Deborah Knight-Griffiths

Preliminary Matters

The hearing to be conducted partly in private.

1. At the commencement of the hearing, Ms Marcelle-Brown requested that the Panel should make a direction that any evidence concerning the Registrant’s health or private life should be given in private. The Presenting Officer did not oppose that application. The Panel considered that, in order to protect the Registrant’s private life, the direction should be made. In fact, during the hearing, on a number of occasions the Panel directed that evidence should be given in private in accordance with this direction. However, the Panel has not considered it necessary to include in this determination any of the detail of the evidence that resulted in the hearing going into private sessions. Accordingly, this determination is a public document and there is no separate private version.

The factual particulars to be decided before any other elements of the case.

2. The Panel considered that this is a case in which it would be appropriate for the factual issues to be decided, and for the parties to be provided with the Panel’s written determination explaining those findings, before any other elements of the case should be considered.

3. The originally scheduled dates for which this case was listed for hearing were Monday, 18 March 2024 to Monday 25 March 2024, inclusive. During that period the Panel received all of the evidence the parties wished to introduce in relation to the factual issues, and also received the submissions of the parties on these issues. Further, there was sufficient time for the Panel to begin its deliberations during those dates. The Panel met in private on 7 May 2024, when it concluded its determination on the facts. On 8 May 2024, the determination on the facts was sent to the parties (with a statement that what was being sent would be subject to corrections of typographical errors). It was sent so that the parties would be prepared to make their submissions on misconduct and current impairment of fitness to practise on the resumption of the hearing on Monday, 15 July 2024. When the hearing resumed on that date, on the morning of the hearing, the Panel was again provided with the bundle of documents that is referred to in paragraph 56 below.

Amendment of the factual particulars.

4. During the hearing, on the application of the HCPC, the Allegation was amended to the form in which it appears above. The application was not opposed on behalf of the Registrant, and following legal advice the Panel agreed that it was appropriate for the amendments to be made, and that they would not give rise of a risk of prejudice to the Registrant. The Allegation referred by the Investigating Committee alleged that the eleven specific shortcomings now particularised as 1(b)(i) to (xi) were omissions that occurred in the context of a partial right second toe amputation; in other words, those alleged shortcomings could not be considered as steps that should have been taken if some procedure that could not properly be categorised as a partial amputation had been performed by the Registrant. Accordingly, the alteration of substance effected by the amendment was to separate out the contention that a partial amputation had been performed (particular 1(a)) and the various steps that it is was alleged should have been undertaken in any event (particular 1(b)(i) to (xi)).

Background

5. The Registrant is a Podiatrist. She has practised through her podiatry practice named First Steps Podiatry (“First Steps”).

6. At the relevant time, HM Forest Bank Prison (“the prison”) was operated by an organisation named Sodexo Justices Services (“Sodexo”). For some time before the events that are relevant to this case, there had been an agreement in place between Sodexo and First Steps that the Registrant would provide podiatric services to prisoners at the prison. The evidence before the Panel that, save when prevented from doing so by external events or matters such as the Registrant’s holidays, the Registrant would attend the prison on Fridays.

7. Service User 1 was a prisoner at the prison. He was a person in poor health. Included in his health problems was diabetes and, before the events with which the Panel has been concerned, he had already had his big toes amputated.

8. The HCPC’s criticism of the Registrant in this case is largely focused on the nature of the procedure she undertook on Service User 1’s right second toe during an appointment that took place on 13 November 2020. The HCPC contends that the procedure was a partial amputation (particular 1(a)), that that procedure should only have taken place in a hospital setting or as part of a hospital’s Diabetes Multidisciplinary Team (particular 5). As a consequence of the amendment described above, other criticisms are advanced that the HCPC contends would apply even if the procedure could not be described as a partial amputation. By particular 1(b), eleven specific pre-operative actions are alleged to have been omitted, and it is also alleged that the Registrant did not obtain a tissue sample and/or wound swab on 6 November 2020, a week before the date of the procedure. It is further alleged that the Registrant inappropriately sutured Service User 1’s wound (particular 4). The undertaking of the procedure in the prison and not as it is alleged it should have been done is said to have involved the Registrant acting outside her scope of practice (particular 6). Finally, by particular 3 there is a criticism that during the period 20 December 2019, to 13 November 2020, the Registrant did not maintain accurate and complete records in respect of the five specific matters there particularised.

9. In order for the evidence, and particularly for the relevance of the evidence of Person B, to be understood, it is necessary to record the fact that on 16 November 2020, Service User 1 was taken to Salford Royal Hospital (“the hospital”) where the relevant toe was examined.

10. A final matter that should be mentioned is that the majority of the events with which this case has been concerned (and all of them relating to the allegation of partial amputation) occurred during the Covid – 19 pandemic. It has been the Registrant’s case that this fact was relevant to her treatment of Service User 1 because it impacted on her ability to provide safe and effective care, for example as a result of staffing shortages in the prison and lack of supplies of clinical materials.

Decision on Facts

11. In approaching its decision on the facts, the Panel heeded the advice it received from the Legal Assessor. In particular, the Panel kept in mind throughout its deliberations the fact that the HCPC carried the burden of proving the alleged facts against the Registrant on a balance of probabilities; at no stage was it for the Registrant to disprove anything.

12. The HCPC called three witnesses to give evidence before the Panel. They were:

• Person A, who at the relevant time was employed by Sodexo as a Policy and Professional Practice Manager. Person A’s responsibilities extended over three prisons, of which the relevant prison was one. Included in her responsibilities was the clinical supervision of the Heads of Healthcare and Clinical Nurse Managers.

• Person B, an Advanced Podiatrist in High Risk Care at the hospital.

• Mr Robert Morley, a Consultant Podiatric Surgeon, who was presented by the HCPC as an expert witness.

13. In addition to the oral evidence of the three witnesses just described, the Panel was provided with witness statements made by both Person A and Person B, and a report dated 8 September 2022 prepared by Mr Morley. Furthermore, the HCPC’s hearing bundle contained approximately 550 pages of documentary exhibits.

14. The Registrant gave evidence. The hearing was scheduled to commence on Monday 18 March 2024. In the event, the commencement of the case was delayed to enable the Registrant to perfect a witness statement, which is dated 19 March 2024 and was served on that day. Additionally, contained in the HCPC hearing bundle were documents submitted by the Registrant in October 2021 for the purposes of the Investigating Committee’s “case to answer” deliberations. Included in these documents was a five page document headed “RESPONSE OF DEBORAH KNIGHT GRIFFITHS” (“the ICP response document”).

15. When the Panel deliberated on the factual issues in the case, it paid attention to the entirety of the evidence, both oral and written. It also had the benefit of closing submissions in writing prepared by the Presenting Officer and Ms Marcelle-Brown. To ensure that this determination is kept to a manageable length, the Panel will explain its reasons for its findings, but, in relation to documents, it will be only those that are particularly relevant that reference will be made.

16. In the light of the significance of resolving what the HCPC had proved as to the nature of the treatment provided by the Registrant to Service User 1 on 13 November 2020, the Panel considered that it was necessary to decide that issue first.

Particular 1(a) - The nature of the Registrant’s treatment of Service User 1 on 13 November 2020.

17. The evidence heard by the Panel suggested that there may have been others present when Service User 1 was treated, as there would have been a prison warder present or nearby. However, no such person was called to give evidence, and it would not be expected that a person not directly concerned would have been able to comment on what was, or what was not done. Person A was not present, and, indeed, stated in evidence that she had never met the Registrant. Person B was not present, her only contact with the Registrant was by email, and that was after 13 November 2020. It follows that the HCPC did not present any direct evidence as to what occurred.

18. The HCPC did put before the Panel, via the evidence of Person B, a hearsay account of Service User 1 about what occurred. If that hearsay account could be relied upon it would tend to support the HCPC’s case. However, the Panel was of the clear view that it would not be fair for that hearsay evidence to be relied upon. As with all hearsay evidence, it could be neither challenged nor explored in any meaningful way. Of greater significance, the evidence heard by the Panel was that Service User 1 could be confused, and it was the evidence of Person B that when Service User 1 said what he did about what had happened on 13 November 2020, he had initially been very vague and had been unable to provide much information. In all the circumstances, the Panel concluded that this was evidence that could not properly be relied upon; to do so would be unfair to the Registrant.

19. In order for the Panel to ensure that the application of the burden of proof underpinned any decision it made, it decided to analyse the case on the basis of the HCPC’s evidence. Only having done that, and only if that analysis tended to support case advanced against the Registrant, would it then consider the Registrant’s response to that case.

20. On 6 November 2020, the Registrant made an entry on the electronic recording system used at the prison, a system known as SystemOne. As with other quotations from such sources, the entry will be quoted as written, including typographical errors. The entry for 6 November 2020, reads as follows:

“History: previous podiatry
Examination: right 2nd infected toe with distal falange protruding , left 2nd toe still showing singns of trauna and ulcer , [Service User 1] has been given the orthotic shoes which were ordered months ago ,
Diagnosis: perscribing flucloxacillin 500 , i have sppoke with him at length about , how depressed he is . he feels contious thast ther othes are listning . needs refering to gp for consultation referal . have tryed to send task and its not arriving with the resipient.
[Entry continues with details of medication and prescriptions not relevant to the issue under consideration.]”

21. On 9 November 2020, at the Registrant’s request, a referral was made by the prison to the Podiatry Surgeon at the hospital. This referral included the following:

“Please see [Service User 1], he has agreed to this, he is a diabetic vasculopath today he has presented with his right 2nd distal phalange protruding and he has a marked ulcer under the head of the MTs”

22. On 13 November 2020, at 10:35, the Registrant made the following entry on SystemOne:

“History: previous podiatry with myself
Examination: right 2nd t oe has bone comming out due to frall , anasthetic given scandanet, toe cleared and stitched inadine dressing applied with melolin squares x 3 tubegause and mefix, dirty nurse advisd on care and dressing regime , given her enail re sos .
Diagnosis: dressing care daily”

23. These documents clearly demonstrate that at the commencement of the treatment session on 13 November 2020, there was a bone protruding from Service User 1’s right second toe. Some procedure was undertaken by the Registrant with regard to that toe (described by her on SystemOne as “cleared”, followed by “stitched”). In order to decide whether the HCPC has presented a case that would enable it to prove that what occurred was a partial amputation, it is necessary to have regard to the evidence of what was presented to Person B when she examined Service User 1’s toe at the hospital three days later, on 16 November 2020.

24. It should be remembered that Person B saw Service User 1 as a result of the referral made on 9 November 2020, which, as stated above, contained the following: “right 2nd distal phalange protruding”. The surprise experienced by Person B when she examined the toe and found that there was no such bone present (whether protruding or otherwise) is unsurprising. The Panel found Person B to be an entirely credible witness who gave evidence that could be safely relied upon; she was a senior practitioner of long standing who had no reason to either misremember what she saw or present untrue evidence against the Registrant. Furthermore, her evidence was consistent with the report of an X-ray she caused to be taken of the toe which stated: ““XR FOOT Rt: Osteolysis and bone destruction of the middle phalanx of the second toe consistent with osteomyelitis”. It would, in the Panel’s judgement, be extraordinary for a comment to be made about the middle phalanx, and not the distal phalanx, had the latter been present.

25. And so the question is, if the bone was present at the commencement of the treatment session on 13 November 2020, and not present three days later, when and how was it removed? The Panel accepted the evidence of Mr Morley that the soft tissue structure of the toe would mean that the bone would be unlikely to simply fall out. Some application of force, for example, by the use of tweezers, would be required to ease it out. The Panel finds that this would be the case in any instance; mere falling out without external action was all the more unlikely because the wound was sutured from the end of the treatment session on 13 November 2020, until Service User 1 presented at the hospital on 16 November 2020.

26. It follows from these findings that upon examination of the HCPC’s case in isolation, the burden of proving that a partial amputation was performed on 13 November 2020, could be proved on the balance of probabilities. The Panel therefore turned to consider the Registrant’s case. For the avoidance of doubt, the Panel did not proceed on the basis that the Registrant was required to disprove the HCPC’s case. If the Registrant’s case cast a credible doubt on the analysis set out above, the Panel would take the view that the HCPC had not discharged the burden of proving the case on the balance of probabilities.

27. The case advanced by the Registrant in oral evidence was that, when cleaning the wound on 13 November 2020, she spotted four or five pieces of bone the size of grains of sand amongst the debris she was removing by flushing the wound. It was her case that she did not perform any action (other than cleaning the wound by flushing) to cause the relevant bone to be removed.

28. In the judgement of the Panel the Registrant was not a credible witness, and her account of her dealings with Service User 1 cannot be relied upon. The reasons for this judgement are contained in the following paragraphs.

29. With regards to the “grains of sand” contention advanced by the Registrant:

• In her witness statement made on the second day of the present hearing, the Registrant stated the following concerning the appointment on 13 November 2020:

“59 At this point, SU1 was on the treatment couch in the medical unit where my clinic was held. This is when I saw SU1’s feet as I removed his socks to find he had trauma on the end of his right 2nd toe. I asked him if he had done this when he fell in the night. He said he thought he had done it when tripping in the shower last night. He had an open wound on the second right toe, which was dirty. The tip of his toe was open and the tip of the bone was visible. I am not able to saw (sic) whether this was the distal joint or the middle joint, but it was still attached to him. This instantly caused there to be a need for referral, which I requested on SystemOne”.

……………..

“67 The wound was rinsed with saline solution four times. This was due to the fact that there was a lot of bodily fluids (faeces) in the wound and around the areas, as well as tiny pieces of what looked like grit. I rinsed out the pieces of what I thought was grit to find that my presumption was incorrect, and they were tiny pieces of bone. They were the size of sand grains. It was four little pieces of bone that washed away with the saline. I did not remove any bone myself. I asked him if he wanted anaesthesia as he was very uncomfortable (despite him having neuropathy) and he reported that he could feel discomfort in his foot at times, so I gave him a small amount of scandanet 3% plain, 1.4ml to make sure I wasn’t causing him pain.”

• In her oral evidence the Registrant stated that she became aware of the “grains of sand” when she heard them falling into a sink when she emptied the vessel into which the saline flushing liquid fell.

• In her ICP response document there was no mention of the “grains of sand”. Rather, what was written there was the following:

“I told [another person in the health wing of the hospital] I had given local anaesthetic and had to clean the end of toe.
Removing the detached pieces of bone from the area, as they would fall off anyway.
The toe could only be described as looking like it had been put in a blender. His foot was such as applying a dressing was always going to be difficult as it needed to stay on until the following Friday as requests for dressing changes did not happen on a regular basis.”
……………………
“I explained why I had done this and how he must go, I made him aware that I was putting myself in an inappropriate position which I should not have done for him because of his refusal to be treated by anyone other than myself.”

30. When asked in evidence before the Panel why there had been no mention of the “grains of sand” before the service of her witness statement on the second day of the hearing, the Registrant stated that the matter had been floating around in her head for the last four years. The Panel rejects the “grains of sand” explanation. It is not simply that it is not mentioned in the ICP response document; on any sensible reading of that document the explanation is inconsistent that proffered by that document. Even the “grains of sand” explanation evolved in the period of less than a week between the making of the witness statement and the Registrant’s oral evidence before the Panel. Furthermore, the Panel does not accept that pieces of bone of the size described by the Registrant would create a sound that would be heard when tipped into a sink.

31. The unreliability of the Registrant’s evidence emerged from another issue. In both her oral evidence before the Panel and in her witness statement made on 19 March 2024, the Registrant stated categorically that she did not see Service User 1 again after 13 November 2020, following his visit to Person B at the hospital. She stated that it was before the next date on which she would otherwise have attended the prison (Friday, 20 November 2020) she was informed that she should not go. This case is entirely inconsistent with the entries on SystemOne, which include an entry in the Registrant’s name at 10:57 on 20 November 2020, in the following terms:

“History: prvious podiatry with myself
Examination: drressiungs changed on both feet looking better stitches removed today , no problems redressed ,
honey melolin mefix
Diagnosis: see next frei”

During the hearing a half-hearted suggestion was made that this entry might have been made by another person who had somehow gained the ability to log into the recording system as the Registrant. The Registrant herself provided the answer to whether this was an entry that in fact made by her, as she wrote in her ICP response document this:

“When I returned the following Friday, he had been to the hospital, I had also received an email from the podiatry department at the hospital, asking me to remove the stitches which I was going to do The area was healing well, and the skin was knitting together, I dressed it and advised the patient and his carer.”

32. The issue of attendance on 20 November 2020, is not material to the issue of what occurred on 13 November 2020, save that it demonstrates that the Registrant’s account of her dealings with Service User 1 cannot be relied upon. It is not necessary, or indeed possible, for the Panel to reach a finding on why the Registrant’s account is so unreliable. It suffices to say that the most generous interpretation that can be placed upon it is that, with the passage of time, she has persuaded herself of an account of how she would like events to have occurred, rather than how they actually happened. The effect, however, on the Panel’s decision making has been that the Panel has felt unable to accept any account given by the Registrant unless it is either supported by other reliable evidence, or is evidence that accords with something that would be inherently likely to be correct.

33. The effect of the unreliability of the Registrant’s evidence on the specific issue of what happened to the distal phalanx is that the Panel finds that there is no reason not to accept the analysis summarised in paragraph 26 above, namely that the Registrant took some positive action to remove the distal phalanx from Service User 1’s right second toe. This finding is entirely consistent with the account the Registrant herself gave to Person B on 18 November 2020 when she sent an email in reply to an email Person B had sent her. In the email the Registrant wrote, concerning the appointment on 13 November 2020, that, ‘… I explained that leaving the toe like it was was not an option, the bone being exposed and the clear signs of infection would cause severe pain and a high probability of loosing more than the toe… I said that I would do what I could but I would like him to see someone for further care and advice if nothing else. I anesthetised the toe and remove the debris which was coming out of the end of the toe and cleared and cleaned the toe. The loose stitching was applied to holed the skin together as there as a lot of loose tissue with the toe flopping over.’ This constituted a partial amputation with the consequence that particular 1(a) is proven.

34. Having decided that a partial amputation was performed on 13 November 2020, the Panel turned to consider the other factual issues.

Particular 1(b) – carrying out an adequate pre-operative assessment on or around 13 November 2020.

35. Particular 1(b) alleges that the Registrant did not carry out an adequate pre-operative assessment of Service Use 1 on or around 13 November 2020, and, in support of that contention, eleven specific matters are particularised. In relation to nine of those eleven issues, complaint is made that the action was not undertaken and/or recorded. The other two (X-ray and written consent) would, if undertaken, necessarily have involved recording. It follows that in order to decide on this particular, the Panel was required to decide if the eleven actions were performed. In relation to nine of them, if performed, it would need to be decided if they were recorded.

36. The Panel will explain its findings in relation to the Registrant’s note keeping generally when it explains its decision on particular 3. For present purposes it is sufficient to record the fact that the Registrant did make an entry on SystemOne of her interaction with Service User 1 on 13 November 2020, and that entry did not record any of the matters included in particular 1(b). With regard to X-ray, it is not suggested that one was undertaken. With regard to written consent, had such consent been given by Service User 1, the written consent itself would not be included in the note, but an entry by the Registrant could and should have recorded the fact that it had been given.

37. With regard to the actions identified in sub-particulars (i) to (iv) inclusive, the Panel finds that the HCPC has not discharged the burden of proving that the actions were not undertaken. The Panel bases this finding on the likelihood of there being present in the treatment room when the Registrant saw Service User 1, a vital signs monitor (in her ICP representations document the Registrant referred to a “Doppler / hands and obs machine” being used), and given the likelihood of such a machine being present, there is a sufficient likelihood of the being used by the Registrant to translate to the HCPC having failed to discharge the burden of proof.

38. With the exception of the 1(b)(i) to (iv) matters, the Panel finds that the absence of a record of them having been undertaken meant that they were not done.

39. Accordingly, the question the Panel was required to answer was this: Did the failure to undertake 1(b)(v) to (xi) meant that an adequate pre-operative assessment was not carried out? The clear answer reached by the Panel is that it did. It accepted the evidence of Mr Morley that these investigations were not only required to be undertaken, but also needed to be recorded. It follows that particular 1(b) is proven in respect of each of the eleven particularised matters.

Particular 2 – not obtaining a necessary and/or appropriate tissue sample and/or wound swab from Service User 1’s right foot on or around 6 November 2020.

40. The Registrant advanced a case by paragraph 52 of her witness statement made on 19 March 2024, that, in relation to 6 November 2020, “I did not obtain a tissue sample and/or wound swab because there was no wound at that time.” This assertion is very clearly contradicted by the Registrant’s own entry on SystemOne made on 6 November 2020 which included, “Examination: right 2nd infected toe with distal falange protruding , left 2nd toe still showing singns of trauna and ulcer ……. Diagnosis: perscribing flucloxacillin 500”.

41. The Panel was satisfied that no tissue sample or wound swab was taken on 6 November 2020. It also accepted the evidence of Mr Morley that one was required.

42. Particular 2 is proven.

Particular 3 – failing to maintain accurate and complete records for Service User 1 in the five respects particularised in (a) to (e).

43. The records concerning Service User 1 made by the Registrant that were provided to the Panel were limited to the SystemOne electronic records. It was the Registrant’s case that there would frequently be a difficulty with entering records on SystemOne, for example because of a faulty keyboard or missing computer. The case she advanced to the Panel in oral evidence was that handwritten clinical notes were made and stored by her in the pharmacy cupboard at the prison, records she was no longer able to access after her contract with Sodexo was terminated shortly after 20 November 2020.

44. The Panel did not accept the Registrant’s evidence that there were separate handwritten clinical notes for the following reasons:

• The explanation did not explain why matters were not fully recorded when it is beyond question that the Registrant was able to use SystemOne (as demonstrated by the entries she made on SystemOne on 6 November 2020, 13 November 2020, and 20 November 2020, quoted above).

• Although one of the allegations which were the subject of the ICP decision was record keeping in the period now being considered by the Panel, there is no assertion in the ICP representations document of there having been separate clinical notes. Indeed, what is stated in the ICP representations document is inconsistent with the case advanced in oral evidence because it is stated, “The treatment was recorded as best as the computer keypad would allow; the normal recordings were done on my notepad to be added to the notes at clinic.” In her reflections on the penultimate page of the same document, she wrote this: “I will not treat any patient where I am unable to record treatment plans at that clinic, insisting on having appropriate equipment, i.e., keyboard which works allowing me to record patient records accurately, any records made at my own clinic will be forwarded the same day to the clinic where the patient was treated.”

• There is no reference to the handwritten patient notes kept in the pharmacy cupboard at paragraphs 80 to 84 of the witness statement the Registrant made after the commencement of the present hearing.

• No request has been made to Sodexo or the prison either by the Registrant or by her Solicitors for a search to be made for handwritten notes.

45. It is possible that the Registrant made some jottings in a personal notepad, but the fact that these did not translate to patient records when she was at her First Steps Podiatry clinic is demonstrated by the fact that she has not tendered them in evidence.

46. Particular 3 is proven in respect of each of the sub-particulars (a) to (e).

Particular 4 – suturing Service User 1’s wound when it was not appropriate to do so.

47. The Registrant accepted this particular, but the Panel nevertheless considered whether it would be appropriate to accept that admission.

48. The fact that the toe was stitched on 13 November 2020, and that the suturing was still present on 16 November 2020, when Person B saw Service User 1, is not in doubt. Person B described the suturing to have been undertaken with what appeared to be a thick black thread. The Panel accepted the evidence of both Mr Morley and Person B that it was not appropriate for this toe to have been sutured. It was infected, and suturing was contra-indicated because the infection should have been allowed to drain out.

Particular 4 is proven.

Particular 5 – not undertaking the partial amputation in a hospital setting and/or as part of a hospital’s Diabetes Multidisciplinary Team which was necessary and/or appropriate.

49. The procedure was in fact undertaken in the medical wing of the prison. It was not undertaken in a hospital setting, nor was it undertaken as part of a hospital’s Diabetes Multidisciplinary Team. The Panel accepted the evidence of Mr Morley that a procedure of the type undertaken was required to be performed in such a setting.

50. Particular 5 is proven.

Particular 6 – working beyond the scope of practice in suturing the wound and/or performing a partial amputation in the circumstances alleged by particular 5.

51. As this particular alleges two separate actions, the Panel considered them separately.

52. So far as the partial amputation is concerned, the Registrant has neither training nor experience as a Podiatric Surgeon, and she did not contend that she did have them. The performance of a partial amputation was outside the scope of her practice. That the Registrant realised that to be so is demonstrated by the passage in her ICP representations document where she wrote, “I explained why I had done this and how he must go. I made him [i.e. Service User 1] aware that I was putting myself in an inappropriate position which I should not have done for him because of his refusal to be treated by anyone other than myself.”

53. So far as suturing is concerned, the allegation is not that suturing is beyond the scope of all Podiatrists in all circumstances. The contention is that it was outside the scope of this Podiatrist. The evidence of the Registrant was that when she was a nursing assistant, she received some suturing training, approximately 18 years before she sutured Service User 1’s toe. The nature of that training was unclear, but of more significance is the fact that it was not suggested that the Registrant had maintained or developed such skills as she gained when trained those years ago. The Panel is satisfied that it was outside the scope of the Registrant’s practice in November 2020. The fact that it was done when inappropriate only serves to underline that it was outside the scope of her practice.

54. Particular 6 is proven with regard to both limbs alleged.

Summary of factual findings

55. All of the factual particulars are proven. It will therefore be necessary for the Panel to proceed if those proven facts constitute misconduct, and, if they do, whether that misconduct is currently impairing the Registrant’s fitness to practise.

The reconvened hearing commencing on Monday, 15 July 2024

56. On the morning of the resumed hearing, the Panel received a bundle of documents submitted on behalf of the Registrant. This bundle extended to 132 electronic pages, and included a reflective statement prepared by the Registrant, CPD certificates, examples of First Step notes, guidance documents relating to peripheral arterial disease and three testimonials. After the Panel delayed the start of the hearing to read this bundle, it was informed that the Registrant proposed to give further evidence. The Registrant gave further evidence, afterwards the Presenting Officer made submissions on behalf of the HCPC on both misconduct and current impairment of fitness to practice, and finally Ms Marcelle-Brown made submissions on behalf of the Registrant.

57. The Panel made clear that although it was offering the parties the opportunity to introduce evidence and make submissions in relation to both misconduct and current impairment of fitness to practise in one segment of the hearing, when it came to making decisions, those issues would be decided by the Panel separately and sequentially.

58. In her evidence in chief, the Registrant dealt with some of the matters dealt with in her reflective statement and elaborated on the details of courses represented by the CPD certificates in her bundle of documents. She explained to the Panel that since she ceased to work at the prison, her involvement in what might be called direct Podiatry practice at First Steps had been limited. She stated that, with the exception of orthotic patients, she did not directly treat patients at her practice. In her evidence the Registrant referred to health issues she experienced, but the Panel does not consider it necessary to include details of these issues in this determination. The Registrant was cross-examined on the contents of the bundle of documents produced at this stage of the hearing, and afterwards she answered a question of the Panel related to the number of people working at First Steps.

59. In his submission to the Panel on misconduct, the Presenting Officer submitted that an approach that the Panel might adopt in deciding whether misconduct had been established would be to pose the question whether the proven factual matters represented serious acts and/or omissions falling short of the conduct that would be proper in the circumstances. He drew attention to the breaches of HCPC Standards set out in the Case Summary contained in the main HCPC hearing bundle. He also reminded the Panel that it had been the evidence of Mr Morley, the expert witness, that the Registrant’s actions had placed Service User 1 at high risk, that in doing so she had acted outside the scope of her practice. Further, that Mr Morely said the record keeping failures over approximately 30 appointments over a lengthy period also represented performance falling far below the required standard. He also submitted that the fact that the shortcomings occurred in a prison setting had little bearing on the issue of misconduct,
particularly given the scale of the issues identified by the factual findings. In short, the Presenting Officer submitted that the Panel should find misconduct to be established.

60. In relation to current impairment of fitness to practise, the Presenting Officer referred to the HCPTS Practice Note on the topic and submitted that there is a significant risk of repetition. He submitted that the greater the departure from acceptable behaviour that is factually established, the more likely the cause of them will be attitudinal deficiencies and, therefore, the more difficult it will be for them to be remediated. That would result in a greater risk of repetition. He submitted that the matters found proven in the present case, including acting outside the scope of practice that had been acknowledged in what the Registrant herself reported having admitted to Service User 1, are examples of serious shortcomings that would be difficult to remediate. On the evidence put before the Panel, the Presenting Officer contended that they had in fact not been remediated. For these reasons he submitted the Panel should find that personal component impairment of fitness to practice had been established. So far as the public component is concerned, the Presenting Officer similarly argued that it should be found, the upholding of proper professional standards and the need to maintain public confidence in the Podiatry profession requiring that finding.

61. On behalf of the Registrant, Ms Marcelle-Brown stated that she did not intend to make any submission on misconduct, save for reminding the Panel that the decision was one for its collective judgement.

62. In relation to current impairment of fitness to practise, Ms Marcelle-Brown submitted that the Registrant should not be disadvantaged by having disputed the HCPC’s factual allegations; she submitted that it is possible to demonstrate remediation despite having challenged the factual basis of the case. Further, she submitted that a proper application of the principles required the Panel to accept that, even if the Panel concluded that the Registrant had breached Standards laid down by the HCPC, that fact should not, of itself, be treated as demonstrating that the Registrant’s fitness to practise is impaired. Ms Marcelle-Brown referred to the 25 year-long career of the Registrant that has been, the present issues apart, unblemished, and of the measures taken by the Registrant to remediate the issues identified in this case. She submitted that with regard to Service User 1, the Registrant had not acted maliciously and that no harm had been caused to Service User 1. She also asked the Panel to have regard to the full engagement of the Registrant in these fitness to practise proceedings, and that she had engaged with Person B following Service User 1’s visit to hospital. Ms Marcelle-Brown referred to the training undertaken by the Registrant and her insight in accepting the limitations she now felt she had as a result of her health issues, and the consequential limitation of her clinical podiatric activities. For all these reasons, the Panel was invited to find that the Registrant’s fitness to practise is not impaired when the personal component was considered. Similarly, Ms Marcelle-Brown submitted that a finding should be made that the Registrant’s fitness to practise is not impaired when the public component is decided because there was little risk of repetition, there is no risk that requires public protection and public confidence would not be undermined.

Decision on Misconduct

63. The Panel accepted the advice of the Legal Assessor in relation to the decision to be made on misconduct. The fact that no positive submission was made on behalf of the Registrant that misconduct was not made out did not remove the Panel’s obligation to fully consider the matter. It should not approach the matter on the basis that there is a burden or standard of proof; the issue is to be decided by the Panel applying its collective judgement to the issue. There is no statutory definition of misconduct, but the Panel could apply the guidance of the Courts in other cases, and this guidance included assessing whether there had been a serious falling short of what would be proper in the circumstances (the yardstick of what is proper being established by the HCPC’s Standards), and whether conduct that fellow professionals would regard as deplorable had been proven. Whatever approach the Panel elected to take, it must remember that the falling short must be serious before it would be appropriate to find that misconduct had been demonstrated. Just as Ms Marcelle-Brown had correctly submitted that a demonstrated breach of the HCPC’s Standards should not, of itself, be equated with impairment of fitness to practise, so too should the Panel not find misconduct simply because a Standard or Standards had been breached. It would still be necessary to assess the seriousness of any breaches.

64. The Panel began its deliberations by considering whether the findings of fact it had made amounted to breaches of the HCPC’s Standards. The Panel started by addressing the Standards of conduct, performance and ethics. The conclusion of the Panel was that the following standards had been breached:

• Standard 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.”

• Standard 2.5, “You must work in partnership with colleagues, sharing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.”

• Standard 2.6, “You must share relevant information, where appropriate, with colleagues involved in the care, treatment or other services provided to a service user.”

• Standard 3.1, “You must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience for.”

• Standard 3.2, “You must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice.”

• Standard 6.1, “You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.”

• Standard 6.2, “You must not do anything … which could put the health or safety of a service user … at unacceptable risk.”

• Standard 9.1, “You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.”

• Standard 10.1, “You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.”

65. In considering the HCPC’s Standards of Proficiency for Chiropodists / Podiatrists that were in force at the time of the relevant events, the Panel acknowledged that these standards are directed to requiring registrants to be able to perform adequately, as opposed to requiring registrants who have that ability to ensure that they apply their ability appropriately. Nevertheless, the Panel considered these standards and decided that the manner of the Registrant’s management of Service User 1 amounted to treatment that could not have been delivered if these standards had been applied. It is not necessary to list the numerous particular respects in which that would be demonstrated because they all fall under the first standard that provides, “Registrant chiropodists / podiatrists must: 1 be able to practise safely and effectively within their scope of practice.”

66. Having identified these breaches, the Panel then considered how serious they were. The Panel was satisfied that they represented serious breaches. The Registrant performed an invasive procedure what was outside the scope of her practice upon an individual who was acutely vulnerable, and he was placed at a real risk of harm as a consequence. The seriousness of the breaches is not lessened by the fact that no tangible harm to Service User 1 has been identified. They were breaches of standards that fell far below the required standard. The Panel was satisfied that they merited the finding that they amounted to misconduct.

Decision on Impairment of Fitness to Practise

67. The Panel accepted the advice from the Legal Assessor in relation to this issue and paid close attention to the Practice Note issued by the HCPTS issued in November 2023 and entitled, “Fitness to Practise Impairment”. Accordingly, it addressed both the personal and public components of impairment of fitness to practise.

68. An important element of a decision on the personal component of current impairment of fitness to practise is whether the identified shortcomings are capable of being remedied, and whether they have in fact been remedied. The Panel does not doubt that shortcomings such as are in issue in this case, serious though they undoubtedly are, are conceptually capable of being remedied. However, the Panel does not find that the Registrant has in fact remedied them. It was submitted by Ms Marcelle-Brown that the reflection document and the evidence of CPD demonstrated remediation. However, the Panel did not accept that proposition. This was in part due to the Registrant’s admission that the more recent reflection document was prepared without knowledge of the Panel’s findings on the facts. Despite the fact that the Registrant gave evidence that the recent reflection document was prepared without reference to that contained in the ICP response document, it was clear to the Panel that there were significant similarities and it appeared that the recent document was based upon the earlier one. Indeed, the Registrant stated in evidence that she had not read the Panel’s findings on the facts, having merely asked to be given a summary of the findings. In the judgement of the Panel, the two reflection documents are broadly similar. The reflection that had been submitted was superficial and did not demonstrate having been embedded in practice or in conduct required by the HCPC. Furthermore, there was no evidence of Personal Development Plans, audits, peer supervision or mentoring of her practice.

69. The finding of the Panel that the Registrant has not remedied the shortcomings is not wholly based on the reasons expressed in the immediately preceding paragraph. A more fundamental reason is the Registrant’s attitude towards what occurred with regard to Service User 1. When the Registrant was cross examined at the resumed hearing on Monday, 15 July 2024, the Presenting Officer asked a question which included the premise that she had undertaken a partial amputation. The Registrant immediately replied saying that there had been no partial amputation. Putting to one side for a moment the fact that this assertion rather begs the question of what she did (per her ICP representations document quoted in paragraph 52) that prompted the Registrant to say to Service User 1 that she was putting herself in in an inappropriate position by doing something she should not have done, for present purposes the significance of the reply is that it cannot give confidence that there would be no repetition. It is important that the Panel should be very clear about the significance of the reply given to the Presenting Officer; the Panel does not question the Registrant’s right to maintain her denial of partial amputation, but if there is an absence of recognition that something happened in the past, in the view of the Panel there can be little confidence that the issue will not be repeated in the future. If a registrant has strayed from proper professional practice in the past, they need to be able to understand what happened and why. The Panel was left with a feeling that these issues eluded the Registrant, and that the major feeling she had about the incident is that she feels hard done by for being criticised.

70. The Panel accepts that the Registrant did not act maliciously towards Service User 1; she did what she did because at the time she thought she was acting in Service User 1’s best interests. In the view of the Panel it is not acting in a service user’s bests interests to undertake actions for which the practitioner is not qualified. Having carefully considered the matter, the Panel considers that there is a risk that is more than negligible that in the future the Registrant would act impulsively in a misguided attempt to aid a service user. For that reason the Panel finds that her fitness to practise is impaired upon consideration of the personal component.

71. So far as the public component of impairment of fitness to practise is concerned, the Panel concluded that the risk of repetition, coupled with the risk of harm to service users were there to be a repetition, is such a finding of public component impairment would be required on that ground alone. However, so serious are these findings that, quite apart from the risk of future harm, that finding is required to declare and uphold proper professional standards. Furthermore, were the past working beyond the scope of practice, something acknowledged by the Registrant to Service User 1, not marked by a finding of impairment of fitness to practise, the Panel believes that public confidence in the profession of Podiatry would be seriously undermined.

72. For all these reasons, the Panel finds that the Registrant’s fitness to practise is currently impaired on both the personal and public components that are required to be considered. The result of that finding is that the allegation is well founded with the consequence that the Panel must go on to consider the issue of sanction.

Decision on Sanction

73. After the Panel handed down its written determination on misconduct and current impairment of fitness to practise, it allowed the parties time to consider the findings made. The Panel then reconvened to receive submissions on sanction.

74. At the outset of his submissions on behalf of the HCPC, the Presenting Officer made it clear that the HCPC did not make a positive submission that any particular sanction should be applied. He commended to the Panel the HCPC’s Sanctions Policy, and, consistent with that document, submitted that the Panel should decide on the basis that the least restrictive order should be made, ensuring that no greater restriction is imposed than is necessary. He also suggested some mitigating factors the Panel might wish to consider, and these included the fact that the failings related to a single service user, that the events occurred in a prison setting and that the Registrant had not acted maliciously, doing what she did believing it to have been in Service User 1’s best interests. Against these factors, the Presenting Officer suggested some factors that the Panel might consider to be aggravating factors, and these included the Panel’s finding already made as to the Registrant’s deficient remediation, that her reflections were superficial and that a true understanding of what had occurred, and why what had occurred, had eluded the Registrant. As a further possible aggravating factor, the Presenting Officer also referred to the potential for service user harm, the prospect that the Panel would find the Registrant’s behaviour to have been deliberate, and that the record keeping entries had been repeated and occurred over a protracted period of time.

75. On behalf of the Registrant, Ms Marcelle-Brown drew the attention of the Panel to paragraphs 8 and 11 of the Sanctions Policy and reminded the Panel that a sanction should not be imposed to punish, but should only be imposed to protect the public. Ms Marcelle-Brown referred to a number of factors she urged the Panel to consider in the Registrant’s favour. These included the passage of time since the incident with Service User 1, the fact that no actual harm was suffered by Service User 1, the remorse she has expressed, the CPD she had undertaken, her willingness to remediate, her in-house training of First Steps staff and the evidence given by the Registrant about her health. Ms Marcelle-Brown stated that she did not intend in her submissions to review all of the available sanctions, but would instead confine her remarks to a suspension order. She said that, without going behind the Panel’s finding in relation to the Registrant’s present inadequate remediation, the making of a suspension order would allow the Registrant to develop her insight; this is not, she submitted, a case of a registrant who has no intention of developing insight. In relation to the risk of repetition, it was submitted that the strongest evidence was that it is now very nearly four years since the incident with Service User 1, and there has been no recurrence. For these reasons, Ms Marcelle-Brown submitted, a striking off order would be disproportionate. It was acknowledged that the case is a serious one, but it was submitted that it is not so serious that the only appropriate sanction could be striking off, an outcome that should be regarded as the sanction of last resort. Finally, in the event that the Panel accepted the submission that a suspension order would be appropriate, Ms Marcelle-Brown urged the Panel to make that order for as short a period as possible.

76. The Panel accepted the advice it received from the Legal Assessor concerning the sanction decision. Accordingly, it paid close attention to the HCPC’s Sanctions Policy and remembered throughout that a sanction should never be imposed in order to punish a registrant against whom a finding has been made. Rather, the factors properly to be considered when deciding on sanction are the need to protect the public from the risk of harm, the upholding of proper professional standards and the importance of ensuring that public confidence in regulated profession is maintained. To ensure that no more restrictive sanction is imposed than these legitimate factors require, the Panel should begin by deciding if any sanction is required, and then, if it decides that a sanction is needed, the available sanctions must be considered in an ascending order of seriousness until one that meets the circumstances is reached. It is also important that the Panel double-checks that any sanction alighted upon by this approach strikes a proportionate response between the factors requiring a sanction and a registrant’s interests. The Panel confirms that it has applied this approach in this case.

77. When it started its deliberations, the Panel identified the aggravating factors that make this a serious case. They were:

• The findings involve a deliberate act which involved the Registrant knowingly working beyond the scope of her practice.

• Service User 1, a vulnerable person, was placed at significant risk of harm. The fact that harm did not materialise is purely fortuitous and does not minimise the seriousness of the breaches.

• The record keeping breaches were repeated and extended over a protracted period.

• The Registrant has demonstrated very limited insight.

• The Registrant has not remediated her failings, with the consequence that there is a risk of recurrence of inappropriate behaviour in a professional context that would in turn create a risk to the public.

78. Against this, the Panel accepted that there were factors to be applied that were in favour of the Registrant. These were:

• The absence of other regulatory findings, either before or since the events giving rise to this case. It was suggested in submissions that the Registrant’s career was of some 25 years duration. It is possible that that submission was based on a period including work undertaken in other healthcare roles before the Registrant qualified as a Podiatrist. However, the Registrant’s evidence contained in paragraph 3 of her witness statement made on 19 March 2024, was that she qualified as a Podiatrist in 2008, and commenced practice a short while later after a short career break taken for family reasons. It follows that the Registrant has now been qualified for approximately 15 or 16 years, and had been qualified for approximately 11 or 12 years at the date of the events relevant to this case. Nevertheless, the Panel considered it relevant to apply to its decision the fact that the only findings made against the Registrant as a registered practitioner are those that have been made by the present Panel in this case.

• The Registrant has had the fitness to practice proceedings hanging over her for considerable period of time, and the Panel accepts that that is a matter which would understandably cause anxiety.

• The Panel accepts that the Registrant did not act maliciously, as the procedure she undertook on Service User 1 was done in a misguided attempt to help him.

• The Panel has kept in mind that the events occurred in a prison setting. Although that was not an unfamiliar working environment for the Registrant, the Panel nevertheless accepts that it would have created difficulties. Furthermore, with the exception of some of the record keeping failings, the events occurred during the Covid-19 pandemic, and that fact undoubtedly gave rise to an additional layer of difficulty.

79. There are two matters to be mentioned in relation to the factors that it would be appropriate to take into account in favour of the Registrant. They are:

• The Panel was asked on behalf of the Registrant to apply to its decision the evidence given by her about her health. For two reasons the Panel did not consider it appropriate to do so. First, the finding made by the Panel is that the Registrant’s fitness to practise is impaired by reason of misconduct; neither the allegation, nor the Panel’s finding, is that her fitness to practise is impaired by an adverse health condition. Secondly, there was a complete absence of any independent evidence relating to the Registrant’s health. Even if it had been appropriate to apply considerations of health to the sanction decision, it would have been necessary for such evidence to have been provided to the Panel.

• As stated in paragraph 25 of the Sanctions Policy, matters of mitigation are likely to be of considerably less significance in regulatory proceedings such as this than in cases where retributive justice is a permissible consideration. This is because the overarching reason for these proceedings is the protection of the public, and necessarily it is the factors leading to the case being viewed as serious that are preeminent in that regard.

80. With these factors kept very much in mind, the Panel asked itself the necessary questions. When the Panel asked the first question, namely, whether any sanction is required, the clear answer given was that it is. This case is far too serious to result in no action being taken.

81. The next issue considered was whether a caution order should be imposed. The Panel had regard to paragraph 101 of the Sanctions Policy which is in these terms:

“101. A caution order is likely to be an appropriate sanction for cases in which:

• the issue is isolated, limited, or relatively minor in nature;

• there is a low risk of repetition;

• the registrant has shown good insight; and

• the registrant has undertaken appropriate remediation.”

In the judgment of the Panel, the present case does not satisfy any of these suggested factors. The Panel rejected a caution order as an appropriate sanction.

82. The Panel then addressed the question of whether a conditions of practice order would be appropriate. Paragraph 106 of the Sanctions Policy states this:

“106. A conditions of practice order is likely to be appropriate in cases where:

• the registrant has insight;

• the failure or deficiency is capable of being remedied;

• there are no persistent or general failures which would prevent the registrant from remediating;

• appropriate, proportionate, realistic and verifiable conditions can be formulated;

• the panel is confident that the registrant will comply with the conditions;

• a reviewing panel will be able to determine whether or not those conditions have or are being met; and

• the registrant does not pose a risk of harm by being in unrestricted practice.”

As the Panel has found, the Registrant has very limited insight into her failings. However, there are three specific reasons why the imposition of conditions of practice are not appropriate in this case. First, it would not appropriate to impose conditions of practice that required the Registrant not to work outside the scope of her practice, nor would it be appropriate to impose a condition that proper records are kept; those requirements are fundamental and arise from the ordinary requirements of registration. Secondly, only direct and constant supervision could prevent a registrant from straying beyond the scope of their practice and ensuring that proper records were kept, and the imposition of such a condition would be inappropriate as it would mean that there could be no autonomous practice. Thirdly, the nature of the Registrant’s practice makes the imposition of conditions of practice inappropriate; per paragraph 7 of her witness statement dated 19 March 2024, First Steps is her company and she has a staff of seven people. That it would not be possible to have confidence of the Registrant’s staff supervising or overseeing her work is demonstrated by the fact that in her evidence to the Panel on 15 July 2024, the Registrant stated that of late she has been training staff. The Panel rejected conditions of practice as an appropriate outcome.

83. Accordingly, the Panel went on to consider whether a suspension order should be made. Paragraph 121 of the Sanctions Policy is in these terms:

“121. A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:

• the concerns represent a serious breach of the Standards of conduct, performance and ethics;

• the registrant has insight;

• the issues are unlikely to be repeated; and

• there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings.”

84. It is important that the Panel should explain in a little detail its views on how the circumstances of the present case do, and do not, meet the suggested criteria in paragraph 121 of the Sanctions Policy.

• The present case is undoubtedly one in which serious concerns have been identified, and it is also a case in which it is not appropriate for those concerns to be addressed by the imposition of conditions of practice. The Panel will return to the issue whether they require the Registrant to be struck off below.

• The concerns do indeed represent serious breaches of the Standards of conduct, performance and ethics.

• For the reasons explained by the Panel in relation to its findings on impairment of fitness to practise, the Registrant does not at present have insight.

• There is a risk of repetition that is more than minimal, and therefore it cannot be positively stated that issues are unlikely to be repeated.

• As to there being evidence that the Registrant will be likely to be able to resolve or remedy her failings, the Panel is unable to say either that the Registrant will be able to address them, but equally cannot find that she will definitely not be able to address them. This is so because:

o As the Panel has already stated, the failings are of a type that are conceptually capable of being remediated.

o In fact, the Registrant has not as yet remediated the failings, and it is now over three years since the relevant events.

o However, the Registrant has made some efforts (albeit unsuccessful to date) to address matters, and has advanced her case on the basis that she wishes to be able to continue with those efforts.

85. The fact that the present case did not fit squarely within the factors set out in paragraph 121, resulted in the Panel considering whether it would be appropriate to make a striking off order. The Panel does not consider that it is necessary to reproduce in this determination the terms of paragraphs 130 and 131 of the Sanctions Policy because it is the long-term consequences of making such an order that is the important factor. In the view of the Panel, notwithstanding the seriousness of the matters proved, it is possible to envisage a practitioner who had committed those acts being permitted to return to unrestricted practice if and when the failings have been satisfactorily addressed. In other words, the findings are not of a category where the only possible outcome in all circumstances could be striking off. It follows from this that were the Panel to make a striking off order, the effect of it would be that the possibility of demonstrating remediation would be removed from the Registrant. Taking a step back and considering the matter in the round, the Panel concluded that it would not be right at the present stage to remove from the Registrant the opportunity to remediate her failings. For this reason, the Panel decided that a suspension order should be made. The Panel is satisfied that the protection a suspension order will provide for the duration of the period of suspension sufficiently addresses the legitimate public safety and public interest issues.

86. There are two matters relevant to the future review of the suspension order that the Panel should explain:

• First, the Panel recognises that it is customary for panels making suspension orders to make suggestions to a suspended registrant as to the steps that might assist a future reviewing panel. The present Panel has made a conscious decision not to make any suggestions in this case. It has been explained earlier in this determination why this Panel does not accept that the Registrant has remediated her failings to date. If the Registrant choses to seek to persuade the future reviewing panel that she has successfully remediated the failings, then it will be for her to decide how she would wish to demonstrate that she has. It will be a matter for the future reviewing panel to determine what information and evidence they would require to be satisfied on the issue, but the Registrant would be well advised to take the view that the future panel might expect not only written material, but also that it might wish to hear directly from her.

• It will be apparent from the explanation of how this Panel arrived at the decision that a suspension order should be made, just how close the Panel came to making a striking off order. The Registrant should keep in mind that when this suspension order is reviewed before it expires, the reviewing panel will have the full sanction range available. As already stated, the outcome of the review will be entirely one for the reviewing panel. However, the Registrant would be well advised to approach that future review on the basis that without significant evidence of meaningful steps towards developing full insight and successful remediation, the reviewing panel will consider making the striking off order the Registrant has narrowly avoided today.

87. Finally, the Panel has decided that the appropriate length of the suspension order should be the maximum period of 12 months. As already noted, it is now well over three years since the relevant events and the Registrant has not, as yet, remediated her failings. In the estimation of the Panel, the future efforts she will be required to make are likely to take some considerable time. It is therefore in the Registrant’s interests that she should have a proper time to provide the evidence she will be required to provide to be permitted to return to practise.

ORDER:

The Registrar is directed to suspend the registration of Deborah Knight-Griffiths for a period of 12 months from the date this Order comes into effect.

 

Right of Appeal

You may appeal to the High Court in England and Wales against the Panel’s decision and the order it has made against you.

Under Article 29(10) of the Health Professions Order 2001, any appeal must be made within 28 days of the date when this notice is served on you. The Panel’s order will not take effect until the appeal period has expired or, if you appeal, until that appeal is disposed of or withdrawn.

Interim Order

Application

1. After the Panel announced its decision that the substantive sanction would be a suspension order, the Panel handed down its written determination explaining the reasons for that decision. It allowed the parties time to read those reasons.

2. The Panel subsequently returned to the hearing room and the Presenting Officer applied for an interim suspension order for a period of 18 months to cover the appeal period. He submitted that an interim order was required because it was necessary for the protection of members of the public and was otherwise in the public interest. In support of the submission that an interim order is required to cover the appeal period on these grounds, the Presenting Officer relied upon the Panel’s reasons contained in the substantive decision, and in particular the risk of future harm.

3. In response to the application for an interim order, Ms Marcelle-Brown referred the Panel to paragraph 134 of the Sanction’s Policy which states that the power to impose an interim order is discretionary, and so panels should not consider it to be an automatic outcome. Furthermore, in relation to the length of any interim order, she submitted that the Panel should consider what the appropriate length should be.

Decision

4. The Panel first addressed the question of whether it had jurisdiction to consider the application for an interim order. It concluded that it did because the notice of hearing sent to the Registrant on 17 October 2023 informing her of the originally scheduled hearing dates alerted her to the possibility of such an application being made. This afforded the Registrant with an opportunity of making representations on this issue.

5. The Panel accepted the advice it received from the Legal Assessor. One aspect of that advice was that it was important that the Panel should acknowledge the default position established by the legislation is that, when a substantive sanction is imposed, there will be no restriction on a registrant’s ability to practise while their appeal rights remain outstanding (i.e. initially the 28 day period during which an appeal can be made, and then the longer period pending the determination of the appeal if it is made). It follows from this that there must be positive reasons to justify the making of an interim order, and those reasons must satisfy at least one of the statutory grounds of an interim order being (i) necessary for protection of members of the public, (ii) otherwise in the public interest, and (iii) in the interests of the Registrant.

6. Having carefully considered the matter, the Panel considered that, for the reasons expressed in the substantive decision, the risk of repetition with the attendant risk of service user harm, requires an interim order on the first and second grounds (namely, protection of the public and the wider public interest).

7. The Panel then considered whether an interim conditions of practice order would address the reasons why an interim order was required. For the same reasons the Panel rejected substantive conditions of practice as an appropriate sanction, the Panel concluded that interim conditions of practice were not appropriate.

8. It followed from these reasons that an interim suspension order is required.

9. The Panel made the Interim Suspension Order for a period of 18 months. It made that order not because it could (18 months being the maximum period) but because (i) if the Registrant does not appeal, the interim order will simply fall away when the time for doing so expires, (ii) if the Registrant does appeal, the final resolution of that appeal could well take at least 18 months.

Interim Order

The Panel makes an Interim Suspension Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest. This order will expire: (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; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

 

History of Hearings for Deborah Knight-Griffiths

Date	Panel	Hearing type	Outcomes / Status
15/07/2024	Conduct and Competence Committee	Final Hearing	Suspended
18/03/2024	Conduct and Competence Committee	Final Hearing	Adjourned part heard