to the maximum of 12 months may be necessary to maintain public confidence and uphold professional standards: see paragraphs 170 and 174 of the Sanctions Policy in particular.

95.    In measuring the overall seriousness of the misconduct, the Panel noted that this case, though serious for the reasons it has already stated, does not fall within the categories of the most ‘serious cases’ listed in paragraph 85 of the Sanctions Policy.

96.    The Registrant does bear culpability for the risks to service users and for the adverse impact of his actions on public confidence in the profession. While not excusing his misconduct at all, the Panel has also borne in mind that the Registrant’s actions were the product of an overwhelmed state of mind and a unique set of circumstances. The Registrant has worked hard to remediate his actions and has done so fully and effectively and re-established himself as a safe and effective practitioner.      

97.    The Panel also took into account that one aspect of the public interest is where a registrant can provide a useful public service to society as a competent practitioner. The many and fulsome references to the Registrant’s professional abilities provided by a variety of healthcare professionals attest to the good quality of the Registrant’s professional practice. 

98.    The Panel has borne in mind that matters of personal mitigation are of considerably less significance in regulatory proceedings, where the overarching concern is the protection of the public, than to a court imposing retributive justice. However, in assessing the proportionality of the sanction in particular, the Panel has given some weight to the fact that the Registrant is the sole breadwinner for his family. 

99.    In all those circumstances, the Panel has concluded that a caution order would be sufficient to mark the gravity of the misconduct. A suspension order, even of a short period, would be disproportionate.

100.    The conclusion of the Panel is that a caution order for a period of 12 months is sufficient to maintain public confidence in the profession and in the regulatory process, and to uphold and declare proper professional standards of conduct and behaviour, providing the necessary deterrent effect on other registrants. 

101.    The Panel did consider imposing a caution order for a longer period but concluded that a caution order for 12 months is sufficient to mark the gravity of the misconduct and satisfy the public interest in this case.

The Registrar is directed to impose a Caution Order for a period of 12 months on the registration of Mr Tony Quane

No notes available

History of Hearings for Tony Quane