Maria-Paz Olivares Penroz

: Radiographer

: RA49958

: Final Hearing

Date and Time of hearing:10:00 15/05/2017 End: 17:00 15/05/2017

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

: Conduct and Competence Committee
: Caution

Allegation

During the course of your employment as a Radiographer with Alliance Medical, you:

1. On 27 October 2015, in attempting to address the issue of missing images from the CT scan (bilateral ) hips you undertook on Patient R on 22 October 2015, did not seek advice on how to proceed from:
(a) the clinical lead;
(b) other AML radiographers;
(c) the registered manager.


2. Decided that Patient R should be rescanned, and:
(a) on 28 October 2015, exposed Patient R to an additional scan unnecessarily, which involved a high dose of radiation, without:
(i) required referral documentation;
(ii) the authorisation of a radiologist.
(b) did not 0raise the issue of potential overexposure with;
(i) the clinical lead;
(ii) other members of staff;
(iii) the registered member.


3. Did not explain the risk of over exposure of radiation to Patient R prior to re-scanning Patient R.

4. The matters set out in paragraphs 1 – 3 constitute misconduct and/or lack of competence.


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

Finding

Preliminary matters:

Service of Notice

1. The notice of this hearing was sent to the Registrant at her address as it appeared in the register on 29 November 2016. The notice contained the date, time and venue of today’s hearing.

2. The Panel accepted the advice of the Legal Assessor, and is satisfied that notice of today’s hearing has been served in accordance with Rule 6(1) of the Conduct and Competence Committee Rules 2003 (the “Rules”).

Proceeding in the absence of the Registrant

3. The Panel then went on to consider whether to proceed in the absence of the Registrant pursuant to Rule 11 of the Rules. In doing so, it considered the submissions of Ms Chaker on behalf of the HCPC.

4. Ms Chaker submitted that the HCPC has taken all reasonable steps to serve the notice on the Registrant. She submitted that it was in the interest of justice and also in the interest of the Registrant that this hearing proceed today, as the purpose of today’s hearing was to deal with this case by means of a consent order. On 10 May 2017, the Registrant wrote to the HCPC indicating that she would not be attending this hearing. Ms Chaker reminded the Panel that there was a public interest in this matter being dealt with expeditiously.

5. The Panel accepted the advice of the Legal Assessor. He advised that, if the Panel is satisfied that all reasonable efforts have been made to notify the Registrant of the hearing, then the Panel had the discretion to proceed in the absence of the Registrant.

6. The Legal Assessor referred the Panel to the case of GMC v Adeogba and Visvardis [2016] EWCA Civ 162 and advised that the Adeogba case reminded the Panel that its primary objective is the protection of the public and of the public interest. In that regard, the case of Adeogba was clear that “where there is good reason not to proceed, the case should be adjourned; where there is not, however, it is only right that it should proceed”.

7. It was clear, from the principles derived from case law, that the Panel was required to ensure that fairness and justice was maintained when deciding whether or not to proceed in a Registrant’s absence.

8. The Panel was satisfied that all reasonable efforts had been made by the HCPC to notify the Registrant of the hearing. It was also satisfied that the Registrant was aware of the hearing.

9. In deciding whether to exercise its discretion to proceed in the absence of the Registrant, the Panel took into consideration the HCPC practice note entitled ‘Proceeding in the Absence of a Registrant’. The Panel weighed its responsibility for public protection and the expeditious disposal of the case with the Registrant’s right to a fair hearing.

10. In reaching its decision the Panel took into account the following:
• The Registrant has not made an application to adjourn today’s hearing and implicit in her email dated 10 May 2017 is an expectation that proceedings today are conducted in her absence;
• The Registrant has engaged with the process and has submitted written representations and character references;
• There is a public interest that these matters are dealt with expeditiously.

11. The Panel was satisfied that the Registrant had voluntarily absented herself from the hearing. There is a distinction between a case where the Registrant is clearly aware of the hearing date, and one where there has been no response from the Registrant. The Panel was also satisfied that it would also be in the interest of the Registrant to proceed in her absence, in the light of the purpose of this preliminary hearing. Therefore the Panel decided to proceed in the Registrant’s absence.

Background:

12. The Registrant was employed as a Senior Radiographer with Alliance Medical Limited. The Registrant was also a Site Radiation Protection Supervisor. On 22 September 2015, the Registrant carried out a CT scan on Patient R. Upon subsequent inspection, the images of the scan appeared to be partially missing from the system. As a result, the Registrant called Patient R back to be rescanned on 28 October 2015. Prior to recalling Patient R, the Registrant did not obtain the required documentation, nor consult the relevant people in relation to reconstructing the images of the scan and the risk of over-exposure of radiation to Patient R. The Registrant also failed to advise Patient R to the risk of over-exposure prior to rescanning him.

13. The allegations came to light when the Registrant’s colleagues became suspicious of the Registrant’s explanation as to why Patient R was being rescanned and so checked the system. Their check revealed that the original scan was still accessible and that re-scan may not have been necessary. The Registrant had not followed the correct procedure for re-scanning the Patient.

14. The matter was referred to the HCPC. On 28 April 2016, a Panel of the Investigating Committee determined that there was a case to answer in relation to the allegation made against the Registrant.

15. Subsequent to the Investigating Committee’s decision, the Registrant made further representations to the HCPC. In the light of those representations, a decision was made by the HCPC that the appropriate method of dealing with this allegation is by way of Consent Order.

16. That is the application that is being made at this hearing.

Decision:

17. In coming to its determination, the Panel considered all the evidence in this case together with the submissions made by Ms Chaker on behalf of the HCPC.

18. The Panel also accepted the advice of the Legal Assessor. The Panel also reminded itself of its over-arching objective to protect the public and the wider public interest.

19. The Panel first considered whether the allegation made against the Registrant was well founded. In the light of the evidence before it, which included witness statements and documentary records, the Panel is satisfied that the HCPC’s case is well founded. The Panel determined that evidence demonstrated that this was a case of misconduct rather than one of lack of competence on the part of the Registrant. The Panel also determined that the allegation, taken in context, was sufficiently serious so as to amount to misconduct for the purposes of these proceedings.

20. The Panel then considered what the likely range of sanctions that could be imposed in the light of the evidence in this case, and compared that with the proposed course indicated in the Consent Order. In doing so, the Panel took into consideration the following factors:

(a) The full admissions made by the Registrant as to the facts, and that her fitness to practise was impaired.

(b) The seriousness of the allegation in the light of the circumstances of the incident.

(c) This was a single incident in an otherwise unblemished career.

(d) The level of insight demonstrated by the Registrant and the remediation undertaken.

(e) The positive references provided by senior colleagues of the Registrant.

(f) The Registrant self-referred these matters to the HCPC.

21. The Panel took into consideration the Indicative Sanctions Policy issued by the HCPC and determined that the just and appropriate sanctions available in this case would range from a Caution Order to Conditions of Practice Order. It determined that in the circumstances of this case, a Suspension Order would neither be a just nor an appropriate sanction in this case.

22. The Panel was satisfied that the evidence demonstrated that the Registrant has full insight into her misconduct, and that the misconduct is not liable to be repeated.

23. The Panel determined that a caution order would be the most likely sanction in this case if the matter proceeded to a substantive hearing. In particular, the Panel noted paragraph 28 of the Indicative Sanctions Policy, which states:

A caution order is an appropriate sanction for cases, where the lapse is isolated, limited or relatively minor in nature, there is a low risk of recurrence, the registrant has shown insight and taken appropriate remedial action. A caution order should also be considered in cases where the nature of the allegation means that meaningful practice restrictions cannot be imposed but where the registrant has shown insight, the conduct concerned is out of character, the risk of repetition is low and thus suspension from practice would be disproportionate. A caution order is unlikely to be appropriate in cases where the registrant lacks insight.

24. The Panel determined that Conditions of Practice would be an unlikely sanction in this case where:

(a)  it is one of misconduct,

(b) the evidence demonstrated that the Registrant has full insight into her misconduct; and

(c) their misconduct is not liable to be repeated.

25. In the circumstances, the Panel were satisfied that the terms of the Consent Order would:

(a) protect the public; and

(b) would not undermine public confidence in the profession or the regulatory process.

26. Notwithstanding the above, the Panel also considered whether this case was so serious that a public substantive hearing was necessary in the wider public interest. It determined that this case was not so serious as to make a public substantive hearing necessary.

27. In the circumstances, the Panel determined that a Consent Order that places a Caution against the Registrant’s name in the Register for a period of three years is a just and appropriate method of dealing with this case.

28. Panel therefore allows this allegation to conclude by way of consensual disposal as set out in the terms of the Consent Order before it.


 

Order

ORDER: That the Registrar is directed to annotate the register entry of Ms Maria-Paz Olivares Penroz with a caution which is to remain on the register for a period of three years from the date this order comes into effect.

Notes

No notes available

Hearing history

History of Hearings for Maria-Paz Olivares Penroz

Date Panel Hearing type Outcomes / Status
15/05/2017 Conduct and Competence Committee Final Hearing Caution