Mr Senu T Sejoro

: Radiographer

: RA51745

Interim Order: Imposed on 12 Feb 2016

: Final Hearing

Date and Time of hearing:10:00 06/03/2017 End: 17:00 08/03/2017

: Health and Care Professions Council, 405 Kennington Road, London, SE11 4PT

: Conduct and Competence Committee
: Suspended

Allegation

Allegation (as amended at final hearing):

While registered as a Radiographer, and employed as Sonographer at East Lancashire Hospitals NHS Trust:

1. On or around 5 May 2015 during Patient A's 20 week scan, you:

a. fell onto Patient A's abdomen;

b. applied pressure to Patient A's abdomen by pushing yourself up to your feet;

2. On the following dates, you entered the patient assessment information onto the incorrect patient's file:

a. 5 May 2015; and

b. 21 July 2015.

3. On or around 10 July 2015 in relation to Patient B, you did not:

i. complete the liquor volume and/or Doppler accurately;

ii. complete the growth test as requested;

4. On or around 27 July 2015, you did not communicate effectively with Patient C during a scan;

5. The matters set out in paragraphs 1 – 4 constitute misconduct and/or lack of competence.

6. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.

Finding

Preliminary matters:

Proof of Service

1.  The Panel was satisfied that good service has been effected. On 9 September 2016 a notice of hearing was sent to the Registrant’s registered address and to the email address he had provided to the HCPC which identified the date, time, location and purpose of this fitness to practise hearing.

Proceeding in Absence

2.  The Panel next considered an application to proceed in the absence of the Registrant. Mr Foxsmith drew the Panel’s attention to an email sent by the Registrant to the HCPC on 30 August 2016 in which he stated that he would not be able to attend the hearing and that he was in Nigeria.

3.  On behalf of the HCPC, Mr Foxsmith submitted that the Registrant had voluntarily waived his right to be present at this hearing. He noted that the Registrant had not requested an adjournment of these proceedings and that there was no indication that an adjournment would secure the Registrant’s attendance at a later date. Mr Foxsmith told the Panel that the HCPC proposed to call three witnesses. Two witnesses had travelled a considerable distance to attend the hearing and to assist the HCPC.  The third had made arrangements to be available to give evidence by telephone. He submitted that it was in the public interest and in the Registrant’s interest that this hearing proceed.

4.  Before reaching its decision the Panel considered the HCPC Practice Note on ‘Proceeding in the Absence’ and accepted the advice of the Legal Assessor.  The Panel determined that this hearing should proceed in the absence of the Registrant. It was satisfied that the Registrant had voluntarily waived his right to be present or represented at this hearing. He was aware of these proceedings and had elected not to participate in them. He had had the opportunity to seek a postponement or an adjournment of this hearing but he had not done so. The Panel did not consider that an adjournment would secure the Registrant’s attendance at a future hearing. It was satisfied that it was in the public interest to ensure that matters concerning a registrant’s fitness to practise were dealt with in a timely manner.

 It noted that the factual Particulars in this case dated from May – July 2015. The Panel was also mindful that there were three witnesses who had made themselves available to give evidence at this hearing and they would be put to further inconvenience if this matter did not proceed today. Finally, the Panel was satisfied that it would be able to deal justly and fairly with the issues in this case, notwithstanding the absence of the Registrant, as the Registrant had provided some written representations some time ago which indicated what his position may have been had he attended.

Application to Amend

5.  On behalf of the HCPC, Mr Foxsmith applied to amend the allegation against the Registrant. He submitted that the purpose of the proposed amendments was to clarify the nature of the case which the HCPC brought against the Registrant and to narrow the scope of the Particulars of the allegation.

6.  The Panel accepted the advice of the Legal Assessor before determining the application to amend. The Panel noted that the first proposed amendment was to discontinue sub - Particular 1(c). This amendment clearly caused no prejudice to the Registrant. The proposed amendments in respect of Particulars 3 and 4 narrowed the scope of the allegation and identified more precisely the actions which the Registrant was asked to undertake. The Panel did not consider that these amendments materially changed the case which the Registrant was being asked to meet. They did not cause any prejudice to the Registrant. Accordingly, the Panel decided to exercise its discretion to amend the allegation.

Application for Special Measures

7.  Mr Foxsmith, on behalf of the HCPC, applied for permission for Patient C to give evidence by telephone. He explained Patient C had two young children, one of which was a new-born with a health issue so Patient C could not attend in person. Options for attendance had been explored with Patient C and the only effective mechanism was for her to give evidence by telephone.

8. The Panel, having accepted advice from the Legal Assessor, was satisfied it was proportionate for Patient C to attend by telephone in light of her personal circumstances. This would allow her to give evidence and ensure that matters were not unduly delayed. There would be no prejudice to the Registrant as Patient C’s evidence would not be any different if she was to attend in person. It was in the public interest to allow the application.

Background

9.  The Registrant is a Radiographer. He was employed to work at the East Lancashire Hospitals Trust (“the Trust”) as a Band 7 Sonographer from 1 April 2015. His appointment was subject to a six month probationary period and was terminated on 28 July 2015.

10. The Registrant received a Trust departmental induction on the morning of his arrival at the Trust. On that day he was also placed in clinical sessions where he accompanied qualified, experienced sonographers. On 13 and 14 April 2015, the Registrant attended a two day corporate induction training programme.

11.  On 3 June 2015, the Registrant had his first probationary review which identified areas of concern in relation to his skills and practice. The Registrant was provided with an action plan with specific tasks identified for improvement. It was agreed that he would also receive additional training sessions provided by staff  on the ultrasound systems used in the hospital and that he would be monitored and mentored for 4 weeks in all aspects of ultrasound except growth scans.

12. On 10 June 2015, the Registrant was placed on a formal performance management plan because his performance had not improved to a satisfactory level. There was a further meeting with the Registrant on 12 June 2015 at which he was advised that he would be called to a formal hearing regarding his performance. The Trust subsequently referred the Registrant to the HCPC.

Decision on Facts

13. The Panel heard evidence from three witnesses for the HCPC. Patient C gave evidence about her attendance at the hospital on 27 July 2015 for a scan which was conducted by the Registrant. Witness 1 is the Clinical Ultrasound Lead for the Trust and is responsible for the ultrasound department. She was the Registrant’s line manager and worked with him during his probationary period. Witness 2 is the Deputy Clinical Ultrasound Lead.

14. The Panel accepted the evidence of Patient C who gave a clear and credible account and had a good recollection of events and how she felt at the time. This was her first pregnancy and so the Panel accepted that she was able to recall the matters in question and how they had affected her.

15. Witness 1’s recollection of events was not always clear. In particular, she was uncertain about a number of dates when incidents were said to have occurred and was unable to explain apparent anomalies in the dates recorded on hospital records and in her witness statement. Nonetheless, the Panel concluded that Witness 1 was doing her best to recall events and to assist. Witness 1’s evidence was balanced and considered, for example, she fairly stated that, in relation to one scan which the Registrant did not successfully complete, she, as a very experienced sonographer, would not have obtained a better image of the baby’s spine, at that time due to the baby’s position.

16. The Panel found Witness 2 to be a helpful, credible and fair witness. She explained the procedures and processes used in the department clearly.

17. The Panel has reminded itself that it is for the HCPC to prove the facts which it alleges and that the standard of proof is on the balance of probabilities.

Particulars 1(a) and 1(b)

18. The Panel accepted the evidence of Witness 1 who was present in the scanning room with Patient A and the Registrant, and who witnessed this incident. Although unable to explain exactly how the incident had come about, Witness 1 gave a vivid description of what the Panel accepted would have been an unusual occurrence. A Datix incident report form, although not contemporaneous, recorded that an incident occurred on 5 May 2015. The report recorded that Patient A failed to attend a subsequent planned scan because the Registrant had fallen on her whilst she was on the couch and pushed himself up on her abdomen. The Panel considered that the description in the incident report form completed by a midwife and the account given by Witness 1 were consistent with the facts alleged in Particular 1(b).

19. The Panel found Particulars 1(a) and 1(b) proved.

Particular 2(a)

20. Witness 2 stated in her evidence that the Registrant made an error on 5 May 2015 in that he entered the report of his assessment on Patient A on to the wrong patient file. She recalled the matter because it had occurred on the same day that the Registrant had fallen on to Patient A’s abdomen and applied pressure on it to push himself back to his feet. Witness 2 recalled that the error was rectified on the same day as the antenatal clinic realised that the error had been made.

21. Witness 1 gave evidence which supported this account. 

22. The Panel accepted the evidence of both these witnesses. It found Particular 2(a) proved.

Particular 2(b)

23. Witness 1 gave evidence in relation to this matter. She confirmed that her witness statement contained an error in that it referred to the incorrect Datix incident report form in relation to this matter. Witness 2 was alerted to the fact that the Registrant had made an error in inputting information on to the wrong patient’s record but she was unable to recall any specific details of the error or the incident.

24. The Panel was satisfied that, taken together, the oral evidence of Witness 1 and Witness 2 and the Datix incident reports were sufficient evidence to prove Particular 2(b). The Panel therefore found Particular 2(b) proved.

Particular 3(i)

25. The Panel accepted the evidence of Witness 2 on this matter. Witness 2 explained that Doppler is an ultrasound technique used to assess the flow of blood from the placenta to the foetus. Liquor volume refers to the fluid around the foetus. It can be established using ultrasound, albeit that accurate measurement is difficult. She told the Panel that experienced sonographers could gauge liquor volume without measuring. The liquor volume provides a means of assessing the functioning and health of the placenta.

26. Witness 2 told the Panel that the Registrant satisfactorily completed the Doppler test but did not accurately complete the liquor volume test. Her evidence was that in order to make an accurate assessment a sonographer would be expected to consider previous liquor volume readings, particularly if they were substantially different to the reading s/he obtained.

27. The Panel therefore found Particular 3(i) proved but only in relation to completing the liquor volume accurately.

Particular 3(ii)

28. The Panel accepted the evidence of Witness 2 that the Registrant was requested to complete growth measurements in respect of this Patient’s baby and did not do so.  Growth measurements had not been taken in the last two weeks, as such, Witness 2 stated that local protocol confirmed the need for the growth measurements to be taken. The Panel therefore found Particular 3(ii) proved.

Particular 4

29. The Panel accepted the evidence of Patient C about her experience of a scan on 27 July 2015 which it found compelling. It accepted her description of the Registrant’s poor communication and found Particular 4 proved.

Decision on Grounds

30. The HCPC relied on the statutory grounds of misconduct and/or lack of competence.

31. Before reaching its decision the Panel carefully considered all of the evidence before it. It heard submissions from Mr Foxsmith and accepted the advice of the Legal Assessor.

32. The Panel noted that there was no statutory definition of ‘misconduct’ but that it is a word of general effect which connotes some act or omission which falls short of what would be proper in the circumstances. Instances of misconduct tend to arise where the Registrant knows what he is required to do and is capable of performing to the required standard but where there is a deliberate, reckless or wilful failure to do what should be done.

33. Lack of competence is a pertinent description where the Registrant is unable to perform to the required standard.

34. In either case the HCPC “Standards of conduct performance and ethics” (2012) and the HCPC “Standards of proficiency for Radiographers” (2012) provide a useful benchmark in respect of the applicable standards of conduct, behaviours, relevant knowledge and skills for a Radiographer. The Panel therefore had regard to those standards.

35. Having carefully considered the evidence available the Panel concluded that the statutory ground which properly described the Registrant’s acts and omissions was that of a lack of competence. The evidence indicated that the Registrant was unable, rather than unwilling, to improve his work to the required standards. He was provided with training and mentoring to assist him in the performance of his duties and he was given time to improve. However, his knowledge, skills and work rate did not improve enough to enable him to work as an autonomous practitioner.

36. The Panel considered that the ultrasound scans that he was tasked with undertaking and which underpin Particulars 1, 3 and 4 of the allegation, were fundamental to his duties as a Band 7 Radiographer and that he ought to have had sufficient knowledge and skills to perform them competently at the outset of his probationary period. Similarly, accurate record keeping and effective communication skills, which underpin Particulars 2 and 4 of the allegation, are fundamental to safe and effective practise in any health care profession.

37. The Panel considered the Registrant’s conduct alongside the evidence as to the standards to be expected of a Radiographer of the Registrant’s experience in a similar situation. The Panel considered that by his acts and omissions the Registrant was in breach of standards 6, 7 and 10  of the HCPC “Standards of conduct performance and ethics” (2012); and of standards 1.1, 8.1, 8.9, 9.3 and 10 of the HCPC “Standards of proficiency for Radiographers” (2012).

38. The implications of the Registrant’s lack of competence in conducting and recording ultrasound assessments and effectively communicating with colleagues and patients were potentially serious.

39. Turning to the factual Particulars themselves the Panel concluded that Particular 1(a) did not, on its own amount to a lack of competence. It remained unclear exactly how the Registrant came to fall on Patient A. It was possible that he did so by accident.

40. As to Particular 1(b) the Panel noted the evidence of Witness 1 which suggested that the Registrant lacked awareness of the potential risks of applying pressure to the patient’s pregnant abdomen in order to right himself. He reacted inappropriately to the situation he found himself in. The Panel considered that in so doing the Registrant fell below the standards expected of a competent Radiographer. It concluded that his behaviour demonstrated a lack of competence which was serious as it could have placed the patient at risk of harm.

41. The Panel noted Witness 2’s evidence that errors in recording results in patient electronic records occurred in the department about once a week. The Panel also noted Witness 1 stated that the department had a large team of Sonographers and that it would be unusual for the same individual to be responsible for two instances of incorrect recording in a very short space of time.

42. In the Registrant’s case he had made the same error on two occasions and he failed to pick up the error himself. The Registrant was dealing with two or three patients per session compared to his colleagues who had a bigger patient caseload (10 -12 per session). The Registrant therefore had more opportunities to check his work than his colleagues but he did not do so effectively. His errors only came to light because other staff noticed the error in patient records and reported it to the Deputy Clinical Lead, Witness 2. An error of this kind is serious and poses a potential risk of harm to patients. The Panel did not consider that the repetition of such an error in a short space of time would be expected of a competent Radiographer. For these reasons the Panel considered that the facts of Particular 2 amounted to a lack of competence.

43. As to Particular 3, the Registrant’s actions placed mother and baby at significant risk of harm. The low level of liquor volume was one of a number of indicators which led to the decision to induce the patient. The Registrant failed to accurately measure the liquor volume, thereby missing a significant indicator. A repeat scan undertaken by Witness 2 on the same day identified low liquor volume confirming the Registrant’s error.  The Panel considered that the facts of this Particular demonstrated a lack of competence.

44. The Registrant failed to introduce himself to Patient C and did not explain what he was doing during the scan which lasted for some time. He listened to the foetal heartbeat for some time without explanation causing real anxiety to Patient C. He also asked her repeatedly if she was sure of her pregnancy dates without explaining why he was asking this question. Patient C was still sufficiently distressed 30 minutes after her scan that her treating Consultant noticed and had to provide her with reassurance. The Panel considered that the lack of communication skills demonstrated by the Registrant during this scan evidenced a lack of competence. As noted above, effective communication is fundamental to safe and effective practise as a Radiographer.

Decision on Impairment 

45. Before reaching its decision on impairment the Panel read carefully the Registrant’s written response to the allegation which he submitted to the Investigating Committee of the HCPC. The Panel admitted the Registrant’s response in evidence. Whilst the Panel disregarded the admissions which that document contained at the fact finding stage it considered that the response contained relevant evidence as to the Registrant’s reflection on the incidents giving rise to the allegation, including information about steps that he had taken to address the issues concerning his practice which he had identified.

46. The Panel had regard to the submissions made on behalf of the HCPC. It considered the HCPC Practice Note on ‘Finding Fitness to Practise Impaired’ and accepted the advice of the Legal Assessor.

47. The Panel reminded itself that it was making an assessment in respect of current impairment of the Registrant’s fitness to practise.

48. Having regard to the evidence it had heard and read and to the Registrant’s response to the allegation, the Panel considered that there was current impairment of the Registrant’s fitness to practise in respect of the personal component. His knowledge and skills as a Radiographer were deficient. There was no independent or objective evidence available to the Panel to demonstrate that he had remediated the deficiencies in his knowledge and skills so that he was now capable of safe and effective autonomous practice.

49. Whilst the Registrant had provided evidence of his reflections on his practise and of some continuing professional development which he has undertaken, the Panel did not consider that these activities were sufficient to remedy his lack of competence. Further, the Registrant’s reflections did not adequately explain what steps he had taken to ensure that incidents such as those found proved in this case would not happen again. In the circumstances, the Panel considered that there was a risk of repetition.

50. The Panel also considered the public component of impairment. It concluded that public confidence in the profession would be undermined if the serious instances of lack of competence found proved in this case did not result in a finding of current impairment.

Decision on Sanction

51. Before reaching its decision on what, if any, sanction to impose in this case the Panel heard submissions on behalf of the HCPC and accepted the advice of the Legal Assessor.

52. The Panel reviewed the Registrant’s representations to the Investigating Committee which met on 28 April 2016. In his response to the allegation the Registrant did not recall the incident which took place on or around 5 May 2015. However, he expressed remorse, apologised for his actions and took responsibility for those matters which he did recall.

53. The Panel considered the HCPC’s ‘Indicative Sanctions Policy.’

54. There were a number of aggravating factors in this case.  The Registrant’s lack of competence led to patients refusing to be scanned by him and had an impact on colleagues whose work levels increased as a consequence. His work rate was slow which meant that he was performing three scans per session whilst his colleagues completed ten or twelve per session. This further increased their workload. The failings identified in this case were wide-ranging.

55. The Panel identified a number of mitigating features. As noted above, the Registrant did express remorse for those matters he recalled and he accepted responsibility for them. The Registrant has demonstrated some insight, particularly in relation to Particular 3, which in the Panel’s view is the most serious Particular of the allegation. The Registrant has also expressed a willingness to improve his practice. The Registrant obtained a volunteer appointment which provided him with the opportunity to shadow a Sonographer in February 2016. It is not clear how long he held the voluntary appointment or what opportunities it afforded him to develop and improve his practice. The Registrant did not provide references from those who supervised him during this appointment. The Panel are aware from his 30 August 2016 email that the Registrant had returned to Nigeria by August 2016.  

56. The material which the Registrant submitted to the Investigating Committee included his reflections on the allegation. However, the Panel has no information on whether, and how, these reflections have been incorporated into his practice to ensure he is a safe and competent Radiographer.

57. The Panel had no information about the Registrant’s experience or qualifications save that Witness 2 recalled that he held a Post Graduate Diploma in Ultrasound and that he was registered with the HCPC.  The Panel also had no information about what work the Registrant had been doing for the past twelve months, nor did it have any indication of his future intentions.

58. The Registrant had provided some information about his continuing professional development reading but did not explain how he would use this to remediate his failings.

59. There has been limited engagement from the Registrant in this matter overall and no meaningful engagement from him in relation to the allegation since the Investigating Committee determined that this case should proceed to a final hearing.

60. The Panel considered that the Registrant’s failings are remediable but he has not yet taken appropriate steps to remedy the shortcomings in his practice. Accordingly, he presents a risk to those who may need to use his services.

61. The Panel has determined that there is a need to impose a sanction in this case. A Caution Order is not an appropriate sanction in this case. The Registrant’s lapses were not isolated or minor. He has not taken sufficient remedial action and the Panel cannot be assured that the risk of repetition is low.

62. The Panel considered a Conditions of Practice Order. So far as the Panel is aware, the Registrant is in Nigeria. The Panel does not know if he is in employment or if he continues in practice as a Radiographer. He has not engaged with the HCPC on this issue.

63. The Registrant’s failings are wide-ranging and some relate to basic skills expected of a competent Radiographer. Therefore it would not be possible to restrict him to specific areas of practice. In the absence of engagement from the Registrant at this final hearing it is not possible to formulate appropriate, verifiable and realistic conditions in this case. In addition, on the information available to it the Panel cannot be confident that the Registrant would comply with any conditions imposed on his registration.

64. The Panel have therefore determined that a Suspension Order is necessary to protect the public, to uphold professional standards and to maintain public confidence in the profession. The Panel considered that a Suspension Order for a period of twelve months would provide the Registrant with the time and the opportunity to re-engage with the HCPC. It will also enable him to consider how he proposes to remedy his lack of competence and to provide that information to his regulator.

65. The Registrant’s Suspension Order will be reviewed before it expires and this Panel considers that a future Review panel may be assisted by:

(1)  Information about any paid or voluntary work as a Radiographer that the Registrant has undertaken since February 2016;

(2) Evidence of any continuing professional development undertaken since February 2016;

(3) References from any recent employers;

(4) Further reflections from the Registrant which include an indication of how he intends to modify or change his practice to address the shortcomings which have been identified and ensure that they are not repeated.

Order

Order: The Registrar is directed to suspend the name of Mr Senu T Sejoro from the register for a period of twelve months from the date this Order comes into effect

Notes

The order imposed today will apply from the expiry of the appeal period of 28 days.

This order will be reviewed by the Committee no later than 04 April 2018 or earlier if new evidence which is relevant to the order becomes available after it was made.

Hearing history

History of Hearings for Mr Senu T Sejoro

Date Panel Hearing type Outcomes / Status
28/02/2018 Conduct and Competence Committee Review Hearing Suspended
06/03/2017 Conduct and Competence Committee Final Hearing Suspended