Mr Punithan Dhanaraj

: Radiographer

: RA62044

: Final Hearing

Date and Time of hearing:10:00 07/03/2017 End: 17:00 13/03/2017

: Radisson Blu Hotel, 80 High Street, The Royal Mile, Edinburgh, EH1 1TH

: Conduct and Competence Committee
: Caution

Allegation

(As amended at the final hearing on 07 March 2016)
Between 12 May 2010 and 4 September 2015, whilst registered as a Radiographer and during the course of your employment at NHS Tayside, you:
1) On 27 April 2015:
a) Did not carry out a short T1 inversion recovery (STIR) sequence in respect of Service User A, which was recorded on the Computerised Radiology Information System (CRIS) system and requested by Colleague F.
b) As a result of your actions described in paragraph 1a) above, Service User A had to be recalled to hospital.
2) On 1 May 2015:
a) Sent Service User B away, before Colleague B had an opportunity to review Service User B's scans;
b) As a result of your actions described in paragraphs 2a) Service User B had to be recalled to hospital.
3) On 1 June 2015:
a) Did not carry out requests of Colleague B in respect of Service User C which were recorded on the CRIS system, namely:
i. the T1 Sagittal oblique sequence in addition to routine scans;
ii. the correct position of the medial muscle body on the scans;
b) As a result of your actions described in paragraphs 3a) i - ii above Service User C had to be recalled to hospital.
4) On 3 June 2015:
a) 
i. Did not follow instructions on the CRIS system as requested by Colleague C;
ii. Sent Service User D away before Colleague C had the opportunity to review Service User D's scans.
b) As a result of your actions described in paragraphs 4a) i - ii, Service User D had to be recalled to hospital.
5) On 11 June 2015, did not carry out the T1 fat sat pre and post contrast scans as requested by Colleague D in respect of Service User E.
6) On 6 July 2015, did not:
a) Attend to and/or communicate with Service User F, despite being informed that he was unwell and in pain, by Colleague E;
b) Communicate with colleagues to ensure the wellbeing of Service User F.
c) Scan Service User G in a timely manner and/or communicate with colleagues in order to prioritise Service User G's scan.
7) The matters described in paragraphs 1 to 6 constitute misconduct and/or lack of competence.
8) By reason of your misconduct and/or lack of competence your fitness to practise is impaired.

Finding

Preliminary matters:
1. The case for the Health and Care Professions Council (“HCPC”) was presented by Ms Charlotte Mitchell-Dunn of Kingsley Napley, Solicitors. The Registrant was present and unrepresented.
Application to amend the allegation:
2. The Panel thereafter considered Ms Mitchell-Dunn’s application to amend Particulars 1 to 6 by deleting the word “patient” and substituting “Service User”; to amend Particular 2b) by deleting “- ii above”; to amend Particular 3a)ii) by deleting the words “the medial muscle body scan “ and substituting “the correct position of the medial muscle body on the scans”; to delete Particular 3a)iii; to amend Particular 3b) by deleting “iii” and substituting “ii” and to amend Particular 6a) by deleting the words “who was” and substituting “despite being informed that he was”  and deleting the words “as requested”.  Ms Mitchell-Dunn advised that the Registrant had been given notice of the amendment. The Registrant confirmed that he had no objection to the proposed amendments. Ms Mitchell-Dunn advised that the amendments were such that there would be no prejudice caused to the Registrant in allowing the amendment.
3. The Panel considered the submissions of Ms Mitchell-Dunn and the advice of the Legal Assessor. The Panel was satisfied that the amendments better reflected the evidence and did not cause any prejudice or injustice to the Registrant. The Panel therefore agreed to grant the application.
4. The Registrant thereafter admitted the facts of Particulars 1 to 5, as amended, and denied the facts of Particular 6.
Background:
5. The Registrant was employed as a Band 6 Specialist MRI Radiographer by NHS Tayside in the MRI Clinical Radiology Team at Ninewells Hospital and Perth Royal Infirmary. He commenced his employment as a Locum Radiographer with NHS Tayside in November 2009. Following a successful interview he became a permanent member of staff in May 2010. He was responsible for all service users undergoing MRI examinations.
6. It is alleged that between 27 April 2015 and 6 July 2015, the Registrant was involved in a number of incidents involving service users.
7. From April until June 2015 it is alleged that there were five incidents whereby he did not follow instructions on the Computerised Radiology Information System (CRIS), and/or the specific instructions of a Radiologist, and/or follow protocol. This meant that he did not carry out accurate scans on service users, and/or sent service users away prior to receiving instructions from a Radiologist.
8. On 6 July 2015, it is alleged that the Registrant did not attend to a service user, despite being informed that he was unwell. It is alleged that subsequently he did not scan a second service user in a timely manner and communicate with colleagues to prioritise this service user’s scan. 
Decision on Facts:
9. The Panel heard oral evidence from three witnesses on behalf of the HCPC, all of whom were employed by NHS Tayside at the time of the allegations:  WM, Lead MRI Radiographer and the Registrant’s Line Manager and who was also appointed as Investigating Officer in respect of the issues identified in relation to the Registrant’s performance; MV, Radiography Assistant and AL, Consultant Radiologist. The Panel also heard evidence from the Registrant.
10. The Panel found WM gave clear and consistent evidence which was linked to a thorough investigation. The Panel found that she was open and honest in her evidence and admitted if she was unable to answer any questions put to her. The Panel also found AL provided clear evidence which, although narrow in its scope, relating as it does, only to Particular 5, was consistent with her statement and again she was clear about the limits of her evidence and admitted if she could not answer any particular questions.  The Panel found MV to be a clear, consistent and confident witness, although her evidence was limited in its scope, related only to Particular 6. It was evident to the Panel that she was motivated to give evidence by her concern for her patient’s welfare.   The Panel therefore found all three HCPC witnesses to be credible.
11. The Panel found the Registrant to be unreliable in his evidence. The Panel found that his evidence before the Panel differed in several respects to the statements he had given in the course of his investigatory interview with NHS Tayside and in his written submission to the Panel. It appeared to the Panel that in some instances, it was convenient for him to have no memory of a particular incident and his memory was self-serving.
12. Where the evidence of the Registrant conflicted with that of the HCPC witnesses, the Panel preferred the evidence of the HCPC witnesses. 
Particulars 1a) and b)
13. The Panel heard evidence from WM in support of this Particular and had sight of the notes of the Registrant’s interview with WM on 20 July 2015 in which he stated that he saw this in CRIS but forgot to do it. The Panel also had sight of the extract from CRIS regarding Service User A and the contemporaneous file note by WM in which the Registrant stated that he did not do the scan and that he had not seen it in CRIS and in which it is noted that the patient had to be recalled.  This shift in explanation by the Registrant is a demonstration of the Panel’s finding of the unreliability of his evidence.  The Panel is therefore of the view that the Registrant’s admissions in regard to this Particular are supported by the evidence and documentation produced by the HCPC and the Panel is satisfied that the facts of Particulars 1(a) and (b) are proved to the requisite standard. 
Particulars 2a) and b)
14. The Panel heard evidence from WM in support of this Particular and also considered the notes of the Registrant’s interview with WM, on 20 July 2015 in which he advised that he called the Radiologist to come and check the scan but he did not respond so the Registrant sent the patient home. In his oral evidence to the Panel the Registrant claimed that he had made additional efforts to contact the Radiologist. He had not made these assertions before. Again this shift in explanation demonstrated the unreliability of the Registrant’s evidence. The Panel also had sight of the extract from CRIS regarding Service User B and the contemporaneous file note by WM in which it is noted that the service user had to be recalled later that day. The Panel is therefore of the view that the Registrant’s admissions are supported by the evidence and documentation produced by the HCPC and the Panel is satisfied that the facts of Particulars 2(a) and (b) are proved to the requisite standard. 
Particulars 3a) and b)
15. The Panel heard evidence from WM in support of this Particular and considered the notes of the investigatory meeting with WM on 20 July 2015 and the Registrant’s explanation before the Panel.  The Panel has also had sight of the extract from CRIS in respect of Service User C from which it can be seen that there was a clear instruction that the scan sequences were not performed to the requested protocol and vital anatomy was not demonstrated.  The outcome was that the patient had to be recalled.  The Panel has therefore concluded that the Registrant’s admissions are supported by the evidence and documentation produced by the HCPC and the Panel is satisfied that the facts of Particulars 3(a) and (b) are proved to the requisite standard. 
Particulars 4a) and b)
16. The Panel heard evidence from WM in support of this Particular. The Panel has also considered the extract from CRIS in respect of Service User D which indicates that there was a specific instruction to review the standard scan sequences. The Panel has also heard evidence for WM that Service User D had to be recalled and scanned again on the same day. The Panel has therefore concluded that the Registrant’s admissions are supported by the evidence and documentation produced by the HCPC and the Panel is satisfied that the facts of Particulars 4(a) and (b) are proved to the requisite standard. 
Particular 5
17. The Panel heard evidence from WM that, having reviewed the scans for Service User E, it was clear that the Registrant had not carried out the scans as requested by AL. The Panel heard from AL that she gave verbal instructions to the Registrant as to the scans required. In his evidence, the Registrant accepted he had heard the instructions and understood them but then failed to carry them out. The Panel has therefore concluded that the Registrant’s admissions are supported by the evidence and documentation produced by the HCPC and the Panel is satisfied that the facts of Particular 5 are proved to the requisite standard. 
Particulars 6a) –c)
18. The Panel heard evidence from WM and MV in relation these Particulars. The Registrant denied these Particulars.
19. With regard to particulars 6a) and 6b), MV gave evidence that she informed the Registrant that Service User F was unwell and asked the Registrant to take a look at him. She also advised that she left the safety questionnaire with him. She stated that she came back approximately twenty minutes later and the Service User had not been seen. The Registrant has in evidence told the Panel that he had no memory of MV telling him the service user was unwell. He did not accept that MV told him about this service user and he ignored her. However previously, in the investigatory interview with WM on 20 July 2015, the Registrant’s position was that he told MV that he was scanning a patient and to leave the checklist on the table. The Panel prefers the evidence of MV who has been consistent throughout the internal investigatory process and before this Panel as opposed to the Registrant whose version of events has changed. The Panel therefore finds the facts of Particulars 6a) and b) proved to the requisite standard.
20. With regard to Particular 6c), the Panel considered the evidence of MV together with the documentary evidence.  From the scan images, it is clear that Service User F, the Service User who preceded Service User G on the scanner, was last scanned at 16.22.58 and Service User G was taken into the scan room prior to 16.50.38, the time documented in the scan produced within the bundle. In the intervening period, Service User F, who was unwell, would have been taken from the scanner, and the room would have been prepared for the next service user. The Panel does not consider that this time period was unreasonable and is not satisfied that this amounted to a failure to scan in a timely manner.  The Panel therefore does not find this Particular proved.
Decision on Grounds:
21. The Panel next considered whether the Registrant’s actions in Particulars 1 to 6 amount to misconduct and/or lack of competence. The Panel is aware that this is a matter for its professional judgement. In reaching its decision, the Panel has also considered the advice of the Legal Assessor.
22. The Panel has considered Particulars 1 to 5 and is of the view that the Registrant’s conduct breached the following standards of the HCPC’s Standards of Proficiency for Radiographers:-
• Standard 1 – You must be able to practise safely and effectively within your scope of practice and in particular must know the limits of your practice and when to seek advice or refer to another professional and be able to manage your own workload and resources effectively and be able to practise accordingly.
• Standard 4 – You must be able to practise as an autonomous professional exercising your own professional judgement and in particular be able to assess a professional situation, determine the nature and severity of the situation and call upon the required knowledge and experience to deal with the problem.
• Standard 8 – You must be able to communicate effectively and in particular be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others.
• Standard 9 – You must be able to work appropriately with others and in particular be able to work, where appropriate, in partnership with service users, other professionals, support staff and others.
• Standard 13 – You must understand the key concepts of the knowledge and in particular recognise the role of other professionals and services in health and social care and be able to distinguish between normal and abnormal appearances evident on images. 
• Standard 14 - You must be able to draw on appropriate knowledge and skills to inform practice and in particular be able to conduct appropriate diagnostic or monitoring procedures, treatment, therapy or other actions safely and accurately. 
23. The Panel is of the view that the Registrant’s actions during the period April to July 2015, demonstrate a pattern of behaviour which is indicative of a lack of the skills, knowledge and experience necessary to conduct scans appropriately.  During this period, the Registrant’s professional performance was unacceptably low as is demonstrated by his failure to follow instructions and protocols and by the repetitive nature of these five Particulars, despite the support and guidance offered by his line manager. In these circumstances the Panel has concluded that his actions amount to a lack of competence as opposed to misconduct.
24. The Panel is of the view that the Registrant’s conduct in Particulars 6a) and b) represented a deliberate and wilful course of action. This fell far short of what would be proper in the circumstances and breached the following standards of the HCPC’s Standards of Conduct, Performance and Ethics in force at the relevant time :-
• Standard 1 – You must act in the best interests of service users
• Standard 7 – You must communicate properly and effectively with service users and other practitioners.
• Standard 13 – You must behave with …… integrity and make sure that your behaviour does not damage the public’s confidence in you or your profession.
25. The Panel considers that the Registrant’s conduct towards a particularly vulnerable service user fell well below the standards expected of a registered health professional. In these circumstances, the Panel is satisfied that the Registrant’s conduct in Particulars 6a) and b) amounts to misconduct.
Decision on Impairment:
26. The Panel next considered whether the Registrant’s current fitness to practise is impaired by that misconduct and lack of competence. In reaching its decision the Panel has considered both the personal component and the public component together with the advice of the Legal Assessor.
27. In terms of the personal component, the Panel has heard evidence from the Registrant that he is sorry for his actions and accepts he made mistakes. He has apologised for the impact on patients and has advised that he was under stress at the time. In addition, the Registrant has admitted the facts of Particulars 1 to 5 which demonstrates a level of insight on his part.   The Panel has also had sight of a positive reference from InHealth, the Registrant’s current employer, where he has been employed since January 2016. In addition, the Registrant has passed all his Core Competencies with InHealth and is now in a permanent position, having successfully completed his probationary period and completed further training. In respect of the lack of competence, the Panel is satisfied that the Registrant has demonstrated insight, remorse and remediation such that the risk of repetition is very low. In relation to the finding of misconduct and the facts of particular 6a) and b), the Panel is not satisfied that the Registrant has fully understood the gravity of his inaction. However, he has worked for a period of approximately 14 months with InHealth and has produced a positive reference from them, leading the Panel to conclude that the risk of repetition is low.
28. In terms of the public component, the Panel has found that the Registrant repeatedly failed to follow protocols and instructions, resulting in the need to recall four patients to hospital and has found wilful misconduct in relation to Service User F. The Panel has concluded that there is a serious risk of an adverse impact on public confidence in the Radiography profession and in the regulatory process, if a finding of impairment were not made in these circumstances.
29. The Panel therefore finds that the Registrant’s current fitness to practise is impaired by his misconduct and lack of competence and is satisfied that the allegation is well founded
Decision on Sanction:
30. The Panel has heard submissions from Ms Mitchell-Dunn and from the Registrant on the issue of sanction. The Panel has also considered the advice of the Legal Assessor and had regard to the HCPC’s Indicative Sanctions Policy.
31. The Panel is aware that the purpose of sanction is not to be punitive and that it must consider the risk the Registrant may pose to those using or needing his services in the future and determine what degree of public protection is required. The Panel must also give appropriate weight to the wider public interest which includes the deterrent effect on other Registrants, the reputation of the profession and public confidence in the regulatory process.
32. The Panel considered the following mitigating factors:- the Registrant has had no previous referrals to the HCPC; the issues arose over a relatively short period of time in the Registrant’s career; he has fully engaged with the process and made admissions as to the majority of the factual particulars. He stated in evidence that he was under stress at the time of the incidents. He has been working as a Radiographer for approximately 14 months and produced to this hearing, a positive testimonial from his current employer. With this employer, he has successfully completed his probationary period and passed his Core Competencies. He has undertaken further training with this employer, including training on MRI.  He has demonstrated full remorse, some insight and has advised the Panel that he has learned from his mistakes. 
33. The Panel also had regard to the following aggravating factors:- the Registrant demonstrated repeated failures, despite being alerted to the failings after each occasion; his actions resulted in the recall of 4 service users and a further vulnerable service user, who was in pain, was left waiting unnecessarily. 
34. The Panel has considered the sanctions available to it in ascending order of severity. The Panel first considered whether to take no further action. It is of the view that this would not be sufficient to address the wider public interest considerations. 
35. The Panel then considered a Caution Order. In terms of the Indicative Sanctions Policy, a Caution may be appropriate where the lapse is isolated or of a minor nature, there is a low risk of recurrence and the Registrant has shown insight and taken remedial action.
36. It is clear from the reference from his employer that the Registrant has successfully completed his probationary period, completed and passed all his Core Competencies and undertaken further training, including an MRI Imaging course. The Panel has accepted that he has remediated his failings in relation to the matters amounting to a lack of competence.  In addition, the Registrant has demonstrated some insight into these matters and the Panel has identified a low risk of repetition. In relation to Particular 6, from the Registrant’s submission on sanction, it is clear to the Panel that the Registrant has now been able to articulate a level of remorse and insight in relation to this matter. Throughout this hearing, the Panel appreciated, and has taken account of, the element of difficulty for the Registrant in that English is not his first language.   His level of remorse and insight in relation to Particular 6 is now such that the Panel has found the risk of repetition is low. The Panel is also of the view that a Caution Order would be sufficient to address the critically important public policy issues.  In these circumstances, the Panel is of the view that a Caution Order would be an appropriate and proportionate sanction.
37. The Panel also considered the appropriateness of a Conditions of Practice Order. However, given that the Panel is satisfied that the Registrant has already addressed the personal component of his conduct, the Panel concluded that practice conditions would not be appropriate. The Panel further considered the appropriateness of a Suspension Order, and concluded that it would be disproportionate in the circumstances of this case where the incidents arose over a relatively short time frame and the Registrant has been working successfully for the last 14 months.
38. The Panel is aware that the benchmark for a Caution Order is three years. In all the circumstances, the Panel has concluded that a period of three years would be sufficient to mark the Registrant’s conduct.

Order

The Panel directs the Registrar to annotate the Register Entry of Punithan Dhanaraj with a Caution Order for a period of three years from the date that this order takes effect.

Notes

This Conduct and Competence Committee Panel Final Hearing took place on 07-10 March 2017 at the Radisson Blu Edinburgh.

Hearing history

History of Hearings for Mr Punithan Dhanaraj

Date Panel Hearing type Outcomes / Status
07/03/2017 Conduct and Competence Committee Final Hearing Caution