Mark Pilmoor

Preliminary Matters

1.   At the outset of the hearing, the Chair confirmed that the Panel had been provided with the following documentation: 

i)   Service bundle consisting of 7 pages;

ii)  Case Summary consisting of 14 pages; 

iii) Registrant’s Hearing bundle consisting of 48 pages; and

iv)  Final Hearing bundle consisting of 81 pages.

Application for parts of the hearing to be heard in private

2.   Ms Girven, appearing on behalf of the HCPC, invited the Panel to conduct the parts of the hearing pertaining to the Registrant’s health and family life in private, in order to protect the Registrant’s right to a private life. 

3.   Mr Bealey, on behalf of the Registrant, confirmed that he supported the  application for parts of the hearing to be considered in private. 

4.   The Legal Assessor’s referred the Panel to the HCPTS Practice Note on ‘Conducting Hearings in Private’, which states that as a general rule hearings are to be in public in accordance with the ‘open justice’ principle.  The Panel was advised that, in certain circumstances, it is in the interests of justice for the hearing to take place wholly or partially in private to protect the private life of the Registrant where matters relating to health and / or private life are to be referred to. 

5.   The Panel considered the submissions made and accepted the legal advice received.

6.   The Panel was mindful of the principle of open justice but determined that any matters pertaining to the Registrant’s health and family life should be heard in private to maintain the Registrant’s right to a private life. The Panel therefore agreed that the hearing should be heard partly in private.

Admissions 

7.   Mr Bealey confirmed that the Registrant admitted Particulars 1, 2 b, 2 c, 3, 4 and 5. 

8.   Ms Girven asked the Panel to formally accept the admissions made by the Registrant.  

9.   The Panel heard and accepted legal advice. It had regard to the HCPTS Practice Note ‘Admissions’ dated January 2026.   

10.  The Panel noted that the Registrant had sent a notice to admit facts to the HCPC which was consistent with the admissions made. It was satisfied that the admissions made were supported by adequate evidence. The Panel was mindful that the Registrant was represented by Counsel and would have had the benefit of legal advice. It determined that the Registrant understood what it was that he was admitting, and that the admissions as to facts were unequivocal and unconditional.

11.  Accordingly, the Panel determined to accept the Registrant’s admissions and found the facts as set out in Particulars 1, 2 b, 2 c, 3, 4 and 5 proved by way of admission.  

Background

12.  The Registrant is a registered Chiropodist (CH13383).

13.  Service User A attended the York Foot Clinic (“the Clinic”) and was seen and treated by the Registrant on 24 February 2023, 21 April 2023 and 18 May 2023.  It is alleged by the HCPC that the Registrant did not maintain accurate records and/or complete records in relation to Service User A’s attendance at the Clinic at any of the three appointments.

14.  It is alleged that the Registrant did not document Service User A’s medical and/or medications history at the appointment on 24 February 2023 and also that he did not document Service User A’s medical concern or that he presented with an ingrowing toenail.

15.  It is also alleged that the Registrant failed to obtain Service User A’s consent before using a scalpel to treat him on 24 February 2023 and that, during that treatment, the Registrant caused an accidental incision to Service User A’s toe with the scalpel. The HCPC allege that the Registrant failed to document that accidental incision to Service User A and also did not document any appropriate worsening advice to Service User A as a result of that incision. 

16.  It is alleged that, following a complaint from Service User A on 9 June 2023, the Registrant responded by email on 16 June 2023 stating that Service User A came to see him on 24 February 2023 with a very sore ingrown toenail that he had treated conservatively on the day and advised that it would probably return due to damage to the nail bed. The Registrant stated that he did not cause the problem, and that Service User A had attended with the problem.  

17.  The HCPC allege that the Registrant’s actions when responding to the Registrant on 16 June 2023 were dishonest in that he sought to misrepresent the reason for Service User A’s initial appointment.

18.  On 22 June 2023 Service User A made a complaint about the Registrant to the HCPC by email.

Decision on Facts

The evidence

19.  The Panel heard live evidence from the following witnesses for the HCPC who gave evidence by video link: 

• Service User A – Complainant;

• VL – Witness; and

• Mr Benn Boshell – Expert Witness

20.  The Panel had sight of numerous documentary exhibits, records and emails as follows:

• Exhibits PN/01 to PN/06 referred to by Service User A;

• VL/01 referred to by VL;

• The Registrant’s records in relation to the appointments with Service User A on 24 February 2023 and 21 April 2023;

• Service User A’s GP records in relation to the appointments on 6 March 2023 and 11 May 2023; and

• Emails from the Registrant to the HCPC dated 10 September 2023, 18 October 2023, 17 November 2023 and 10 December 2023.

21.  The Panel heard from Service User A who gave evidence on affirmation.  Service User A adopted the evidence within his signed witness statement dated 28 July 2024, together with his exhibits PN/01 to PN/06 and provided the following additional oral evidence in response to questions put to him by Ms Girven:

• Paragraph 3 of his witness statement recorded the date for the first appointment at the Clinic as 24 February 2024.  The correct date of the first appointment was 24 February 2023;

• He had never seen a private chiropodist prior to that date;

• He had no pain, no in growing toenails and no issues with the nail to the toe in particular prior to that first appointment;

• The Registrant was very apologetic when he cut the side of the toe when trimming it. He felt very sorry for the Registrant, that it was an accident and that mistakes happen;

• Prior to the second appointment on 21 April 2023, the injury to his foot was not healing. He had tried bathing it in salt water, had taken advice from his GP that was not working  either, so he wanted a second opinion;

• When the Registrant said at that second appointment that the injury looked like a classic in growing toenail he was a bit shocked and did not know what to do about it. He had previously had no pain but was then in pain for the best part of a year.

• The appointment on 18 May 2023 was a free follow up and he thought the Registrant would offer to correct the issue for free.  He confirmed there was no problem before the Registrant cut his toe with the scalpel. It was not a recurring issue or anything he had done.

22.  In response to questions put to him by Mr Bealey, Service User A stated the following:

• He had not seen a chiropodist for over 10 years which was for insoles due to his arthritis. The previous appointment had not been with a private chiropodist.

• The appointment on 24 February 2023 was just a general appointment due to concerns with purple marks on his feet, like chilblains, bent toes and hard skin. He was with a health scheme at work which included a chiropody fee each year so booked in at the Clinic which was local to him.

• Prior to the photographs exhibited he had no previous photographs of his feet.

• He has immune suppressant injections so if he has an injury then it will not heal quickly. During the first appointment he had signed a form at reception to confirm what medication he took.

• During the treatment at that first appointment, the Registrant identified hard skin on the bottom of his feet and removed that, explaining as he went along. He also identified issues with his toenails and filed those, explaining what he was doing.  

• He said the Registrant did not explain what he was doing with the scalpel, he just used it to trim the nail back and the sides of the nail and cut him. He then said the Registrant must have explained what he was doing or he would not have let him carry on. He assumed it was standard procedure to cut the nail back.

• He disagreed with the suggestion that the Registrant had explained that he had the beginnings of ingrowing toenails and said that was false.

• He also disagreed that he was told he had an involuted toenail and confirmed that he had no pain altogether.

• When he left that first appointment he did not have any major concerns.  He said he felt quite sorry for the Registrant, that the Registrant was very apologetic and had not cut him on purpose.

• When it was suggested that the Registrant had not cut him, he responded by asking how he had received the injury to his toe.

• He acknowledged that he had not asked to see a different chiropodist at his second appointment but stated that it was a small clinic and it did not occur to him to ask for anyone else.

• He attended that second appointment as the wound was not healing and it was affecting his life. He trusted the Registrant to give him a second opinion but rejected the suggestion that this was due to nothing happening at the first appointment, stating “apart from he injured me”. [Sic]

• At the second appointment the Registrant trimmed his nails back, cleaned his toe and dressed it, then advised him that he would likely need nail surgery in the future.

• At the GP appointment on 11 May 2023, he confirmed that the Registrant had told him it was an ingrowing toenail and they agreed, confirming that nail surgery would be required and referred him to an NHS chiropodist who removed about a fifth of his nail.

• He could not explain why the GP notes from 11 May 2023 recorded him saying that he had an ingrowing toenail for a few months as he was only told of this during the second appointment with the Registrant on 21 April 2023.

• He rejected the suggestion that he had the start of an ingrowing toenail at the first appointment on 24 February 2023, saying that was completely untrue.

• He did not mention the cut to the Registrant during the second appointment as he assumed the Registrant was aware of it already and that it was obvious from the first appointment.

• He went to the third appointment on 18 May 2023 as it was offered free of charge. He had to pay for the second appointment. He was given similar advice on care and surgery that he had been given at the second appointment.

• He had surgery on 8 June 2023 which he thought had been arranged quickly due to a cancellation.

• He acknowledged that he first emailed the clinic to raise concerns on 9 June 2023 and that he reported the concerns to the HCPC on 22 June 2023, which was 4 months after the first appointment when the issue was caused. He confirmed that it took some time for the clinic to respond to his email dated 9 June 2023.

• When it was suggested that he attended the first appointment with initial signs of an ingrowing toenail he responded by saying that he completely disagreed.

• He said that it was extremely painful and if he had an ingrowing toenail he would have gone to his GP and not to a private chiropodist.

• When asked of the relevance of mentioning prices, he stated that he had received a terrible service and that, if he had caused a problem and could have rectified it, then he would have done so and not charged for that.

• When asked if that was the real reason for making the complaint, he detailed the impact the injury had on his life for approximately 8 months, including the physical pain, the financial impact and the impact on him personally and socially during that time.

23.  In response to re-examination questions put to him by Ms Girven, Service User A stated the following:

• The GP note dated 11 May 2023 include the history he gave to the nurse during that appointment.

• The email he sent to the HCPC on 22 June 2023 includes his recollection of his appointment with the Registrant on 21 April 2023.

24.  In response to questions put to him by the Panel, Service User A stated the following:

• At the first appointment with the Registrant on 24 February 2023 there was no discussion about an ingrowing toenail.

• He first discovered that he might have an ingrowing toenail at the second appointment with the Registrant on 21 April 2023.

• The reference in the GP notes to an ingrowing toenail was what he told the nurse in May after being advised of this by the Registrant. 

25.  The Panel heard from the witness VL who gave evidence on affirmation.  VL adopted the evidence within her signed witness statement dated 13 August 2024, together with her exhibit VL/01 and provided the following additional oral evidence in response to questions put to her by Mr Bealey:

• Service User A presented to her on 8 June 2023 with an ingrown toenail;

• Her notes relating to the surgery on Service User A on 8 June 2023 contained no reference to any cuts or injuries to the toe, or any cut to the side of the nail bed;

• When asked if it followed for there to be no record of a cut because there was no cut, she responded that the appointment on 8 June 2023 was for nail surgery following triage by the GP practice. In her clinical judgement, for her to proceed straight to surgery on the day Service User A was seen, then there must have been something going on, such as an infection, but she confirmed that they do not record that.

26.  Prior to hearing evidence from the expert witness, Mr Bealey, on behalf of the Registrant raised an issue in relation to the admissibility of paragraph 3.26 of the expert’s report dated 7 October 2024. He submitted that the paragraph provided a factual assessment of the evidence and that findings of fact are matters for the Panel only and not experts, who only provide their opinion on matters requiring their expertise.

27.  Ms Girven acknowledged that it was unclear from the paragraph within the expert’s report as to what evidence or documents he had considered in order to reach the conclusion and whether he had used his expertise in doing so. She submitted that the question of admissibility could be determined after the expert had provided oral evidence during which he could be given an opportunity to confirm how he came to the conclusion within the paragraph in question.

28.  The Legal Assessor advised that the approach suggested by Ms Girven appeared wholly sensible in that the Panel could consider the evidence of the expert witness in relation to what evidence, documents or expertise he relied upon to reach the conclusion concerned. She referred the Panel to the HCPTS Practice Note on ‘Evidence’ which confirmed that expert witnesses may give opinions on matters requiring specialist knowledge within their field of expertise. Therefore, if the Panel determined after hearing oral evidence that the conclusion was not based on evidence of an expert nature, the Panel could disregard it as part of the evidence.

29.  The Panel confirmed that it was content to hear the expert’s evidence first then make a decision in relation to the admissibility of his evidence after it had been concluded.

30.  The Panel then heard from the expert witness Mr Benn Boshell who gave evidence on affirmation. Mr Boshell adopted the evidence within his signed expert report dated 7 October 2024 and provided the following additional oral evidence in response to questions put to him:

• The clinical notes created by the Registrant in relation to Service User A’s attendance at the Clinic on 24 February 2023 and 21 April 2023 were difficult to decipher.  When shown copies of the notes, the expert witness attempted to provide his understanding of what the notes meant.

• He outlined what notes would be expected in relation to a patient attending for a general check-up, including details of the presenting complaint, the history of the problem, the pattern and any aggravating factors, any previous treatment that may have helped, the severity of problem, the pain scale and the type of pain.

• He would have expected a record of a patient’s consent from within the clinical notes when a scalpel was to be used during treatment as it was a sharp instrument and therefore there was an increased risk of accidental harm.

• The conclusion at paragraph 3.26 in his report was based on Service User A’s witness statement that he did not attend the Clinic with an ingrowing toenail but for some other medical advice. In the absence of any evidence of the patient having an ingrowing toenail during the initial treatment and that the Registrant caused a cut to Service User A which caused a wound that developed into an ingrowing toenail.

• He could not be certain on what basis he believed that the Registrant caused a cut to Service User A. He was initially uncertain if the information was from Service User A’s witness statement or an admission from the Registrant, but then confirmed that the information would have been from Service User A’s witness statement that the Registrant had cut his toe with a scalpel on 24 February 2023.

• He confirmed that on all occasions when Service User A attended the treatment the clinical notes were severely lacking in detail with no record of consent within the notes.

• His view in relation to the new patient treatment form, whilst including a list of the medication taken by Service User A, there was no record of any medical conditions, no medical history or any other relevant issues, such as allergies or previous surgical procedures.

31.  In response to cross-examination questions put to him by Mr Bealey, Mr Boshell stated the following:

• He was not suggesting that a scalpel was a totally inappropriate tool to use during treatment, but to use a scalpel required patient consent.

• He accepted that involuted toenails was a relative risk factor for developing ingrowing toenails and whilst not painful to a patient initially, an involuted toenail could go on to lead to an ingrowing toenail in the future.

• He accepted that a management method used to treat an ingrowing toenail was to cut down the nail and remove any sharp edges that might develop.

• He accepted that it was possible that an involuted toenail could develop into an ingrowing toenail within about 8 weeks to 2 months.

• He did not accept that a breach to the skin on the toe by the side of the nail would not lead to an ingrowing toenail. He stated that a breach to the skin could lead to an ingrowing toenail if the surrounding skin had been cut and the nail continued to grow whilst trapped under the skin.

32.  In response to a re-examination question put to him by Ms Girven, Mr Boshell confirmed that he was unable to provide an approximate figure of how many times an involuted toenail was a precursor to an ingrowing toenail.

33.  In response to a question put to him by the Panel, Mr Boshell stated that the medications listed by Service User A would give a practitioner some level of indication of the medical conditions he had, but the list would not provide the specific information about those conditions.

34.  Following the release of the Mr Boshell as an expert witness in this case, Ms Girven confirmed that the Panel should disregard the opinion that he provided within paragraph 3.26 of his report. She submitted that the HCPC’s position was still that the Registrant did cause a cut to Service User A, but the conclusion of the expert within his report as to whether there was a cut or not should be disregarded by the Panel.

35.  The Panel then heard evidence from the Registrant who gave evidence on oath. The Registrant adopted the evidence within his signed statement dated 16 September 2025 and provided the following additional oral evidence in response to questions put to him by Mr Bealey:

• He qualified in June 1997 and had always worked in the private sector.  He had been working at the York Foot Clinic for 3 years in 2023 as part of a partnership with 2 other podiatrists. 

• Appointments were booked through a receptionist in 2023 and the appointment would just appear on the booking system with a name and time, unless there was a specific complaint or reason for the booking, in which case he would be notified about it.

• He was first aware of Service User A on 24 February 2023 through the booking system. He was not made aware of any specific reason for the booking. He believed it was just a regular appointment.

• Service User A would have completed the consent form when he attended reception for the appointment and confirmed any medication he was taking on that form. When Service User A came into the clinic, he would have handed him the form at the start of the appointment. He would have asked Service User A about any underlying concerns and if he had seen a podiatrist before. He believed this was Service User As first appointment privately.  

• The medications listed on the consent form would have indicated nothing unduly to him. It was pain medication for arthritic problems that Service User A mentioned and he also said his medication slightly compromised his immune system.  He confirmed he made a note of this, mentally, and that Service User A seemed calm and relaxed.

• His usual procedure then was to look at a patient’s feet, take an overview and a note of any changes, make various checks and see what needed to be done. He acknowledged that his notes from 24 February 2023 were “not great” but translated his abbreviated notes and confirmed how Service User A’s feet presented during the appointment and the treatment given, which included callous reduction, drilling, both first toes cleared and advice given in relation to warming his feet.

• He explained what an involuted toenail is, that it is not always painful, that the nail is curved on both sides and that, if left it can become an ingrowing toenail as it can penetrate the flesh. He stated that this was evident with Service User A, that this was a very common problem and these things usually get worse unless they are kept on top of.

• He explained that his procedure for clearing or treating involuted nails would depend on how tight they are. He confirmed that sometimes he used clippers or filing, but in relation to Service User A the scalpel was the best instrument to use to reduce the pressure. He stated that he was being proactive and not reactive.

• In response to Service User A’s evidence that he cut his toe during the course of this treatment, he stated that he had no recollection of a cut, it was not in his notes, and he would have noted that.

• He acknowledged the issues with his notes and, as a result, he could not be confident that he would have recorded a cut or accidental incision, but he had no recollection of a cut and he believes that he would have recorded it and noted the dressing also. He stated that his notes would have included “B” for bleed, and he would have noted the antiseptic dressing and to come back if any problems.  He stated that he always advised patients to contact him if something was still sore, but he did not hear anything, so he did not give it any more thought. He stated that any breach to the skin can cause an infection in a few days, but there was no call back to the clinic from Service User A until 8 weeks later.

• He next saw Service User A on 21 April 2023 and presumed he had come back for routine footcare again. He stated he did not recognise Service User A’s name until he checked his details, and it was just routine appointment. He stated there was nothing out of ordinary about coming back after 8 weeks and nothing on the booking system to explain a reason for the appointment.

• He said at the second appointment on 21 April 2023 things had become much worse and Service User A had a full-blown ingrown toenail to his right big toe. He said the nail had turned inwards, had penetrated the flesh and was quite sore, so he treated it with dressings and antiseptic. He translated the abbreviated notes he had made of that appointment which included a spike of nail flesh, nail removed in a conservative manner, dressed and spare dressings given. He confirmed that he suggested nail surgery to Service User A as this was following a classic pattern, from an involuted toenail to an ingrown toenail and if he did not have surgery then he would be in an endless cycle of attending the clinic to treat it.  

• He could not recall if Service User A mentioned or raised any cut during that second appointment and stated that he was more concerned with the ingrown toenail and how painful it was. He then said that the cut was not mentioned.

• In the final appt with Service User A on 18 May 2023, he recalled that the receptionist had said Service User A had contacted the Clinic in a lot of pain so he had “squeezed him in” to his schedule that day. He recalled the toe looked “very bad” and he advised him to book in for nail surgery. He advised Service User A that he could pursue the surgery through the NHS, which would be free, but likely to take 3-4 months. He said he did what he could for Service User A that day as he was in a lot of distress and that was the last he heard of Service User A until the complaint was received.

• His recollection was that Service User A did not make mention of any cut during third appointment. He recalled that he was quiet, was wearing a mask and that his only complaint was about the ingrowing toenail. He stated that Service User A gave no indication that he had caused the problem.

• He stated he could not recall when he first became aware of the email from Service User A, but said that a photograph of his toe was sent with the email which his receptionist showed to him. He said that his response to the email was primarily to the photograph and that he was looking at a general overview of his notes, particularly from the second appointment when the nail was badly ingrown. He stated that he was in between clients, that he needed to deal with the email, that he looked at his notes with the last one saying that it had ingrown badly and based his response on that. He stated that he had not intended to be misleading but he had responded from an overview of the 3 visits. He was shown a copy of Service User A’s email dated 9 June 2023 and added that he disputed the injury and also that a breach of the skin would cause an ingrown toenail.

• He stated that, with more time, he would write his response to Service User A’s email differently and word it better. He stated that he had come into the Clinic with an ingrowing toenail although it wasn’t particularly sore then, but then it became sore.  He said the email implies that when Service User A came in with it really sore on first visit, which he had not meant and said he should not have included the date in his response. He said that he just wanted Service User A to come in for nail surgery as a matter of urgency and that it was not meant to be misleading. 

• He denied that sending the email was dishonest, that it was not in his nature to be dishonest and that he had nothing to hide or cover up. He stated that he was not a beginner in his job and, whilst acknowledging that his records were poor, clinically he had nothing to hide. He said he had carried out a very routine procedure that had escalated and the blame was being put on him. He stated that he is not a dishonest person and had no reason to be.

• The Registrant acknowledged that his notes and record keeping was woeful and, as a result, he had admitted a number of charges. On general reflection now, looking back, he stated he had naively never thought someone would review his notes in relation to a complaint. He stated that since this Allegation he had attended a record keeping course and was very diligent with his note keeping. He stated the allegations had been a major shock to him, that he had become lax and cavalier with his record keeping and that, whilst he cannot undo it, he had dealt with it. He stated that the allegations were awful for all concerned and had a very negative impact on his health. 

• He detailed the changes that he had made since 2023 to improve his record keeping, with a new and improved consent form, constant assessment of his note taking and allowing an extra 10 minutes after each appointment for record keeping. He confirmed that he does not take as many clients now and that he was becoming over-stretched. He confirmed that he intended to continue monitoring his records and complete a further course every 6 months. He confirmed that he now implements the SOAP technique referred to by the expert witness, recording the views and wishes of his patients, together with the outcomes expect by the patients and himself.

• He stated that the allegations had impacted on his personal health, that he is a worrier and cares deeply about his job. [Redacted]  He felt that he had let himself down in relation to the record keeping and that will never happen again. [Redacted].

36.  In response to questions put to him by Ms Girven, the Registrant stated the following:

• He stated that the consent form including the list of medications had been completed by Service User A at the first appointment on 24 February 2023 and accepted it did not record any medical history and that he did not make any personal notes of his medical history.

• He accepted that that Service User A did not attend on 24 February 2023 with an ingrown toenail or present with an ingrown toenail, that there is no mention of an ingrown toenail in the notes and also no mention of an involuted toenail.

• He accepted that Service User A attended on 24 February 2023 for a general check-up, that he did not recall Service User A complainant of any acute issues and that his stated reasons for attending was due to having purple marks, bent toes and hard skin.

• He stated that Service User A did not directly mention any issues with his right big toe on 24 February 2023, that he was not reporting directly that it was hurting and that he had asked him to check and deal with any problems.  

• Due to the passage of time, he is unable to recall individual conversations with clients, but, based on his notes, he accepted it was possible that he did not tell Service User A on 24 February 2023 that he had an involuted toenail.

• He confirmed that, at the time, he did not inform any patients what instrument he was using as he presumed they would allow him to use whatever was needed. He believed that the consent form gave him permission to do what he felt was appropriate so, at the time, he did not directly ask patients for permission to use a scalpel or explain why he was using a scalpel.

• He accepted that on 24 February 2023 he had treated both of Service User A’s big toes but had not recorded a particular issue with Service User A’s right big toe. He confirmed that when Service User A subsequently attended on 21 April 2023 there was no issue with his left big toe and that hadn’t developed into an ingrown toenail.

• He accepted that a scalpel was a sharp instrument but did not recall accidentally cutting Service User A’s right big toe on 24 February 2023 when he was trimming his nail. He also could not recall applying antiseptic to the cut but stated that this was not in his notes, so in his view it did not happen, although accepted his note keeping was in question.

• He confirmed that he was relying on his notes during his evidence to recall what happened and was not able to remember any other details that were not in his notes.  

• He accepted that it was possible that he cut Service User A’s big toe with the scalpel. He does not recall apologising to Service User A but confirmed that he would have apologised if he had cut someone.

• He accepted, having looked at his notes, that there was no advice in relation to a cut to Services User A’s big toe or any advice about an involuted toenail.

• He stated that his note from 21 April 2023 when he saw Service User A for the second time, confirmed that he had a full-blown ingrown toenail so his toe had definitely worsened. He could not recall Service User A mentioning at the appointment on 21 April 2023 that his issues had been caused by the cut.

• He stated that he told Service User A at the appointment on 21 April 2023 that he had an ingrown toenail but denied telling him that this was due to a cut.

• He accepted that in Service User A’s email to the clinic on 9 June 2023 he mentions that he was cut to the side of his big toe during his first appointment on 24 February 2023.

• He accepted that in his email response to Service User A he said that Service User A had attended the appointment on 24 February 2023 with a very sore ingrown toenail. He accepted that his email did not confirm that the ingrown toenail was first noted on 21 April 2023. He stated that his response in his email was based on an overview of his notes and acknowledged that his notes from 24 February 2023 did not confirm that Service User A had attended with an ingrown toenail.

• He did not accept that his comment that Service User A attended the appointment on 21 April 2023 with the same problem was incorrect. He stated that it was the same problem but was then much worse.  He accepted that the problem on 21 April 2023 was for an ingrown toenail but there was no direct problem of an ingrown toenail on 24 February 2023.

• He accepted that Service User A had attended for a routine check up on 24 February 2023 but denied he had misrepresented the reason for that initial appointment in his email by saying it was for an ingrown toenail. He said that, whilst it was a routine appointment, he identified a problem of a potential ingrown toenail at that stage, otherwise he would have had no reason to go down the side of his nail.

• He acknowledged that his email did not respond to Service User A’s allegation of a cut and stated the reason for this was because he did not recall a cut. He also stated that a breach to the skin would not cause an ingrown toenail.

• He agreed that it was important to keep records and this was not just in case of a complaint.

37.  In response to re-examination questions put to him by Mr Bealey, the Registrant stated the following:

• His notes from 24 February 2023 in relation to the treatment given to Service User A was indicative of an involuted toenail, even though there was no direct reference to an involuted toenail in the notes.

• He will have explained to Service User A what he was doing when cutting the side of his nail as patients get nervous during first appointments when they see the instruments being used, so he will have given some explanation for the treatment taking place.

• He said that often when patients attend general appointments in relation to once concern, he identifies another concern and that patients attend with one problem, but invariably there are potentially more problems.

• He acknowledged that patients would not book a general check-up if they did not already consider that there was a problem with their feet.

• He accepted there were issues with his notes and that they were below the standards required, however, he stated that at the time, he was able to understand his notes in relation to what a previous appointment was about.

38.  In response to questions put to him by the Panel, the Registrant stated the following:

• At the time when he saw Service User A he was overstretched in relation to the number of patients he was seeing and recalled that, whilst it varied, in a typical day he was seeing about 15 patients a day.

• He now has breaks and longer time to write up his notes after each Service User has left and will also create time at lunch to write up notes.

• He denied Particular 2 a as he was aware of Service User A’s medication from his form and that his medical history was on his own notes on the records, although there are no more notes available in addition to what the Panel have already.

39.  There being no further questions the Registrant was released from his oath. Mr Bealey confirmed there was no further evidence to call and the Registrant’s case was closed. He confirmed that the personal notes referred to by the Registrant in his evidence were no longer available due to the passage of time and the fact that the Registrant has since changed jobs.

Submissions

40.  Ms Girven, on behalf of the HCPC, confirmed that the burden of proof was on the HCPC and that the standard of proof was the balance of probabilities.  

41.  She took the Panel through her observations on the oral evidence provided by the witnesses. She submitted that Service User A had provided evidence that was generally consistent with the documentary evidence and medical records and therefore, she submitted significant weight should be attached to his evidence. She submitted that VL’s evidence was clear, although provided limited assistance to the Panel.  In relation to the expert evidence, she submitted that, with the concession in relation to paragraph 3.26, the Panel could accept his evidence in its entirety and that in his oral evidence, the expert had given his opinion that a cut of the kind described by Service User A could cause an ingrown toenail. She therefore submitted that the Panel could attach significant weight to this evidence. She also took the Panel through the Registrant’s evidence and submitted that his recollection of events was not entirely clear, which she acknowledged may be due to the passage of time but submitted that he had relied heavily on the limited records provided.  She therefore asked the Panel to prefer Service User A’s evidence over the Registrant’s.

42.  Ms Girven then took the Panel through each of the denied allegations and detailed the evidence that she submitted supported the HCPC’s case.  In relation to the denied allegation of dishonesty, she referred the Panel to the 14 page Case Summary she had provided and submitted that the Panel should apply the two-stage test set out in Ivey v Genting Casinos (UK) Ltd t/a Crockfords [2017] UKSC 67. She took the Panel through the subjective and objective tests and referred to the evidence that she submitted supported the HCPC’s case. Ms Girven invited the Panel to find the denied allegations, including the dishonesty allegation proved.

43.  Mr Bealey, on behalf of the Registrant, referred the Panel to the 8 page document he had provided setting out his written submissions on the facts. He took the Panel through the document in relation to the legal framework relating to the standard and burden of proof, the proper approach to the assessment of evidence and factual findings, contemporary documents and the potential issues relating to witness testimony, the guidance in relation to dishonesty and character evidence.  Mr Bealey referred the Panel to the relevant caselaw and also the HCPTS Practice Note entitled ‘Making Decisions on a Registrant’s State of Mind’.

44.  Mr Bealey referred the Panel to the submissions made within the document in relation to the written and oral testimony in this case and took the Panel through the evidential issues in relation to each of the denied allegations that he submitted undermined the HCPC’s case.

45.  Mr Bealey submitted that the HCPC had not produced sufficient evidence such that, when taken against the evidence presented on behalf of Registrant, the Panel could find the factual charges proved. He submitted that the Registrant had fully engaged in the disciplinary hearing, including giving evidence before to the Panel. He submitted that, on the balance of probabilities, the outstanding allegations are not made out and invited the Panel to find the denied allegations not proved. 

The Panel’s approach

46.  The Panel accepted the advice of the Legal Assessor which is a matter of record. In summary, the advice included, but was not limited to, the burden and standard of proof, witness memory, good character, assessing the state of mind of a registrant and the caselaw relating to dishonesty, in particular the test set out in the case of Ivey v Genting Casinos (UK) Ltd [2017] UKSC 67. 

47.  The Panel was mindful that the burden of proving the facts was on the HCPC. The Registrant did not have to prove anything. The individual Particulars of the Allegation could only be found proved if the Panel was satisfied that the case was proved on the balance of probabilities.

48.  In reaching its decision, the Panel took into account the oral evidence provided by the witnesses and the Registrant, the documentary evidence included in the bundles provided by the HCPC and the Registrant and the oral submissions made by the parties.  

Decision

49.  In relation to Particular 1, the Panel found the facts proved for the following reasons:

• The evidence of Service User A that the Registrant had not notified him of the use of a scalpel prior to carrying out the procedure or obtained his consent to do so;

• The consent form exhibited as PN/01 does not include consent to use a scalpel;

• The Registrant’s notes of the appointment do not document the use of a scalpel or obtaining Service User A’s consent to do so; and

• The Registrant made an admission to this Particular during the hearing.

50.  The Panel therefore found the facts of Particular 1 proved on the balance of probabilities.

51.  In relation to Particular 2 a, the Panel found the facts proved for the following reasons:

• The evidence of Service User A who confirmed he completed the list of medications on the consent form; 

• The consent form exhibited as PN/01 simply confirms the medications listed by Service User A but does not confirm when the medication is taken, in what amounts or for what reason; 

• The Registrant’s evidence was that he transferred the medical history for Service User A to his personal notes, but evidence of those personal notes was not before the Panel;

• The first time the Registrant made reference to any personal notes was during his oral evidence;

• The Registrant’s explanation for the personal notes being unavailable was questionable in light of the allegations dating back to 2023 when he was still working at the Clinic and he had the opportunity to obtain them at that point;

• The expert evidence confirmed that the Registrant’s notes in relation to Service User A’s attendance at the first appointment were severely lacking and that the Registrant did not use the recommended SOAP format which would have captured Service User A’s medical history and medication history; and

• There was no documentary evidence before the Panel of either Service User A’s medical history or his medications history.

52.  The Panel therefore found the facts of Particular 2 a proved on the balance of probabilities in relation to the failure of the Registrant to document Service User A’s medical history and his medications history.

53.  In relation to Particular 2 b, the Panel found the facts proved for the following reasons:

• The evidence of Service User A that he attended the appointment with concerns about purple marks on his feet, hammer toes that had started to develop and hard skin; 

• The Registrant’s notes of the appointment do not document Service User A’s medical concerns or any of the reasons provided by Service User A as to why he attended the appointment; and

• The Registrant made an admission to this Particular during the hearing.

54.  The Panel therefore found the facts of Particular 2 b proved on the balance of probabilities.

55.  In relation to Particular 2 c, the Panel noted that it was not required to make any finding of fact that Service User A presented with an ingrowing toenail on 24 February 2023.  
The Panel found the facts of Particular 2 c facts proved for the following reasons:

• The Registrant’s notes of the appointment do not document that Service User A’s presented with an ingrowing toenail; and 

• The Registrant made an admission to this Particular during the hearing.

56.  The Panel therefore found the facts of Particular 2 c proved on the balance of probabilities.

57.  In relation to Particulars 2 d and 2 e, the Panel first considered whether it found that the Registrant had caused an accidental incision to Service User A’s toe during the initial appointment on 24 February 2023. The Panel was satisfied on the balance of probabilities that the Registrant did cause the accidental incision on that date for the following reasons:

• The evidence of Service User A was consistent from the outset.  His witness statement confirmed a cut down the side of his skin. The GP record dated 16 March 2023 confirmed his account to the nurse that a podiatrist had caused an accidental cut to his toe and confirm that a small incision was seen by the nurse.  Service User A also mentioned the accidental cut in his email to the Clinic on 9 June 2023 and in his email to the HCPC on 22 June 2023; 

• The Panel assessed Service User A as a measured witness and that his evidence at the hearing was strong, open and honest.  His account was that he felt sorry for the Registrant when the cut was made and that “everyone makes mistakes”;

• The Panel considered the evidence of the Registrant and noted that he lacked recollection of the incision and was reliant on the poor notes he had made of the appointment at the time. The Panel also noted that the Registrant had accepted under cross-examination that it was possible that the accidental incision occurred, although again he referred to his notes stating he believed that he would have recorded it;

• The Panel acknowledged that the Registrant’s notes of the appointment on 21 April 2023, whilst limited, recorded the use of bandages, which supported his assertion that he would have recorded this on 24 February 2023 if bandages had been required. However, it considered that the Registrant’s evidence was inconsistent and lacking in detail and therefore preferred the evidence of Service User A over the evidence of the Registrant;

• The Panel considered the evidence of VL who had not observed any cut to Service User A’s toe but noted that her involvement with him was in June, which was some months after the initial appointment with the Registrant. The Panel considered it was likely that the cut would have been masked in that it was clear that Service User A’s toenail was ingrown by that stage and required surgery;

• The Panel noted that the expert witness did not specifically address the issue of the cut to Service User A’s toe so his evidence was not relevant to this point;

• The Panel acknowledged that the evidential burden was on the HCPC and assessed if sufficient evidence had been produced to discharge that burden. It noted that the Registrant was of good character and therefore more likely to be believed and noted that no clinical concerns had been raised in the last 30 years;

• However, having taken everything into account, in light of the consistent account from Service User A in relation to the accidental cut, the Panel’s assessment of Service User A’s evidence at the hearing, the support for his evidence within the GP record made by the nurse on 16 March 2023, together with the Registrant’s account that he was unable to state that the accidental cut did not happen and in fact conceding that it could have done, the Panel determined on the balance of probabilities that the Registrant did cause an accidental incision to Service User A’s toe at the initial appointment on 24 February 2023.

58.  Therefore, in relation to Particular 2 d, the Panel found the facts proved for the following reasons:

• The Panel was satisfied on the balance of probabilities that the Registrant did cause the accidental incision on 24 February 2023;

• The Registrant’s notes in relation to that appointment did not document any accidental incision made to Service User A’s toe; and

• The Registrant confirmed in oral evidence that he had not documented any accidental incision in the notes he made of that appointment.

59.  The Panel therefore found the facts of Particular 2 d proved on the balance of probabilities.

60.  In relation to Particular 2 e, the Panel found the facts proved for the following reasons:

• Panel was satisfied on the balance of probabilities that the Registrant did cause the accidental incision on 24 February 2023;

• The Registrant’s notes in relation to that appointment did not document any worsening advice given to Service User A in relation to the incision to their toe; and

• The Registrant confirmed in oral evidence that he had not documented any worsening advice given to Service User A in relation to the incision to their toe in the notes he made of 
that appointment.

61.  The Panel therefore found the facts of Particular 2 e proved on the balance of probabilities.

62.  In relation to Particular 3, the Panel found the facts proved for the following reasons:

• The evidence of Service User A that the Registrant had advised him on 21 April 2023 that he may require nail surgery;

• The Registrant’s notes of the appointment do not document that he advised Service User A that he may require nail surgery; and

• The Registrant made an admission to this Particular during the hearing.

63.  The Panel therefore found the facts of Particular 3 proved on the balance of probabilities.

64.  In relation to Particular 4, the Panel found the facts proved for the following reasons:

• The evidence of Service User A that an appointment took place on 18 May 2023;

• The Registrant’s admission in evidence that an appointment took place on 18 May 2023 and that he failed to record any details of this appointment; and

• The Registrant made an admission to this Particular during the hearing.

65.  The Panel therefore found the facts of Particular 4 proved on the balance of probabilities.

66.  In relation to Particular 5, the Panel found the facts proved for the following reasons:

• Exhibit PN/05 provides clear evidence that the Registrant advised Service User A on 16 June 2023 that he had attended the appointment on 24 February 2023 whilst presenting with an ingrowing toenail; and

• The Registrant made an admission to this Particular during the hearing.

67.  The Panel therefore found the facts of Particular 5 proved on the balance of probabilities.

68.  In relation to Particular 6, the Panel did not find this fact proved on the balance of probabilities.

69.  The Panel noted the HCPC’s case that the Registrant had sought to misrepresent the reason for Service User A’s initial appointment on 24 February 2023 in his email to Service User A on 16 June 2023 and that his actions in doing so were dishonest.

70.  The Panel noted that the burden to prove the Particular was on the HCPC on the balance of probabilities.

71.  The Panel considered the test set out in the case of Ivey v Genting Casinos (UK) Ltd [2017] UKSC 67 in relation to the alleged dishonesty, in order to determine whether the Registrant acted as an honest person would have acted in the circumstances.

72.  The Panel first considered what the Registrant knew or believed as to the facts and circumstances in which the alleged dishonesty arose and noted the following: 

• The Registrant accepted in evidence that he sent the email to Service User A on 16 June 2023 when asked to do so by his receptionist who brought Service User A’s email to his attention, together with a photograph;

• He stated this was during a busy day when he was seeing, on average, 15 patients a day and that he had quickly drafted a response based on his notes regarding Service User A’s appointments, which he acknowledged were not very detailed;

• The Registrant’s notes of the appointment on 24 February 2023 made no reference to an ingrown toenail yet the email dated 16 June 2023 clearly stated that was the reason for Service User A’s attendance;

• The Registrant accepted that he had incorrectly included the date of 24 February 2023 within his email and should not have done so;

• The Registrant’s character was unblemished for 30 years and, whilst he had acknowledged his approach to note taking had become lax and cavalier, he had no history of dishonesty and the references provided supported that; and

• The Panel considered that the Registrant’s email dated 16 June 2023 was also lax and cavalier and that, perhaps due to the circumstances within the Clinic on that day, he had not taken the time to consider his response properly and had relied upon incomplete notes to send a quick reply in order to deal with the email received.

73.  The Panel acknowledged that the burden of proof was on the HCPC to prove the allegation on the balance of probabilities, but the Panel was not satisfied that there was cogent evidence to underpin the allegation of dishonesty or to safely conclude that the Registrant sought to misrepresent the reasons for the initial appointment. 

74.  The Panel also considered, given the registrant’s knowledge and belief of the circumstances, whether the Registrant’s conduct would be considered dishonest by the standards of an “ordinary decent person”.  The Panel acknowledged that this was purely an objective test and that the Registrant’s own standards of honesty are irrelevant. The Panel considered that the Registrant’s cavalier response to Service User A’s email was reckless and not something that he had given sufficient time or attention to. However, it determined that, in light of the circumstances surrounding the reply to the email and the Registrant’s good character, it was more persuaded by his explanation that he had mistakenly included the date of 24 February 2023 in his email, which was incorrect and the result of rushing to respond to the email during a busy day, rather than a deliberate act of dishonesty.

75.  In conclusion, the Panel did not find Particular 6 this fact proved on the balance of probabilities.

Decision on Misconduct

Submissions

76.  Ms Girven addressed the Panel in respect of the ground of misconduct which she submitted was established in this case.

77.  She outlined the definition of misconduct in accordance with the case of Roylance v General Medical Council (No 2) [2000] AC 311 and the requirement of seriousness in accordance with the case of Nandi v GMC [2004] EWHC 2317 (Admin).

78.  Ms Girven submitted that the facts alleged in the proven Particulars established that the Registrant had acted in a way that fell far below what would be proper in the circumstances and what the public would expect of a HCPC registered chiropodist. She referred to the report and oral evidence of the expert witness and took the Panel through each proven Particular outlining relevant points that she submitted supported a finding of the ground of misconduct.

79.  She submitted that, as set out in the Case Summary, the Registrant had breached the HCPC 2016 Standards of Conduct, Performance and Ethics in relation to the following standards:

• 1.2 - you must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided 

• 1.4 - you must make sure that you have consent from service users or other appropriate authority before you provide care, treatment or other services 

• 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 

• 8.3 - you must give a helpful and honest response to anyone who complains about the care, treatment or other services they have 

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

• 10.1 - you must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to 

80.  In addition, as also set out in the Case Summary, Ms Girven submitted that the Registrant’s conduct breached the following standards set out within the HCPC’s Standards of Proficiency for Chiropodists / Podiatrists in place at the time of the allegations are engaged in this case: 

• 2.1 - understand the need to act in the best interests of service users at all times 

• 2.2 - understand what is required of them by the Health and Care Professions Council 

• 2.5 - understand the importance of and be able to obtain informed consent 

• 2.6 - be able to exercise a professional duty of care 

• 3 - be able to maintain fitness to practise 

• 3.1 - understand the need to maintain high standards of personal and professional conduct 

• 4.1 - recognise that they are personally responsible for and must be able to justify their decisions 

• 4.2 - be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning 
appropriately 

• 7.7 - understand the need to provide service users or people acting on their behalf with the information necessary to enable them to make informed decisions

• 7.8 - understand the need to empower patients to manage their foot health and related issues and recognise the need to provide advice to the patient on self-treatment where appropriate 

• 14 - understand the need to establish and maintain a safe practice environment 

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

81.  Ms Girven submitted that the identified breaches of the HCPC Standards in relation to the proven Particulars supported a finding of the statutory ground of misconduct.

82.  Mr Bealey referred the Panel to the document he had provided setting out his written submissions on grounds. He took the Panel through the document in relation to the legal framework relating to the ground of misconduct and submitted that it was a matter for the Panel what weight it attached to the evidence of the expert.  

83.  He acknowledged that the Registrant had accepted he had become lax and cavalier in relation to his record keeping in 2023 but submitted that his clinical skills were not in question. He submitted that it was a matter of degree whether the proven Particulars fell so far below the standard required to meet the test of deplorability. He asked the Panel to consider each Particular individually to assess whether it met the misconduct test and reminded the Panel that, in relation to Particular 5, it had not found that the Registrant’s actions in sending the email involved dishonest behaviour.

Panel’s Decision 

84.  The Panel considered whether the facts found proved in Particulars 1 to 5 amounted to the ground of misconduct.

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

86.  The Panel took account of the submissions of Ms Girven and Mr Bealey and accepted the advice of the Legal Assessor.

87.  With regard to misconduct, the Panel considered the definition as confirmed in the case of Roylance v GMC (No 2) [2000] 1 A.C. 311 and also the requirement of seriousness in accordance with the case of Nandi v GMC [2004] EWHC 2317 (Admin). The Panel approached the matter on the basis that it would need to be satisfied that the proven conduct was sufficiently serious to amount to professional misconduct.  

88.  The Panel found the Registrant to have been in breach of the HCPC Standards of Conduct, Performance and Ethics (2016) and the Standards of the HCPC’s Standards of Proficiency for Chiropodists / Podiatrists as set out by Ms Girven in the Case Summary.

89.  The Panel considered each of the proven Particulars in turn to assess whether it amounted to serious professional misconduct. The Panel agreed that failing to obtain informed consent from a service user, failure to document accurate and detailed records of a service user’s medical and medication history, failing to document accurate and detailed records of each service user’s appointment including the service user’s concerns, treatment, any issues during the treatment and ongoing advice, together with providing incorrect information to service users when requested to do so was in breach fundamental tenets of the profession and fell significantly below the standards expected.  

90.  The Panel agreed with the evidence of the expert witness that the Registrant’s records of the appointments he had with Service User A were woefully inadequate and so poor that, even as an expert in the field, he was unable to interpret them. The Panel considered that the records created by the Registrant fell far short of the standards required by the professional body in numerous ways. The Panel agreed that consent is an important pillar of the profession and informed consent must be obtained prior to any treatment. It also agreed that the Registrant had a professional obligation to ensure any information provided to a service user was correct and that the information provided to Service User A, whilst based primarily on poor note keeping, exemplified the cavalier and lax attitude of the Registrant at the time and fell far short of what was expected of a registered professional.

91.  The Panel agreed that the Registrant’s conduct constituted serious breaches of professional boundaries, which could properly be described as “deplorable” by the standards of fellow professionals and ordinary, decent members of the public.

92.  The Panel determined the conduct alleged in each of the proven Particulars constituted serious professional misconduct and therefore amounted to the ground of misconduct.

Decision on Impairment

Submissions

93.  Ms Girven confirmed that the HCPC does not propose to present any additional evidence on the issue of impairment and that the decision whether the proven facts amount to impairment of the Registrant’s fitness to practise is a matter for the Panel.

94.  Ms Girven referred the Panel to the HCPTS Practice Note entitled ‘Fitness to Practise Impairment’ and outlined the guidance and considerations the Panel will need to take into account when assessing if the Registrant’s fitness to practise is currently impaired. She referred to the case of Cohen v GMC [2008] EWHC 581 (Admin) and highlighted the need to focus on public protection and the ‘critically important public policy issues’.

95.  Ms Girven also referred to the considerations set out in the case of CHRE v Nursing and Midwifery Council and Grant [2011] EWHC 927 (Admin) and submitted that the Registrant has acted in a way so as to put a service user at unwarranted risk of harm and is liable to do so in the future, he has breached a fundamental tenet of the profession and is liable to do so in the future and that, in her submission, there is a serious risk of repetition in this case.

96.  Ms Girven submitted that, in order to properly assess whether the Registrant is currently fit to practise, two broad components should be considered by the Panel, those being the ‘personal’ component and the ‘public’ component and took the Panel through the considerations to assist in their determination in relation to these components.

97.  With regard to the ‘personal component’, Ms Girven accepted that the Registrant’s acts are remediable but submitted that the remediation he had undertaken so far was insufficient to satisfy the Panel that there was no longer a risk of repetition. She acknowledged that the proven Particulars date back to 2023 and related to one service user, although submitted that they did not relate to an isolated incident but to numerous appointments and an email sent to the Service User. She submitted that the Registrant had only completed one course in relation to record keeping and that, whilst he stated he undertook regular audits of his records himself, his explanation of why his colleague was unable to review his records due to patient confidentiality was inadequate and could have easily been addressed by redacting the relevant records. Ms Girven also submitted that the Registrant lacked insight as to the impact of his actions on Service User A, the public and the podiatry profession more widely, submitting that he appeared more focussed on how the proceedings had impacted on him and his current working practise. 

98.  In relation to the ‘public component’, Ms Girven referred to the need to uphold public confidence in the podiatry profession and uphold proper standards. She submitted that, in light of the seriousness of the concerns and the need to protect service users, a member of the public would be concerned if a finding of impairment was not found.  

99.  Ms Girven therefore submitted that the Registrant’s fitness to practise is currently impaired on both the personal and public components.

100. Prior to Mr Bealey providing any submissions to the Panel in relation to impairment, the Registrant gave evidence on oath. When asked questions by Mr Bealey, the Registrant stated the following:

• He had amended the consent form used in 2023 to include consent for using various instruments, scalpels specifically. He had agreed this with a colleague that this new form fit their criteria.

• He currently works in a two-chair clinic, which are separate businesses but occasionally they share some patients. They keep separate records for privacy, even if they share a patient, when they will only discuss the patient in advance rather than share records. 

• He now uses the SOAP plan when taking notes and maintaining records which includes being subjective in recording the patients views and worries, objective in recording his views etc, noting what he has done to alleviate the problem and recording the plan for what may happen in future including the treatment and likely outcome. He now ensures his notes accurately reflect each client session and he audits these to ensure they are in accordance with the SOAP plan. He is confident that following the SOAP guidelines that his notes will cover everything required.

• He conducted an audit of his patient records a few months ago and continues to complete audits to ensure his patient notes cover all criteria and meets the guidelines. He took the Panel through the audit form within the bundle he had provided and confirmed he completes the audit himself assessing records at random, that he is quite honest, notes his failing and ensures he improves in future.

• He has increased the lengths of his appointments and uses the extra time for note taking and has extended his lunch break to complete or check these. He said it has become quite an obsession now.

• He learnt a lot on the training course including patient expectations, eliciting information, consent, explaining instruments, for example. He said that he now explains every instrument that he uses and why he is using it and records in his notes where verbal consent has been given.

• His colleague does not have access to his patient records due to patient confidentiality. 

• He completes a subjective review of his note applying the training from the course he completed. He no longer uses abbreviations and now has comprehensive notes which he appreciates are not just for his reading.

• He will continue to complete audits and any further CPD training but he has no training planned after today in relation to note keeping.

• In 2023 he incorrectly believed that it was sufficient for him to know what he had done in relation to a patient. He said at the time he had too many clients and insufficient time, which he said was not an excuse but an explanation. He simply recorded enough for him to know what he had done for when a client returned.

• He had spent the last 2 - 3 years worrying about this and working on it.  He had put every effort into making his notes perfect in his view.

101. In response to questions from Ms Girven, the Registrant stated:

• He has not completed any official audits of patient records since 2 September 2025, but he audits each record he completes now, applying what is required. He will do more audits in future.

• He has not asked his colleague for feedback on his records following occasions when they share a client as they do not share patient records, they simply discuss an overview of the patient.

• He understands the importance of making a clear record, that the record is not just for him, so it must be clear to anyone who reads it to understand what has happened.

• He is totally reliant on his patient records to maintain a clearer picture of where he is up to and future treatment. The records he has now make appointments much easier to deal with.

• When treating his colleague’s patients he treats them as a new client for the purposes of his own records.

• He again explained the measures had had put in place to ensure he did not return to the same point that he was in 2023, although he had thought that his record keeping was adequate at that time.

• He accepted he had not made any record of the appointment with Service User A on 18 May 2023, which was not appropriate, but he prioritised alleviating the client’s pain over making a record of the appointment due to time restrictions. He did not think this was acceptable and said that he would not squeeze a client in now, that he now put himself first and would now tell a client that they would have to wait.

• In relation to the impact of his actions on Service User A and the public generally, he was sorry for pain, stress and impact caused and considered that Service User A’s faith in the profession would have been sullied. He said that the impact on himself has been great, that he has suffered physically and mentally and this has been a very hard lesson learned.

102. In response to questions from the Panel, the Registrant stated:

• He clarified that, when a new patient attends the clinic, a new consent form is completed then he writes up the patient’s details under the SOAP format. He confirmed there were no other forms, just the consent form and the patient record.

• He accepted the new consent form did not allow sufficient space for a patient to complete details of their medical history and relevant information, but he would expand on this and complete any additional information on the patient records during his initial assessment with them.

• He has a personal receptionist who works remotely and she will provide him with some information about a patient following any discussion she had with them, for example if they were nervous or in a lot of pain. He said this is helpful as in 2023 there was one receptionist for three podiatrists, so she was quite busy.

• He uses a site called Podware to complete his patient records, which is an online App and specifically for podiatrists. The App includes things such as treatment records, plans and the patient history and is all confidential.

• He accepted that completing his own audits was akin to marking his own homework but stated that he is keeping himself in check by marking himself severely and keeping to the guidelines. He said he is unable to ask his colleague to review his notes due to confidentiality.

• The note taking he took was not separate to CPD.

• When asked if he had any further reflections in relation to the public perception of his actions than the impact he had mentioned in relation to Service User A and himself, he acknowledged that Service User A would be very unhappy with him and the profession. He said he is very proud of his profession, but he cannot control what Service User A says to his friends and family. He said he had no idea what the impact could be, but that Service User A was unlikely to recommend podiatry or himself, which hurt him deeply.

• He did not consider that there was any potential issues with him preparing his notes and auditing them himself.

103. In response to a clarification question from Mr Bealey, the Registrant confirmed that, within the bundle he had provided, there was an example of the patient records produced by the App Podware for the Panel’s information. He explained that each patient record has two pages. One page of the record was for the patient’s personal details and the second page was to record any treatment.

104. In his submissions to the Panel, Mr Bealey referred to his written documents in relation to impairment. He took the Panel through the relevant legal considerations as outlined in the document and submitted that, whilst the Registrant may have been impaired in 2023, he was not currently impaired on either the personal or public components.

105. He took the Panel through the remedial action taken by the Registrant since 2023 as documented withing his written submissions, which he submitted was reasonable and proportionate in order to meet the concerns that the Panel may have. He submitted that there had been no repetition of the concerns or any other concerns relating to the Registrant’s conduct over the last 29 years of practise.

106. In relation to the Registrant auditing his own records, he submitted that confidentiality was of utmost importance to the Registrant and it was not unusual for professionals to self-police their own work. He submitted that there was no requirement by the HCPC to employ a third party to check the work of a registrant and that it fell upon a registrant to ensure their practice meets the HCPC standards, which the Registrant ensures he does.

107. Mr Bealey submitted that the Registrant’s actions relate to one isolated case 3 years ago and do not relate to his clinical work. He submitted that the Panel can be confident that the risk of repetition is low. He submitted that the Registrant had provided clear examples of the actions he had undertaken since 2023 and that was sufficient to satisfy the Panel that the conduct found proven has been remedied. 

108. Mr Bealey therefore submitted that the correct decision was to find that the Registrant is not currently impaired.

Panel’s Decision on Impairment

109. The Panel was reminded by the Legal Assessor that the test to consider is whether the Registrant’s fitness to practise is impaired today rather than at the time the concerns were raised. The Panel was also referred to the HCPTS Practice Note entitled ‘Fitness to Practise Impairment’, in particular the guidance in relation to both the personal and public components, to consider whether the Registrant’s fitness to practise is currently impaired in respect of each component.

110. In relation to the personal component, the Panel had significant concerns about the Registrant’s levels of insight and remediation. It acknowledged that the Registrant had demonstrated some level of insight but agreed that this was still developing. The Panel considered that the Registrant lacked understanding of the impact of his actions on Service User A, the public and the public’s trust in the profession. The Panel agreed that the Registrant’s behaviours in respect of the misconduct are remediable and that he had started remediating. The Panel noted that he had attended a course in relation to record keeping, he had been auditing his notes and he had changed his working practice by reducing the number of patients seen per day in order to create more time for completing and checking his notes. However, the Panel had concerns in relation to the consent form he had created, that the last evidenced audit of his notes was in September 2025 and his understanding of what he can share with his professional colleagues was lacking as any concerns regarding patient confidentiality could be addressed by suitable redactions. Therefore, whilst the Panel agreed that the Registrant had taken some remedial action, it still had significant concerns about the level of remediation completed at this stage.  

111. The Panel therefore agreed that there is a high risk of the Registrant repeating the conduct and determined that the Registrant’s fitness to practise is impaired in respect of the personal component.

112. In relation to the public component of impairment of fitness to practise, the Panel found that all three components were made out in relation to the protection of the public from the risk of harm, ensuring that public confidence in the profession is maintained and upholding proper professional standards. 

113. The Panel’s finding in relation to the personal component confirmed the need to protect the public from the risk of future harm. The Panel agreed that ordinary members of the public would be concerned by the Registrant’s behaviour in failing to uphold professional standards and abide by the law and that service users would lose trust and confidence in the profession and the regulatory process were there to be no finding of impairment.  

114. As a result, the Panel determined that the Registrant’s fitness to practise is currently impaired in relation to both the personal and public components.

Decision on Sanction 

Submissions

115. Ms Girven confirmed that sanction is a matter for the Panel and that the HCPC does not propose a specific sanction.  

116. Ms Girven referred the Panel to the relevant guidance in the HCPC’s ‘Sanctions Policy’ updated in March 2026 and helpfully outlined the sanctions and orders available. She took the Panel through the guidelines in relation to each sanction and confirmed that these must be considered in ascending order, starting with the least restrictive, taking into account all aspects of the case. She confirmed the HCPC’s position that it was not suggested that the situations in which a striking off order would be appropriate as set out within the Sanctions Policy apply in this case.  

117. Ms Girven referred to the mitigating and aggravating factors, submitting that the mitigating factors in this case included the Registrant’s apology and some remorse and that the aggravating factors included the risk of harm to Service User A. She acknowledged that the Panel had found evidence of some insight and remediation, although these were still at the early stages and that there was a high risk of repetition.  

118. Finally, Ms Girven referred to paragraph 143 of the Sanctions Policy which confirms that Panels must consider the impact of any sanction on the Registrant’s circumstances. However, the Policy confirms that these considerations must not lessen a sanction that the Panel believes is necessary to protect the public and maintain public confidence in the profession. 

119. Mr Bealey referred the Panel to the written submissions on sanction that he had provided. He took the Panel through the document, confirming that, in his submission, the most suitable sanction in this case was a Caution Order or a Conditions of Practice Order, as both were proportionate and addressed the risks identified.

120. He submitted that any sanction imposed is not meant to be punitive, although the obvious consequences of a sanction is that it is punitive in nature. He referred to the case of Bijl v. General Medical Council (Privy Council, 2 October 2001) and submitted that a sanction should not be used to sacrifice the career of an otherwise competent professional.

121. Mr Bealey outlined the mitigating factors of apology and remorse, the admissions made to majority of the Particulars, the Registrant’s previous good character with the HCPC for around 30 years, that the concerns were not clinical but related to record keeping, the partial remediation identified by the Panel, the Registrant’s engagement with the HCPC and these fitness to practice proceedings, which suggested, in his submission, a willingness on behalf of the Registrant to address any failing and reduced the risk of repetition. Mr Bealey also referred the Panel to the numerous character references provided which evidenced the Registrant’s positive clinical history and asked the Panel to consider the Registrant’s personal matters outlined previously in this hearing.

122. Mr Bealey referred the Panel to his written submissions which set out why a caution may be appropriate, that it would mark the Registrant’s record and would be an incentive for him to continue remediation he has already started. He also referred to the guidance within the Sanctions Policy with regard to when a Conditions of Practice Order would be most appropriate. In particular, he submitted, these included when a registrant has demonstrated insight, when the concerns are capable of being remedied or managed and when appropriate and proportionate conditions can be formulated. He submitted that the Registrant’s engagement with the HCPC and the proceedings should reassure the Panel that he will comply with any conditions on his practice and that a Conditions of Practice Order would allow the Registrant to continue with his practise whilst not exposing the public to any risk of harm. He referred the Panel to paragraph 28 of his written submissions which outlined some appropriate conditions that he submitted were reasonable in this case.

123. Mr Bealey submitted that a Suspension Order or a Strike Off Order were not proportionate in this case, particularly as the conduct was remediable. He submitted that the Registrant should be given the chance to comply with appropriate conditions on his practice and that he would be under no illusions that, during any future review of the order, a more serious consequence could follow if he failed to comply.   

124. Mr Bealey therefore invited the Panel to impose a Caution Order or a Conditions of Practice Order which, he submitted, they were the most appropriate sanctions in this case.

Decision on sanction

125. The Panel considered the submissions made by Ms Girven and Mr Bealey, together with the advice of the Legal Assessor. 

126. Accordingly, the Panel acknowledged that punishment of the Registrant should form no part of the reason for the imposition of a sanction. Rather, protection of the public, the maintenance of public confidence in the profession and the regulation of it, together with the upholding of proper professional standards are factors that should dictate whether a sanction is required, and, if it is, what that sanction should be. Any sanction decided upon should be the least restrictive to address these proper sanction aims. The various sanction options must be considered in an ascending order of seriousness.

127. The Panel considered the mitigating factors in this case and noted the following:

• Some remediation shown in the Registrant’s recognition that his records, notes and consent forms were inadequate and the changes he has made to his working practice to improve these, which demonstrates a motivation to change, although further improvement is required;

• Apology to Service User A during these proceedings and remorse and insight shown in relation to the embarrassment he has caused to the profession;

• Engagement with the HCPC during this investigation, admissions made to some Particulars and engagement with the fitness to practise proceedings;

• No previous concerns raised in relation to the Registrant’s practise over a near 30-year career and no other issues have been identified since these concerns were raised in 2023; and

• The testimonials provided were from a wide range of people, including some professional references.

128. The Panel then considered the aggravating factors in this case and noted the following:

• Whilst the concerns related to Service User A, the inadequate and incomplete records were repeated over three appointments resulting in incorrect information being provided to Service User A;

• Accidental harm caused to Service User A not recorded within the notes created for that appointment;

• Only partial remediation and understanding as to the full extent of the improvements required; and

• Limited exposure to targeted CPD.

129. The Panel considered the mitigating and aggravating factors and how they affected their assessment of seriousness. The Panel agreed that the lack of remediation and insight, in particular, caused the Panel concern as this increased the risk of repetition and therefore increased the risk to the public. 

130. The Panel therefore agreed that this is a case that requires the imposition of a sanction. To take no further action would neither protect the public from the risk of future harm that has already been identified, nor would it maintain confidence in the profession or the regulator.

131. The Panel acknowledged that a Caution Order would mark the conduct found proven, but it agreed that is would not protect the public or meet the wider public interest. The Panel agreed that the concerns were not minor and did not relate to an isolated incident, that there was a high risk of repetition and were not fully remediated. The Panel therefore agreed that a Caution Order would not be appropriate.

132. The Panel then considered a Conditions of Practice Order. It considered the guidance within the Sanctions Policy, together with the suggested conditions detailed within the written submissions provided by Mr Bealey and the HCPC Conditions Bank. The Panel considered the mitigating and aggravating factors identified and agreed that appropriate restrictions on the Registrant’s practice would be a proportionate sanction in this case as it would address the concerns identified and therefore reduce the risk to the public. 

133. The Panel determined that a Conditions of Practice Order would protect the public and meet the wider public interest. It considered that 12 months would be an appropriate length of the Order as it would allow the Registrant time to adequately address the concerns raised and demonstrate the improvements required before the Order was reviewed.

134. The Panel considered the guidance within the Sanctions Policy in relation to a Suspension Order and agreed that such an order was not proportionate at this stage as the Registrant’s actions were remediable and it was not necessary to deprive the profession of an otherwise competent professional.

135. The Panel therefore stepped back from a Suspension Order agreeing that it was disproportionate at this stage and agreed that a Conditions of Practice Order for a period of 12 months would not only protect the public but would give the Registrant the opportunity over the course of a year to fully demonstrate remediation and practise safely.

136. The Panel therefore determined that the appropriate sanction in this case was a Conditions of Practice Order for a period of 12 months. The Panel considered their overarching objective is to protect the public and in this case such an order was necessary and proportionate. The Panel also agreed that a Conditions of Practice Order would satisfy the wider public interest and maintain public confidence in the profession and the regulatory process.

137. The Panel considered whether this sanction was a proportionate response and took into account the Registrant’s interests and how such an order would affect him. However, the Panel agreed that the Registrant’s interests were outweighed by their overarching requirement to protect the public.

138. The Panel was therefore satisfied that a Conditions of Practice Order was a proportionate response. It determined that no lesser sanction would protect the public from the risk of repetition or would sufficiently ensure public confidence in the Profession or would send an appropriate message to other registrants of the unacceptability of the Registrant’s actions.

139. The Panel considered that the following would assist a future Panel when reviewing the Conditions of Practice Order:

• The Registrant’s continued attendance and engagement with the regulatory proceedings;

• A detailed reflective statement to address the impact of his actions on both public protection and public confidence in the profession; and

• Evidence of training and reflection that relates to the concerns identified.

 

Order: The Registrar is directed to annotate the HCPC Register to show that, for a period of 12 months from the date that this Order takes effect (“the Operative Date”), you, Mark Pilmoor, must comply with the following conditions of practice:

The Conditions are:

1. To complete a specific clinical record keeping and consent to treatment course with an appropriate professional body (for example the Royal College of Podiatry) as soon as possible or within 6 months from the date this Order comes into effect.

2. To complete a training and reflection log detailing his own reflections and insight into his own practice as a result of the targeted training and CPD completed and provided this to the HCPC on a quarterly basis from the date this Order comes into effect.

3. To meet with and be mentored by an independent HCPC registered Podiatrist on a monthly basis form the date this Order comes into effect to audit a random selection of redacted patient records, including consent forms, patient assessment and treatment records, and provide feedback to the Registrant. Evidence of the monthly meeting, feedback from the mentor and the Registrant’s actions on that feedback to be provided to the HCPC on a quarterly basis from the date this Order comes into effect.

4. To provide a blank sample copy of the consent forms, patient assessment and treatment records to the HCPC within a month of the date this Order comes into effect.

5. You must inform the following parties that your registration is subject to these conditions: 

A. any organisation or person employing or contracting with you to undertake professional work; 

B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application); and

C. any prospective employer for professional work (at the time of your application).

6. You must allow the HCPC to share, as necessary, details about your performance, compliance with, and/or progress under these conditions with: 

A. any organisation or person employing or contracting with you to undertake professional work; 

B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application); and

C. any prospective employer for professional work (at the time of your application).

7. You will be responsible for meeting any and all costs associated with complying with these conditions.

Interim Order

Submissions

1.  Ms Girven made an application for an Interim Conditions of Practice Order for 18 months. She pointed out that the primary Order would not take effect for at least 28 days and the public would not be protected by any order until then. If an appeal were to be made by the Registrant, the primary Order would not come into effect until that appeal had been withdrawn of otherwise disposed of.

2.  Ms Girven submitted that it was necessary that an Interim Conditions of Practice Order was imposed for reasons of public protection and that it is otherwise in the public interest. She also submitted that it was proportionate to impose an interim order as it related only to the period prior to the primary Order coming into effect. 

3.  In relation to the conditions included in the primary Order, Ms Girven submitted that Conditions 1 and 4 need not be included in an Interim Order, if imposed and Conditions 2 and 3 should confirmed the dates which the conditions need to be complied with. She submitted that without this, consideration of compliance with the Interim Order and later the Conditions of Practice Order would become confusing due to the different dates each order came into effect.

4.  Mr Bealey submitted that the test to be applied in relation to an Interim Order was whether it was necessary or not and, in light of the fact the  Registrant had not been subject to any Interim Order since the commencement of the proceedings and no further concerns had been raised, he submitted that an Interim Order was therefore not necessary at this stage.

5.  He submitted that, should the Panel determine that an Interim Order was necessary, an Interim Conditions of Practice Order was appropriate rather than an Interim Suspension Order which he submitted was not proportionate or necessary.

6.  In relation to the conditions of any Interim Conditions of Practice Order, Mr Bealey submitted that he shared the concerns of the HCPC in relation to the time scales when the Order came into effect and, without clearly confirming the timescales required, the Registrant could be confused as to what was required and when.

Panel Decision 

7.  The Panel accepted the advice of the Legal Assessor and took into account the guidance as set out in the HCPTS Practice Note entitled ‘Interim Orders’ updated in June 2026. In particular, the Panel had regard to the section relating to Interim Orders imposed at final hearings after a sanction has been imposed. 

8.  The Panel was advised to consider whether such an order is necessary for the protection of the public, otherwise in the public interest, or if it is in the Registrant’s own interests. The Panel also considered the principle of proportionality, balancing the Registrant’s interests against the need to protect the public. 

9.  The Panel considered whether to impose an Interim Order. In its findings on impairment the Panel concluded that there is a need to protect the public from the risk of harm. The Panel decided that it would be wholly incompatible with those earlier findings and the imposition of a Conditions of Practice Order to conclude that an Interim Order was not necessary for the protection of the public. The Panel decided that an Interim Order was necessary in the wider public interest for similar reasons but agreed that there was no evidence to suggest that an Interim Order was necessary in the Registrant’s own interests.

10. The Panel therefore determined that an Interim Conditions of Practice Order is appropriate and proportionate pending the expiration of an appeal period, although determined that a 12 month Interim Order in line with the primary Order made was more proportionate, rather than an 18 month Order.

11. In relation to the date the Interim Conditions of Practice Order came into effect with regard to the conditions included in the Order, the Panel agreed that an Interim Order would come into effect immediately and where conditions stipulated completion within a timescale of the Order coming into effect, that timescale would start immediately.

12. The Panel took into account the Registrant’s interests, but decided that his interests were outweighed by the need to protect the public. The Panel concluded that an Interim Conditions of Practice Order should be imposed on public protection grounds and otherwise in the public interest.

The Panel makes an Interim Conditions of Practice Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and is otherwise in the public interest.

This Order will expire:

i.  (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; 
ii. (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal.

The length of this Interim Order is 12 months.

History of Hearings for Mark Pilmoor

Date	Panel	Hearing type	Outcomes / Status
12/10/2026	Conduct and Competence Committee	Final Hearing	Conditions of Practice